Evidence Rating: No Effects | One study
Date:
This program was designed to reduce violence risk behaviors as well as PTSD and depressive symptoms by providing adolescents with a variety of services following a traumatic injury. The program is rated No Effects. There were no statistically significant differences between the intervention and control groups in substance use problems, or PTSD and depressive symptoms, though intervention group patients reported a statistically significant reduction in weapons carrying.
A No Effects rating implies that implementing the program is unlikely to result in the intended outcome(s) and may result in a negative outcome(s).
This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.
Program Goals/Target Population
Physical injury is a leading cause of death and disability for children and adolescents in the United States and constitutes a major public health challenge (National Center for Injury Prevention 2006). Violence, substance use problems, and mental health symptoms occur frequently among adolescents presenting to acute care medical settings after traumatic physical injury. Past research has suggested that collaborative care interventions can help in reducing risk behaviors and symptoms associated with traumatic injury in young primary care patients (Roy-Byrne et al. 2010; Gilbody et al. 2006).
The goal of the Stepped Collaborative Care for Adolescents intervention was to reduce violence risk behaviors such as weapon carrying, substance use problems, posttraumatic stress disorder (PTSD) symptoms, and depressive symptoms by providing adolescent patients with a variety of medical care services soon after their traumatic physical injuries occurred. The intervention targeted adolescent survivors of intentional injuries (such as physical assaults) and unintentional injuries (such as car accidents) between the ages of 12 and 18 years old who were admitted to the University of Washington’s Harborview level I trauma center inpatient surgical ward or emergency department for 24 hours or more.
Program Components
Patients who received the intervention obtained care from a social worker and nurse practitioner who were part of the trauma center–based care management team, for up to 12 months after the injury occurred. The intervention was designed to be delivered in the surgical inpatient ward, outpatient surgery clinics, and over the telephone, as patients re-engaged in primary care and community rehabilitation. Most of the intervention activities occurred within the first six months after the injury. The time intensity of the stepped-care intervention gradually decreased after a year of services. The intervention involved components of care management, motivational interviewing, pharmacotherapy, and cognitive–behavioral therapy (CBT).
Care managers attempted to solve each patient’s unique constellation of post-injury concerns and coordinated care across surgical inpatient, primary care, and community service delivery settings. Patients received motivational interviewing sessions from care managers who addressed substance use, weapon carrying, and other risk behaviors. Some patients received medication evaluations and pharmacotherapy from nurse practitioners targeting high levels of PTSD and depressive symptoms. Patients discussed PTSD treatment preferences with the collaborative care team and provided input regarding the choice, timing, and delivery of medication, CBT, or combined treatment interventions. The nurse practitioner team member prescribed medications with supervision from the study psychiatrist.
Eligible patients received multisession CBT, and additional CBT elements were delivered during routine care management. The CBT, which was delivered by trained team members who had master’s degrees in social work, included psychoeducation, muscle relaxation, cognitive restructuring, and graded exposure. Receipt and frequency of services rendered were based on the needs of each patient. Symptoms were repeatedly measured in patients over the 12 months.
Zatzick and colleagues (2014) found no statistically significant differences between the Stepped Collaborative Care for Adolescents intervention and control groups in alcohol or drug use, high-level posttraumatic stress disorder (PTSD) symptoms, or high-level depressive symptoms, at 12 months after the injury. However, the intervention group patients reported fewer incidents of carrying a weapon, compared with the control group patients. This difference was statistically significant. Overall, the preponderance of evidence suggests the program did not have the intended effect on intervention group patients.
Study 1
Alcohol or Drug Use
There were no statistically significant differences in alcohol or drug use at 12 months after the injury between the intervention group patients and control group patients.
High-Level Depressive Symptoms
There were no statistically significant differences in depressive symptoms at 12 months after the injury between the intervention group patients and control group patients.
High-Level PTSD Symptoms
There were no statistically significant differences in PTSD symptoms at 12 months after the injury between the intervention group patients and control group patients.
Weapon Carrying
Intervention group patients reported fewer incidents of carrying a weapon, compared with the control group patients, at 12 months after the injury. This difference was statistically significant.
Study 1
Zatzick and colleagues (2014) conducted a randomized clinical trial to evaluate the effectiveness of a stepped collaborative care intervention in reducing violence and injury risk behaviors (i.e., weapon carrying), alcohol and drug use problems, and posttraumatic stress disorder (PTSD) and depressive symptoms in injured adolescents. To be eligible for treatment, participants had to be between the ages of 12 to 18 and admitted to the University of Washington’s Harborview Medical Center, a level I trauma center, through the inpatient surgical ward or emergency department for 24 hours or longer between March 1, 2008, and October 31, 2009. Adolescent survivors of intentional and unintentional traumatic physical injuries and/or traumatic brain injuries were eligible for the study. However, adolescents with severe injuries that prevented participation or those with self-inflicted intentional injuries were excluded. Additional exclusions included adolescents who were non-English speaking or those who had two parents who were non-English speaking. Adolescents approached in the surgical ward were evaluated with the Glasgow Coma Scale and were required to have a cumulative score of 15 at the time of the evaluation, indicating mild brain injury. Adolescent patients were also required to score at least 7 out of 10, indicative of normal, on the two Mini-Mental State Examination items that assess orientation to location and date. Those who did not meet these requirements were excluded from the study. Assent was obtained from all participants and both adolescent assent and parental consent were obtained for patients younger than 18 years old.
Participants were randomly assigned to the intervention group (n = 59) and control group (n = 61). Those in the intervention group spent on average 13.1 hours receiving stepped collaborative care intervention services with most services (75 percent) being rendered within six months after the injury. Those in the control group received the usual care and services generally delivered to all those who are admitted to the level I trauma center. Usual postinjury care included routine outpatient surgical, primary care, and emergency department visits. Specialty mental health services were occasionally provided.
On average, study participants were 15 years old, 38 percent identified as nonwhite, 62 percent identified as white, and 25 percent identified as female. They had an average injury severity score of 15.7 and stayed in the hospital an average of 6 days. There were no statistically significant differences in demographic characteristics or injuries between the intervention and control groups. There were also no statistically significant differences between intervention and control group patients in any risk behaviors, such as weapon carrying (32.8 percent), alcohol and drug use (44.2 percent), high levels of PTSD symptoms (17.5 percent), and high levels of depressive symptoms (10.0 percent).
There were four outcomes of interest measured at 12 months after injury: 1) weapon carrying, 2) alcohol or drug use, 3) high-level PTSD symptoms, and 4) high-level depressive symptoms. All patients received evaluations of each outcome measure, in addition to functional impairments and health service use, at baseline in the emergency department or surgical ward before randomization, and again 12 months after discharge during telephone follow-up interviews.
Ten items from the National Longitudinal Study of Adolescent Health were used to assess a full spectrum of adolescent violence and injury risk behaviors. The Composite International Diagnostic Index was used to assess adolescent alcohol abuse and dependence criteria. The Alcohol Use Disorders Identification Test, a 3-item self-report screening measure used for early identification of problem alcohol use in the acute care setting, was used to augment the Composite International Diagnostic Index. Posttraumatic stress symptoms were assessed through the adolescent version of the University of California, Los Angeles, PTSD Reaction Index (PTSD-RI) for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The 9-item Patient Health Questionnaire (PHQ-9) depression screen was used to assess depressive symptoms. Previously developed items assessing postinjury health service use were administered at baseline and at the 12-month follow-up interview. Insurance status, length of hospital and intensive care unit stays, and other clinical characteristics were abstracted from the trauma registry and electronic medical records.
Poisson regression analyses with robust error variances were used to test the impact of the intervention on weapon carrying, substance use problems, and PTSD and depressive dichotomous outcomes a year after the injury occurred. The study authors did not conduct subgroup analyses.
Preparatory training for the care management, motivational interviewing, cognitive–behavioral therapy, and medication components consisted of didactics focusing on the treatment manual contents, role-plays with standardized patients, and individual preceptorship sessions with expert supervisors in motivational interviewing, cognitive–behavioral therapy, and pharmacotherapy (Zatzick et al. 2013).
These sources were used in the development of the program profile:
Study 1
Zatzick, Douglas, Joan Russo, Sarah Peregrine Lord, Christopher Varley, Jin Wang, Lucy Berliner, Gregory Jurkovich, et al. 2014. "Collaborative Care Intervention Targeting Violence Risk Behaviors, Substance Use, and Posttraumatic Stress and Depressive Symptoms in Injured Adolescents: A Randomized Clinical Trial." JAMA Pediatrics 168(6):532–39.
These sources were used in the development of the program profile:
Gilbody, Simon, Peter Bower, Janine Fletcher, David Richards, and Alex J. Sutton. 2006. “Collaborative Care for Depression: A Cumulative Meta-Analysis and Review of Longer-Term Outcomes.” Archives of Internal Medicine 166(21):2314–21.
National Center for Injury Prevention. 2006. CDC Injury Factbook. Atlanta, Ga.: Centers for Disease Control and Prevention.
Roy-Byrne, Peter, Michelle G. Craske, Greer Sullivan, Raphael D. Rose, Mark J. Edlund, Ariel J. Lang, Alexander Bystritsky, et al. 2010. “Delivery of Evidence-Based Treatment for Multiple Anxiety Disorders in Primary Care: A Randomized Controlled Trial.” JAMA 303(19):1921–28.
Zatzick, Douglas F., Gregory J. Jurkovich, Ming-Yu Fan, David Grossman, Joan Russo, Wayne Katon, and Frederick P. Rivara. 2008. “Association Between Posttraumatic Stress and Depressive Symptoms and Functional Outcomes in Adolescents Followed Up Longitudinally After Injury Hospitalization.” Archives of Pediatrics & Adolescent Medicine 162(7):642–48.
https://jamanetwork.com/journals/jamapediatrics/article-abstract/379770Zatzick, Douglas, Gregory Jurkovich, Frederick P. Rivara, Joan Russo, Amy Wagner, Jin Wang, Chris Dunn, et al. 2013. “A Randomized Stepped Care Intervention Trial Targeting Posttraumatic Stress Disorder for Surgically Hospitalized Injury Survivors.” Annals of Surgery 257(3):390–99.
Zatzick, Douglas, Joan Russo, David C. Grossman, Gregory Jurkovich, Janice Sabin, Lucy Berliner, and Frederick Rivara. 2006. “Posttraumatic Stress and Depressive Symptoms, Alcohol Use, and Recurrent Traumatic Life Events in a Representative Sample of Hospitalized Injured Adolescents and Their Parents.” Journal of Pediatric Psychology 31(4):377–87.
https://academic.oup.com/jpepsy/article/31/4/377/925286Following are CrimeSolutions-rated programs that are related to this practice:
A client-centered, semidirective psychological treatment approach that concentrates on improving and strengthening individuals’ motivations to change. The practice is rated Effective. Individuals in the treatment groups significantly reduced their use of substances compared to those in the no-treatment control groups.
Evidence Ratings for Outcomes
Drugs & Substance Abuse - Multiple substances |
The practice is aimed at reducing substance use (alcohol and other hard drugs) by providing motivations and/or skills to promote behavior change in a relatively brief time, typically between one to five sessions. The target population are juveniles and young adults ages 11 to 30. This practice is rated Effective for reducing illicit substance use, marijuana use, and alcohol use. The practice is rated Promising for reducing the use of other hard substances.
Evidence Ratings for Outcomes
Drugs & Substance Abuse - Multiple substances | |
Drugs & Substance Abuse - Marijuana | |
Drugs & Substance Abuse - Alcohol | |
Drugs & Substance Abuse - Other hard substances |
Age: 12 - 18
Gender: Male, Female
Race/Ethnicity: White, Other
Setting (Delivery): Inpatient/Outpatient
Program Type: Alcohol and Drug Prevention, Children Exposed to Violence, Cognitive Behavioral Treatment, Motivational Interviewing, Violence Prevention, Wraparound/Case Management
Targeted Population: Children Exposed to Violence
Current Program Status: Not Active