Program Profile: Stepped Collaborative Care for Adolescents (Washington State)

Study Title: Collaborative Care Intervention Targeting Violence Risk Behaviors, Substance Use, and Posttraumatic Stress and Depressive Symptoms in Injured Adolescents: A Randomized Clinical Trial (which is associated with Outcome 1)

Research Design

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 (e.g., carrying a weapon), 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 be admitted to the University of Washington’s Harborview Medical Center, a level 1 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, traumatic brain injuries, or both were eligible for the study. However, adolescents with severe injuries that would prevent participation or those with self-inflicted intentional injuries were excluded. Additional exclusions included adolescents who were non-English speaking or 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 not meeting 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.

Sample

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 1 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 (the authors did not specify which races/ethnicities were included in the “nonwhite” category), 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 six 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).

Data Collection/Outcome Measures

The outcomes scored for the CrimeSolutions review of this study included weapon carrying, a self-report measure. An item from the National Longitudinal Study of Adolescent Health was used to assess weapon carrying. Specifically, adolescents were asked “During the past year before your injury, did you ever carry a weapon on you (e.g., knife, club, or gun)?” All patients received evaluations of the outcome measure, 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. Insurance status, length of hospital and intensive care unit stays, and other clinical characteristics were abstracted from the trauma registry and electronic medical records.

Statistical Analysis 

A poisson regression analysis with robust error variance was used to test the impact of the intervention on carrying a weapon a year after the injury occurred. The study authors did not conduct subgroup analyses.

Citation: 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.