Jessica Roche

Efficacy of a Universal Brief Intervention for Violence Among Urban Emergency Department Youth

BACKGROUND Violent injury is the leading cause of death among urban youth. Emergency department (ED) visits represent an opportunity to deliver a brief intervention (BI) to reduce violence among youth seeking medical care in high-risk communities. OBJECTIVE The objective was to determine the efficacy of a universally applied BI addressing violence behaviors among youth presenting to an urban ED. METHODS ED youth (14 to 20 years old) seeking medical or injury-related care in a Level I ED (October 2011-March 2015) and screening positive for a home address within the intervention or comparison neighborhood of a larger youth violence project were enrolled in this quasi-experimental study. Based on home address, participants were assigned to receive either the 30-minute therapist-delivered BI (Project Sync) or a resource brochure (enhanced usual care [EUC] condition). The Project Sync BI combined motivational interviewing and cognitive skills training, including a review of participant goals, tailored feedback, decisional balance exercises, role-playing exercises, and linkage to community resources. Participants completed validated survey measures at baseline and a 2-month follow-up assessment. Main outcome measures included self-report of physical victimization, aggression, and self-efficacy to avoid fighting. Poisson and zero-inflated Poisson regression analyses analyzed the effects of the BI, compared to the EUC condition, on primary outcomes. RESULTS A total of 409 eligible youth (82% participation) were enrolled and assigned to receive either the BI (n = 263) or the EUC condition (n = 146). Two-month follow-up was 91% (n = 373). There were no significant baseline differences between study conditions. Among the entire sample, mean (±SD) age was 17.7 (±1.9) years, 60% were female, 93% were African American, and 79% reported receipt of public assistance. Of participants, 9% presented for a violent injury, 9% reported recent firearm carriage, 20% reported recent alcohol use, and 39% reported recent marijuana use. Compared with the EUC group, participants in the therapist BI group showed self-reported reductions in frequency of violent aggression (therapist, -46.8%; EUC, -36.9%; incident rate ratio [IRR] = 0.87; 95% confidence interval [CI] = 0.76 to 0.99) and increased self-efficacy for avoiding fighting (therapist, +7.2%; EUC, -1.3%; IRR = 1.09; 95% CI = 1.02 to 1.15). No significant changes were noted for victimization. CONCLUSIONS Among youth seeking ED care in a high-risk community, a brief, universally applied BI shows promise in increased self-efficacy for avoiding fighting and a decrease in the frequency of violent aggression.

Underage drinking, brief interventions, and trauma patients: are they really special?

BACKGROUND While the relationship between underage drinking and injury has been well established, few studies have examined whether presenting for an acute injury moderates the efficacy of a brief intervention (BI) on alcohol misuse. METHODS Patients (aged 14–20 years) in the emergency department screening positive for risky drinking (Alcohol Use Disorders Identification Test–Consumption score) completed a baseline assessment, were randomized to conditions (a standalone computer-delivered BI [n = 277], a therapist-delivered BI [n = 278], or a control condition [n = 281]), and completed a 3-month follow-up. This secondary analysis of Project U-Connect examined regression models (controlling for baseline values) to examine the main effects of injury and the interaction effects of injury by BI condition on alcohol consumption and consequences. RESULTS Among 836 youth enrolled in the randomized controlled trial (mean age, 18.6 years; 51.6% were male; 79.4% were white), 303 (36.2%) had a primary complaint of intentional or unintentional injury. At baseline, injured patients were more likely to be male (p < 0.001) and have higher alcohol consumption (p < 0.01), but were less likely to misuse prescription drugs (p = 0.02) than those presenting for medical reasons. Regression models (controlling for baseline values) demonstrated that injury presentation predicted greater alcohol consumption prior to a BI. The computer BI was more effective at reducing alcohol consequences among those presenting with injury than those presenting for other reasons. Injury did not affect the efficacy of the computer BI on alcohol consumption, and injury did not affect the efficacy of the therapist BI on alcohol outcomes. CONCLUSIONS A therapist or computer BI reduced alcohol consumption and consequences among risky drinkers regardless of reason for emergency department presentation highlighting the opportunity to reach a broad array of youth. Although the therapist BI was not moderated by injury presentation, the computer BI was particularly effective at reducing alcohol consequences among those presenting with injury at 3-month follow-up. LEVEL OF EVIDENCE Therapeutic/care management study, level III.

Sex Differences in the Association Between Gaming and Serious Violence Among Predominantly African American Youth

Video gaming, a remarkably popular hobby in the United States, has been consistently identified as a correlate of aggressive behavior, and this association is not limited to violent video gaming. Prior studies of sex differences in the association between video gaming and aggression have not controlled for other well-known violence correlates (e.g., substance use, community violence exposure, violence attitudes) or focused primarily on high-risk youth. In this study, we used data from an emergency department in Flint, Michigan ( N = 409, 59.9% female, 93.4% African American) to identify sex differences in the association between video gaming and serious peer violence. Youth aged 14 to 20 years were recruited from October 2011 to March 2015, and self-administered computerized surveys including measures of demographics, violence perpetration, gaming frequency, substance use, community violence exposure, and violence attitudes. The primary outcome was an indicator of any serious violence perpetration (e.g., choking, burning, weapon violence) in the past 2 months. Using logistic regression, we estimated the association between gaming and serious violence perpetration, and how it varied by sex, while controlling for demographics, substance use, community violence exposure, and violence attitudes. Approximately 36.6% of males and 27.3% of females reported past 2-month serious violence. On adjusted analysis, hours spent gaming was associated with violence among females (odds ratio [OR] = 1.40, 95% confidence interval [CI] = [1.16, 1.78]), but not males (OR = 1.03, 95% CI = [0.89, 1.19]); in the model including both males and females, the interaction between hours gaming and sex was significant ( p < .01). Our findings suggest video gaming is a stronger marker of severe violence perpetration in females than males among at-risk youth. Violence interventions among females may be improved by including content related to video gaming and identifying other prosocial activities for youth as an alternative to video gaming. Additional research is required to clarify the causal process underlying the identified associations, and to determine what aspects of video gaming are risk-enhancing.

Arrests Among High-Risk Youth Following Emergency Department Treatment for an Assault Injury

INTRODUCTION Violence is a leading cause of morbidity and mortality for youth, with more than 600,000 emergency department visits annually for assault-related injuries. Risk for criminal justice involvement among this population is poorly understood. The objective of this study was to characterize arrests among high-risk, assault-injured, drug-using youth following emergency department treatment. METHODS Youth (aged 18-24 years) with past 6-month drug use who were seeking emergency department treatment for either an assault or for non-violence reasons were enrolled (December 2009-September 2011) in a 2-year longitudinal study. Arrests in the 24 months following the emergency department visit were analyzed in 2016-2017 using survival analysis of objective Law Enforcement Information Network data. Hazard ratios quantifying the association between risk factors for arrest were estimated using Cox regression. RESULTS In the longitudinal cohort, 511 youth seeking emergency department care (assault injury group n=299, comparison group n=212) were aged ≥18 years and were included for analysis. Youth in the assault injury group cohort had a 47% higher risk of arrest than the comparison group (38.1% vs 25.9%, RR=1.47, p<0.05). In unadjusted analyses, male sex, assault injury, binge drinking, drug use disorder, and community violence exposure were all associated with increased risk of arrest during the follow-up period. Cox regression identified that male sex (hazard ratio=2.57), drug use disorder diagnosis (hazard ratio=1.42), assault injury at baseline (hazard ratio=1.63), and community violence exposure (hazard ratio=1.35) increased risk for arrest. CONCLUSIONS Drug-using assault-injured youth have high rates of arrest. Emergency department and community interventions addressing substance use and violence involvement may aid in decreasing negative violence and criminal justice outcomes among high-risk youth. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT01152970.

105 Rates of violence and substance use among a high-risk sample during the flint water crisis (fwc): results from the flint youth injury study

Statement-of-purpose On April 25, 2014, Flint’s water source was changed without adding essential anti-corrosive agents, leading to lead contamination of the potable water supply. Individual-level consequences resulting from this community-wide traumatic event have yet to be examined. We examined rates of violence and substance use following the initial date of the Flint Water Crisis (FWC) exposure among youth already enrolled in an on-going longitudinal study. Methods Drug-using youth (age: 14–24) seeking assault-injury treatment and a comparison cohort of youth seeking ED care for other reasons were enrolled in a longitudinal study (Baseline: 09/2009–12/2011; Follow-ups: 6, 12, 18, 24 months). Eligible youth were re-contacted and enrolled in a 2nd wave study (Baseline: 03/2014–01/2016) with two additional biannual follow-ups. For this analysis, we conducted pre/post analyses of paired data for participants completing follow-ups within the 24 months preceding/following the initial date of exposure and examined differences in rates of substance use and violence. Results 352-youth enrolled in both studies; 313 (88.9%) had follow-up data within 24 months pre- and post-initial exposure date. In the analytic sample, baseline age was 20.1 (SD:2.4), 49.8% were male, 75.4% required public assistance, and 59.4% were assault-injured. Despite overall decreasing trends in violence and substance use among this cohort at-large, we found that the prevalence of violence (37.7%-vs.-49.5%,p<0.001) increased in the post-period, including rates of victimisation (31.9%-vs.-45.4%,p<0.001) and aggression (30.0%-vs-39.9%,p<0.001), and rates of non-partner (24.6%-vs.-32.3%,p<0.05) and partner (28.1%-vs.-40.9%,p<0.001) violence. Pre-post differences in alcohol (AUDIT-C:M=1.3,SD=2.9,p<0.001) and marijuana (ASSIST: M=1.2,SD=8.8,p<0.05) were also both positive. Conclusion/Significance While causal attributions are limited, we observed increases in violence and substance use among this high-risk sample after the initial FWC exposure, suggesting that negative health effects associated with this on-going crisis extend beyond the environmental exposure to lead and highlights the need for additional resources and research focused on addressing the consequences of this wide-scale community trauma.

77 Development and pilot testing of a remote therapy intervention for aggression and alcohol use among adolescents in the emergency department

Statement of Purpose The purpose of this study was to develop and pilot test a remote therapy intervention (RTI) for youth with aggression and alcohol use. Methods/Approach First, we conducted secondary data analysis of the SafERteens study. Participants (ages 14–18) receiving a therapist brief intervention (n=215) were classified as responders (26%) or non-responders (74%) based on aggression and/or binge drinking at 3 month follow-up. Bivariate analyses showed that as compared to responders, at baseline non-responders reported greater alcohol use, and peer/dating victimisation and aggression. Logistic regression analysis showed that significant predictors of responder status were depression and delinquency. Second, we pilot tested an 8-session RTI addressing aggression and alcohol use. Youth (ages 14–20) in an urban emergency department screening positive for past 2 month alcohol use and aggression were enrolled in an open pilot study with a 4 month follow-up. The sessions combined elements of motivational interviewing and cognitive behavioural therapy to address alcohol use and aggression (e.g., conflict resolution), as well as markers of response (e.g., depression, delinquency). The intervention was delivered in-person by a therapist during the ED visit and remotely by phone in the 12 weeks following the ED visit. Results In total, 16 youth participated [M age=18.8; 31% male; 50% African-American]. Over 50% of participants completed 5 or more sessions, with >90% rating the sessions as very/extremely helpful. Paired analyses (baseline, follow-up) showed significant decreases in aggression, victimisation, alcohol consequences, and violence consequences; although not significant, use of alcohol decreased from 100% to 40%. Conclusion Based on feedback from participants, future recommendations include tailoring the number of sessions based on need and delivery of sessions by video or in-person. Significance and Contributions to Injury and Violence Prevention Science Findings will inform the development of adaptive interventions for aggression and alcohol use, with dose increased or decreased based on response.