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1.  A Survey of Screening & Intervention for Comorbid Alcohol, Drugs, Suicidality, Depression & PTSD at Trauma Centers 
Comorbid mental health and substance use problems are endemic among injured trauma survivors. The American College of Surgeons has mandated alcohol screening and brief intervention at trauma centers and is anticipated to produce best practice policy guidelines recommendations for drug screening and posttraumatic stress disorder (PTSD). Few investigations, however, have examined screening and intervention procedures for the full spectrum of comorbid mental health and substance use conditions at United States (US) trauma centers.
Trauma programs at all US Level I and Level II trauma centers were contacted and asked to complete a survey describing screening and intervention procedures for alcohol and drug use problems, suicidality, depression, and PTSD.
Three hundred and ninety-one of 518 (75%) of US Level I and II trauma centers responded to the survey. Over 80% of Level I and II trauma centers reported routinely screening for alcohol and drugs. As anticipated by current American College of Surgeons policy, Level I centers were significantly more likely to provide alcohol intervention when compared to Level II centers. The frequencies of routine trauma center screening and intervention for suicidality, depression, and PTSD was markedly lower; only 7% of centers reported routinely screening for PTSD.
Alcohol screening and intervention occurs frequently at US trauma centers and appears to be responsive to American College of Surgeons policy mandates. Future orchestrated clinical investigation and policy could productively address screening and intervention procedures for comorbid PTSD, depression, and suicidality.
PMCID: PMC4256134  PMID: 24733143
2.  Disseminating Alcohol Screening and Brief Intervention at Trauma Centers: A Policy Relevant Cluster Randomized Effectiveness Trial 
Addiction (Abingdon, England)  2014;109(5):754-765.
Background and aims
In 2005 the American College of Surgeons passed a mandate requiring that Level I trauma centers have mechanisms to identify and intervene with problem drinkers. The aim of this investigation was to determine if a multilevel trauma center intervention targeting both providers and patients would lead to higher quality alcohol screening and brief intervention (SBI) when compared with trauma center mandate compliance without implementation enhancements.
Cluster randomized trial in which intervention site (site n =10, patient n =409) providers received 1-day workshop training on evidence-based motivational interviewing (MI) alcohol interventions and four 30-minute feedback and coaching sessions; control sites (site n =10, patient n =469) implemented the mandate without study team training enhancements.
Trauma centers in the United States of America.
878 blood alcohol positive inpatients with and without traumatic brain injury (TBI).
MI skills of providers were assessed with fidelity coded standardized patient interviews. All patients were interviewed at baseline, and 6- and 12-months post-injury with the Alcohol Use Disorders Identification Test (AUDIT).
Intervention site providers consistently demonstrated enhanced MI skills compared with control providers. Intervention patients demonstrated an 8% reduction in AUDIT hazardous drinking relative to controls over the course of the year after injury (RR =0.88, 95%, CI =0.79, 0.98). Intervention patients were more likely to demonstrate improvements in alcohol use problems in the absence of TBI (p =0.002).
Trauma center providers can be trained to deliver higher quality alcohol screening and brief intervention than untrained providers, which is associated with modest reductions in alcohol use problems, particularly among patients without traumatic brain injury.
PMCID: PMC4014067  PMID: 24450612
Alcohol; Screening and Brief Intervention; Traumatic Injury; American College of Surgeons; Policy Mandate; Motivational Interviewing; Dissemination and Implementation Research
3.  Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) for Alcohol at Trauma Centers Study Design 
General hospital psychiatry  2012;35(2):174-180.
In 2005 the American College of Surgeons passed a mandate requiring that Level I trauma centers have a mechanism to identify patients who are problem drinkers and have the capacity to provide an intervention for patients who screen positive. The aim of the Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) cluster randomized trial is to test a multilevel intervention targeting the implementation of high quality alcohol screening and brief intervention (SBI) services at trauma centers.
Twenty sites selected from all US Level I trauma centers were randomized to participate in the trial. Intervention site providers receive a combination of workshop training in evidence-based motivational interviewing (MI) interventions and organizational development activities prior to conducting trauma center-based alcohol SBI with blood alcohol positive injured patients. Control sites implement care as usual. Provider MI skills, patient alcohol consumption, and organizational acceptance of SBI implementation outcomes are assessed.
The investigation has successfully recruited provider, patient, and trauma center staff samples into the study and outcomes are being followed longitudinally.
When completed, the DO-SBIS trial will inform future American College of Surgeons’ policy targeting the sustained integration of high quality alcohol SBI at trauma centers nationwide.
PMCID: PMC3594343  PMID: 23273831
Acute care medical trauma centers; Injury; Alcohol; Screening and brief intervention; American College of Surgeons
4.  Substance Use and PTSD Symptoms in Trauma Center Patients Receiving Mandated Alcohol SBI 
In an effort to integrate substance abuse treatment at trauma centers, the American College of Surgeons has mandated alcohol screening and brief intervention (SBI). Few investigations have assessed trauma center inpatients for comorbidities that may impact the effectiveness of SBI that exclusively focuses on alcohol. Randomly selected SBI eligible acute care medical inpatients (N=878) were evaluated for alcohol, illegal drugs, and symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) using electronic medical record, toxicology, and self-report assessments; 79% of all patients had one or more alcohol, illegal drug, or PTSD symptom comorbidity. Over 70% of patients receiving alcohol SBI (n=166) demonstrated one or more illegal drug or PTSD symptom comorbidity. A majority of trauma center inpatients have comorbidities that may impact the effectiveness of mandated alcohol SBI. Investigations that realistically capture, account for, and intervene upon these common comorbid presentations are required to inform the iterative development of College policy targeting integrated substance abuse treatment at trauma centers.
PMCID: PMC3528356  PMID: 22999379
5.  Nationwide Survey of Alcohol Screening and Brief Intervention Practices at US Level I Trauma Centers 
In 2007, the American College of Surgeons (ACS) Committee on Trauma implemented a requirement that Level I trauma centers must have a mechanism to identify patients who are problem drinkers and the capacity to provide an intervention for patients who screen positive. Although the landmark alcohol screening and brief intervention (SBI) mandate is anticipated to impact trauma practice nationwide, a literature review revealed no studies that have systematically documented SBI practice pre-ACS requirement.
Trauma programs at all US Level I trauma centers were contacted and asked to complete a survey about pre-ACS requirement trauma center SBI practice.
One hundred forty-eight of 204 (73%) Level I trauma centers responded to the survey. More than 70% of responding centers routinely used laboratory tests (eg, blood alcohol concentration) to screen patients for alcohol and 39% routinely used a screening question or standardized screening instrument. Screen-positive patients received a formal alcohol consult or had an informal alcohol discussion with staff members approximately 25% of the time.
The investigation observed marked variability across Level I centers in the percentage of patients screened and in the nature and extent of intervention delivery in screen-positive patients. In the wake of the ACS Committee on Trauma requirement, future research could systematically implement and evaluate training in the delivery of evidence-based alcohol interventions and training in development of trauma center organizational capacity for sustained delivery of SBI.
PMCID: PMC3104599  PMID: 18954773
6.  Brief Alcohol Interventions With Mandated or Adjudicated College Students 
This article summarizes the proceedings of a symposium presented at the 2003 RSA Meeting in Ft. Lauderdale, Florida, organized and chaired by Nancy Barnett. The purpose of the symposium was to present information and efficacy data about approaches to brief intervention with students who get into trouble on their campuses for alcohol and as a result are required to attend alcohol education or counseling. Presentations were (1) Differences Between Mandated College Students and Their Peers on Alcohol Use and Readiness to Change, by Tracy O’Leary Tevyaw; (2) An Effective Alcohol Prevention Program for Mandated College Students, by Kim Fromme; (3) Two Brief Alcohol Interventions for a Referred College Population, by Kate Carey; and (4) Brief Motivational Intervention With College Students Following Medical Treatment or Discipline for Alcohol, by Nancy Barnett. The data presented in this symposium indicated that students who are evaluated or disciplined for alcohol use are on average heavy drinkers who drink more heavily than their closest peers. Brief intervention approaches described by the speakers included group classroom sessions, individual motivational intervention, individual alcohol education, and computerized alcohol education. Reductions in consumption and problems were noted across the various intervention groups. Brief motivational intervention as a general approach with mandated students shows promise in that it reduced alcohol problems in a group of mandated students who were screened for being at risk (in the Borsari and Carey study) and increased the likelihood that students would attend further counseling (in the Barnett study).
PMCID: PMC2726616  PMID: 15218881
College; Brief Intervention
7.  Phone-Delivered Brief Motivational Interventions for Mandated College Students Delivered During the Summer Months 
Across the United States, tens of thousands of college students are mandated to receive an alcohol intervention following an alcohol policy violation. Telephone interventions may be an efficient method to provide mandated students with an intervention, especially when they are away from campus during summer vacation. However, little is known about the utility of telephone-delivered brief motivational interventions.
Participants in the study (N = 57) were college students mandated to attend an alcohol program following a campus-based alcohol citation. Participants were randomized to a brief motivational phone intervention (pBMI) (n = 36) or assessment only (n = 21). Ten participants (27.8%) randomized to the pBMI did not complete the intervention. Follow-up assessments were conducted 3, 6, and 9 months post-intervention.
Results indicated the pBMI significantly reduced the number of alcohol-related problems compared to the assessment-only group. Participants who did not complete the pBMI appeared to be lighter drinkers at baseline and randomization, suggesting the presence of alternate influences on alcohol-related problems.
Phone BMIs may be an efficient and cost-effective method to reduce harms associated with alcohol use by heavy-drinking mandated students during the summer months.
PMCID: PMC3972287  PMID: 24512944
8.  Alcohol Use and Problems in Mandated College Students: A Randomized Clinical Trial Using Stepped Care 
Over the past two decades, colleges and universities have seen a large increase in the number of students referred to the administration for alcohol policies violations. However, a substantial portion of mandated students may not require extensive treatment. Stepped care may maximize treatment efficiency and greatly reduce the demands on campus alcohol programs.
Participants in the study (N = 598) were college students mandated to attend an alcohol program following a campus-based alcohol citation. All participants received Step 1: a 15-minute Brief Advice session that included the provision of a booklet containing advice to reduce drinking. Participants were assessed six weeks after receiving the Brief Advice, and those who continued to exhibit risky alcohol use (n = 405) were randomized to Step 2, a 60–90 minute brief motivational intervention (BMI) (n = 211) or an assessment-only control (n = 194). Follow-up assessments were conducted 3, 6, and 9 months after Step 2.
Results indicated that the participants who received a BMI significantly reduced the number of alcohol-related problems compared to those who received assessment-only, despite no significant group differences in alcohol use. In addition, low risk drinkers (n = 102; who reported low alcohol use and related harms at 6-week follow-up and were not randomized to stepped care) showed a stable alcohol use pattern throughout the follow-up period, indicating they required no additional intervention.
Stepped care is an efficient and cost-effective method to reduce harms associated with alcohol use by mandated students.
PMCID: PMC3514601  PMID: 22924334
9.  The Basics of Alcohol Screening, Brief Intervention and Referral to Treatment in the Emergency Department 
Nearly eight million emergency department (ED) visits are attributed to alcohol every year in the United States. A substantial proportion is due to trauma. In 2005, 16,885 people were killed as a result of alcohol-related motor vehicle crashes. Patients with alcohol-use problems (AUPs) are not only more likely to drive after drinking but are also at greater risk for serious alcohol-related illness and injury. Emergency departments have an important and unique opportunity to identify these patients and intervene during the “teachable moment” of an ED visit. The American College of Emergency Physicians, Emergency Nurses Association, American College of Surgeons-Committee on Trauma, American Public Health Association, and the National Highway Traffic Safety Administration, have identified Alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) as a pivotal injury- and illness-prevention strategy to improve the health and well-being of ED patients. We provide a general overview of the basis and need for integrating SBIRT into EDs. Models of SBIRT, as well as benefits and challenges to its implementation, are also discussed.
PMCID: PMC2672213  PMID: 19561690
10.  The Comparative Effectiveness of Individual and Group Brief Motivational Interventions for Mandated College Students 
Individual brief motivational intervention (iBMI) is an efficacious strategy to reduce heavy drinking by students who are mandated to receive an alcohol intervention following an alcohol-related event. However, despite the strong empirical support for iBMI, it is unknown if the results from rigorously controlled research on iBMI translate to real-world settings. Furthermore, many colleges lack the resources to provide iBMI to mandated students. Therefore, group-delivered BMI (gBMI) might be a cost-effective alternative that can be delivered to a large number of individuals. The purpose of this study was to conduct a comparative effectiveness evaluation of iBMI and gBMI as delivered by staff at a university health services center. Participants (N = 278) were college students who were mandated to receive an alcohol intervention following an alcohol-related incident. Participants were randomized to receive an individual (iBMI; n = 133) or a Group BMI (gBMI; n = 145). Results indicated that both iBMI and gBMI participants reduced their peak estimated blood alcohol concentration (BAC) and the number of negative alcohol-related consequences at 1-, 3-, and 6-months postintervention. The iBMI and gBMI conditions were not significantly different at follow-up. These findings provide preliminary support for the use of iBMI and gBMIs for college students in real-world settings.
PMCID: PMC4062841  PMID: 24731111
brief intervention; personalized feedback; college drinking; mandated students; comparative effectiveness
11.  Defining and Characterizing Differences in College Alcohol Intervention Efficacy: A Growth Mixture Modeling Application 
While college alcohol misuse remains a pervasive issue, individual-level interventions are among the most efficacious methodologies to reduce alcohol-related harms. Growth mixture modeling (GMM) was used as an exploratory moderation analysis to determine how many types of college drinkers exist with regards to intervention efficacy over a 12-month period.
Data from three randomized-controlled clinical trials were combined to yield a sample of 1,040 volunteer and mandated college students who were given one of three interventions: a brief motivational intervention, Alcohol Edu for Sanctions, or Alcohol 101 Plus. Participants were assessed at baseline, and 1, 6, and 12 months following intervention.
Through the examination of heavy drinking behaviors, piecewise GMMs that identified 6 subpopulations of drinkers. Most of the sample (76%) was lighter drinkers that demonstrated a strong intervention response, but returned to baseline behaviors over the subsequent 12 months. In contrast, 11% of the sample reported no significant change over the 12-month period. Four minority subpopulations were also identified. In sum, 82% of the sample responded to intervention, but 84% of the sample reported intervention decay over the subsequent 12 months. Women, upperclassmen, beginning drinking later in life, not engaging in drinking games, and lower norms predicted a greater likelihood of responding to intervention.
Individual-level interventions are successful at effecting change in most college students, but these effects tend to decay to baseline behaviors by 12 months. These results suggest intervention efforts need to find ways to engage freshmen men and those who play drinking games.
Public Health Significance
This study suggests that there are distinct subgroups of college students defined by how they respond to alcohol intervention, and that interventions need to target freshmen men and those who play drinking games. Although most students initially response to intervention effects, most also show intervention decay over the next 12 months, which suggests that we need to determine ways of improving the long-term effects of alcohol interventions.
PMCID: PMC4380636  PMID: 25730522
intervention efficacy; growth mixture modeling; college student alcohol intervention; brief motivational interventions; computer-delivered interventions
12.  Psychophysiological Reactivity to Emotional Picture Cues Two Years after College Students Were Mandated for Alcohol Interventions 
Addictive behaviors  2010;35(8):786-790.
This study examined alcohol use behaviors as well as physiological, personality, and motivational measures of arousal in students approximately 2 years after they were mandated to a brief intervention program for violating university policies about on-campus substance use. Students were categorized into serious (medical referrals, n=13) or minor (residence advisor referrals, n = 30) infraction groups based on the nature of the incident that led to their being mandated. Self-report measures of arousal, sensation seeking, reasons for drinking, and past 30-day alcohol use were completed. Physiological arousal during exposure to emotional picture cues was assessed by indices of heart rate variability. The minor infraction group reported significantly escalating alcohol use patterns over time and a pattern of less regulated psychophysiological reactivity to external stimuli compared to the serious infraction group. The serious infraction group was higher in sensation seeking and there was some evidence of greater disparity between their physiological and self-reported experiences of emotional arousal in response to picture cues than in the minor group. Thus, the two infraction groups represent different subsets of mandated students, both of whom may be at some risk for using alcohol maladaptively. The findings suggest that intervention strategies that address self-regulation may be beneficial for mandated college students.
PMCID: PMC2872043  PMID: 20409645
emotional reactivity; affective cue; self-reported arousal; heart rate variability; psychophysiology; college students
13.  Incident-Specific and Individual Level Moderators of Brief Intervention Effects with Mandated College Students 
Brief Motivational Interventions (BMI) and Computer-delivered interventions (CDI) have been successful in reducing drinking behaviors with mandated college students. However, research examining moderators of intervention effects have found mixed results. The current study sought to replicate and extend the research on moderators of intervention efficacy with mandated students. Baseline alcohol-related problems, readiness to change, gender, incident consequences, and participant responses to the event (personal attributions about the incident, aversiveness of the incident) were examined as moderators of intervention and booster condition efficacy on alcohol use and problems. Mandated students (N = 225) were randomized to complete either a BMI or CDI (Alcohol 101; Century Council, 1998), with or without a 1-month booster session, following a campus alcohol sanction. Outcomes were measured 3 months after baseline. Attributions moderated intervention condition such that participants low in personal attributions for their incident showed significantly less drinking following a CDI than a BMI. Men and individuals who reported low incident aversiveness showed higher drinks per occasion after receiving a booster, while individuals high in alcohol-related problems reported fewer heavy drinking days after completing a booster session. Findings suggest that identifying specific characteristics related to the precipitating event may inform intervention approaches in this high-risk population, however additional research is needed to offer concrete guidance to practitioners in the field.
PMCID: PMC3676278  PMID: 21766975
14.  Individual and Situational Factors that Influence the Efficacy of Personalized Feedback Substance Use Interventions for Mandated College Students 
Little is known about individual and situational factors that moderate the efficacy of Personalized Feedback Interventions (PFIs). Mandated college students (N = 348) were randomly assigned to either a PFI delivered in the context of a brief motivational interview (BMI; n = 180) or a written PFI only (WF) condition and followed up at 4 months and 15 months post-intervention. We empirically identified heterogeneous subgroups utilizing mixture modeling analysis based on heavy episodic drinking and alcohol-related problems. The four identified groups were dichotomized into an improved (53.4%) and a non-improved (46.6%) group. Logistic regression results indicated that the BMI was no more efficacious than the WF across all mandated students. However, mandated students who experienced a serious incident requiring medical or police attention and those with higher levels of alcohol-related problems at baseline benefited more from the BMI than from the WF. It may be an efficacious and cost-effective approach to provide a written PFI for low-risk mandated students and an enhanced PFI with a BMI for those who experience a serious incident or with higher baseline alcohol-related problems.
PMCID: PMC2818838  PMID: 19170456
alcohol; college students; brief intervention; personalized feedback intervention; evidence-based treatment
15.  Main Report 
Genetics in Medicine  2006;8(Suppl 1):12S-252S.
States vary widely in their use of newborn screening tests, with some mandating screening for as few as three conditions and others mandating as many as 43 conditions, including varying numbers of the 40+ conditions that can be detected by tandem mass spectrometry (MS/MS). There has been no national guidance on the best candidate conditions for newborn screening since the National Academy of Sciences report of 19751 and the United States Congress Office of Technology Assessment report of 1988,2 despite rapid developments since then in genetics, in screening technologies, and in some treatments.
In 2002, the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA) of the United States Department of Health and Human Services (DHHS) commissioned the American College of Medical Genetics (ACMG) to: Conduct an analysis of the scientific literature on the effectiveness of newborn screening.Gather expert opinion to delineate the best evidence for screening for specified conditions and develop recommendations focused on newborn screening, including but not limited to the development of a uniform condition panel.Consider other components of the newborn screening system that are critical to achieving the expected outcomes in those screened.
A group of experts in various areas of subspecialty medicine and primary care, health policy, law, public health, and consumers worked with a steering committee and several expert work groups, using a two-tiered approach to assess and rank conditions. A first step was developing a set of principles to guide the analysis. This was followed by developing criteria by which conditions could be evaluated, and then identifying the conditions to be evaluated. A large and broadly representative group of experts was asked to provide their opinions on the extent to which particular conditions met the selected criteria, relying on supporting evidence and references from the scientific literature. The criteria were distributed among three main categories for each condition: The availability and characteristics of the screening test;The availability and complexity of diagnostic services; andThe availability and efficacy of treatments related to the conditions. A survey process utilizing a data collection instrument was used to gather expert opinion on the conditions in the first tier of the assessment. The data collection format and survey provided the opportunity to quantify expert opinion and to obtain the views of a diverse set of interest groups (necessary due to the subjective nature of some of the criteria). Statistical analysis of data produced a score for each condition, which determined its ranking and initial placement in one of three categories (high scoring, moderately scoring, or low scoring/absence of a newborn screening test). In the second tier of these analyses, the evidence base related to each condition was assessed in depth (e.g., via systematic reviews of reference lists including MedLine, PubMed and others; books; Internet searches; professional guidelines; clinical evidence; and cost/economic evidence and modeling). The fact sheets reflecting these analyses were evaluated by at least two acknowledged experts for each condition. These experts assessed the data and the associated references related to each criterion and provided corrections where appropriate, assigned a value to the level of evidence and the quality of the studies that established the evidence base, and determined whether there were significant variances from the survey data. Survey results were subsequently realigned with the evidence obtained from the scientific literature during the second-tier analysis for all objective criteria, based on input from at least three acknowledged experts in each condition. The information from these two tiers of assessment was then considered with regard to the overriding principles and other technology or condition-specific recommendations. On the basis of this information, conditions were assigned to one of three categories as described above:Core Panel;Secondary Targets (conditions that are part of the differential diagnosis of a core panel condition.); andNot Appropriate for Newborn Screening (either no newborn screening test is available or there is poor performance with regard to multiple other evaluation criteria).
ACMG also considered features of optimal newborn screening programs beyond the tests themselves by assessing the degree to which programs met certain goals (e.g., availability of educational programs, proportions of newborns screened and followed up). Assessments were based on the input of experts serving in various capacities in newborn screening programs and on 2002 data provided by the programs of the National Newborn Screening and Genetics Resource Center (NNSGRC). In addition, a brief cost-effectiveness assessment of newborn screening was conducted.
Uniform panel
A total of 292 individuals determined to be generally representative of the regional distribution of the United States population and of areas of expertise or involvement in newborn screening provided a total of 3,949 evaluations of 84 conditions. For each condition, the responses of at least three experts in that condition were compared with those of all respondents for that condition and found to be consistent. A score of 1,200 on the data collection instrument provided a logical separation point between high scoring conditions (1,200–1,799 of a possible 2,100) and low scoring (<1,000) conditions. A group of conditions with intermediate scores (1,000–1,199) was identified, all of which were part of the differential diagnosis of a high scoring condition or apparent in the result of the multiplex assay. Some are identified by screening laboratories and others by diagnostic laboratories. This group was designated as a “secondary target” category for which the program must report the diagnostic result.
Using the validated evidence base and expert opinion, each condition that had previously been assigned to a category based on scores gathered through the data collection instrument was reconsidered. Again, the factors taken into consideration were: 1) available scientific evidence; 2) availability of a screening test; 3) presence of an efficacious treatment; 4) adequate understanding of the natural history of the condition; and 5) whether the condition was either part of the differential diagnosis of another condition or whether the screening test results related to a clinically significant condition.
The conditions were then assigned to one of three categories as previously described (core panel, secondary targets, or not appropriate for Newborn Screening).
Among the 29 conditions assigned to the core panel are three hemoglobinopathies associated with a Hb/S allele, six amino acidurias, five disorders of fatty oxidation, nine organic acidurias, and six unrelated conditions (congenital hypothyroidism (CH), biotinidase deficiency (BIOT), congenital adrenal hyperplasia (CAH), classical galactosemia (GALT), hearing loss (HEAR) and cystic fibrosis (CF)). Twenty-three of the 29 conditions in the core panel are identified with multiplex technologies such as tandem mass spectrometry (MS/MS) or high pressure liquid chromatography (HPLC). On the basis of the evidence, six of the 35 conditions initially placed in the core panel were moved into the secondary target category, which expanded to 25 conditions. Test results not associated with potential disease in the infant (e.g., carriers) were also placed in the secondary target category. When newborn screening laboratory results definitively establish carrier status, the result should be made available to the health care professional community and families. Twenty-seven conditions were determined to be inappropriate for newborn screening at this time.
Conditions with limited evidence reported in the scientific literature were more difficult to evaluate, quantify and place in one of the three categories. In addition, many conditions were found to occur in multiple forms distinguished by age-of-onset, severity, or other features. Further, unless a condition was already included in newborn screening programs, there was a potential for bias in the information related to some criteria. In such circumstances, the quality of the studies underlying the data such as expert opinion that considered case reports and reasoning from first principles determined the placement of the conditions into particular categories.
Newborn screening program optimization
– Assessment of the activities of newborn screening programs, based on program reports, was done for the six program components: education; screening; follow-up; diagnostic confirmation; management; and program evaluation. Considerable variation was found between programs with regard to whether particular aspects (e.g., prenatal education program availability, tracking of specimen collection and delivery) were included and the degree to which they are provided. Newborn screening program evaluation systems also were assessed in order to determine their adequacy and uniformity with the goal being to improve interprogram evaluation and comparison to ensure that the expected outcomes from having been identified in screening are realized.
The state of the published evidence in the fast-moving worlds of newborn screening and medical genetics has not kept up with the implementation of new technologies, thus requiring the considerable use of expert opinion to develop recommendations about a core panel of conditions for newborn screening. Twenty-nine conditions were identified as primary targets for screening from which all components of the newborn screening system should be maximized. An additional 25 conditions were listed that could be identified in the course of screening for core panel conditions. Programs are obligated to establish a diagnosis and communicate the result to the health care provider and family. It is recognized that screening may not have been maximized for the detection of these secondary conditions but that some proportion of such cases may be found among those screened for core panel conditions. With additional screening, greater training of primary care health care professionals and subspecialists will be needed, as will the development of an infrastructure for appropriate follow-up and management throughout the lives of children who have been identified as having one of these rare conditions. Recommended actions to overcome barriers to an optimal newborn screening system include: The establishment of a national role in the scientific evaluation of conditions and the technologies by which they are screened;Standardization of case definitions and reporting procedures;Enhanced oversight of hospital-based screening activities;Long-term data collection and surveillance; andConsideration of the financial needs of programs to allow them to deliver the appropriate services to the screened population.
PMCID: PMC3109899
16.  Effectiveness of a Web-Based Brief Alcohol Intervention and Added Value of Normative Feedback in Reducing Underage Drinking: A Randomized Controlled Trial 
Current insights indicate that Web-based delivery may enhance the implementation of brief alcohol interventions. Previous research showed that electronically delivered brief alcohol interventions decreased alcohol use in college students and adult problem drinkers. To date, no study has investigated the effectiveness of Web-based brief alcohol interventions in reducing alcohol use in younger populations.
The present study tested 2 main hypotheses, that is, whether an online multicomponent brief alcohol intervention was effective in reducing alcohol use among 15- to 20-year-old binge drinkers and whether inclusion of normative feedback would increase the effectiveness of this intervention. In additional analyses, we examined possible moderation effects of participant’s sex, which we had not a priori hypothesized.
A total of 575 online panel members (aged 15 to 20 years) who were screened as binge drinkers were randomly assigned to (1) a Web-based brief alcohol intervention without normative feedback, (2) a Web-based brief alcohol intervention with normative feedback, or (3) a control group (no intervention). Alcohol use and moderate drinking were assessed at baseline, 1 month, and 3 months after the intervention. Separate analyses were conducted for participants in the original sample (n = 575) and those who completed both posttests (n = 278). Missing values in the original sample were imputed by using the multiple imputation procedure of PASW Statistics 18.
Main effects of the intervention were found only in the multiple imputed dataset for the original sample suggesting that the intervention without normative feedback reduced weekly drinking in the total group both 1 and 3 months after the intervention (n =575, at the 1-month follow-up, beta = -.24, P = .05; at the 3-month follow-up, beta = -.25, P = .04). Furthermore, the intervention with normative feedback reduced weekly drinking only at 1 month after the intervention (n=575, beta = -.24, P = .008). There was also a marginally significant trend of the intervention without normative feedback on responsible drinking at the 3-month follow-up (n =575, beta = .40, P =.07) implying a small increase in moderate drinking at the 3-month follow-up. Additional analyses on both datasets testing our post hoc hypothesis about a possible differential intervention effect for males and females revealed that this was the case for the impact of the intervention without normative feedback on weekly drinking and moderate drinking at the 1-month follow-up (weekly drinking for n = 278, beta = -.80, P = .01, and for n = 575, beta = -.69, P = .009; moderate drinking for n = 278, odds ratio [OR] = 3.76, confidence interval [CI] 1.05 - 13.49, P = .04, and for n = 575, OR = 3.00, CI = 0.89 - 10.12, P = .08) and at the 3-month follow-up (weekly drinking for n = 278, beta = -.58, P = .05, and for n = 575, beta = -.75, P = .004; moderate drinking for n = 278, OR = 4.34, CI = 1.18 - 15.95, P = .04, and for n = 575, OR = 3.65, CI = 1.44 - 9.25, P = .006). Furthermore, both datasets showed an interaction effect between the intervention with normative feedback and participant’s sex on weekly alcohol use at the 1-month follow-up (for n = 278, beta = -.74, P =.02, and for n = 575, beta = -.64, P =.01) and for moderate drinking at the 3-month follow-up (for n = 278, OR = 3.10, CI = 0.81 - 11.85, P = .07, and for n = 575, OR = 3.00, CI = 1.23 - 7.27, P = .01). Post hoc probing indicated that males who received the intervention showed less weekly drinking and were more likely to drink moderately at 1 month and at 3 months following the intervention. For females, the interventions yielded no effects: the intervention without normative feedback even showed a small unfavorable effect at the 1-month follow-up.
The present study demonstrated that exposure to a Web-based brief alcohol intervention generated a decrease in weekly drinking among 15- to 20-year-old binge drinkers but did not encourage moderate drinking in the total sample. Additional analyses revealed that intervention effects were most prominent in males resulting in less weekly alcohol use and higher levels of moderate drinking among 15- to 20-year-old males over a period of 1 to 3 months.
Trial Registration
ISRCTN50512934; (Archived by WebCite at
PMCID: PMC3057308  PMID: 21169172
Web-based brief alcohol intervention; adolescents; normative feedback; moderate drinking; alcohol use
17.  Two Brief Alcohol Interventions for Mandated College Students 
Encouraging but limited research indicates that brief motivational interventions may be an effective way to reduce heavy episodic drinking in college students. At 2 campuses, students (83% male) mandated to a substance use prevention program were randomly assigned to 1 of 2 individually administered conditions: (a) a brief motivational interview (BMI; n = 34) or (b) an alcohol education session (AE; n = 30). Students in the BMI condition reported fewer alcohol-related problems than the AE students at 3- and 6-month assessments. Trends toward reductions in number of binge drinking episodes and typical blood alcohol levels were seen in both groups. Process measures confirmed the integrity of both interventions. The findings demonstrate that mandated BMIs can reduce alcohol problems in students referred for alcohol violations.
PMCID: PMC2663045  PMID: 16187809
mandated; student; alcohol; college; brief intervention
18.  Different associations of alcohol cue reactivity with negative alcohol expectancies in mandated and inpatient samples of young adults 
Addictive behaviors  2013;38(4):2040-2043.
Alcohol cue reactivity, operationalized as a classically conditioned response to an alcohol related stimulus, can be assessed by changes in physiological functions such as heart rate variability (HRV), which reflect real time regulation of emotional and cognitive processes. Although ample evidence links drinking histories to cue reactivity, it is unclear whether in-the-moment cue reactivity becomes coupled to a set of consolidated beliefs about the effects of alcohol (i.e., expectancies) and whether treatment helps dissociate the relation of positive versus negative expectancies to cue reactivity. This study examined the relationship between reactivity to alcohol picture cues and alcohol expectancies in two groups of emerging adults: an inpatient sample with alcohol use disorders (n=28) and a college student sample who previously were mandated to a brief intervention for violating university policies about alcohol use in residence halls (n=43). Sequential regression analysis was conducted using several HRV indices and self-report arousal ratings as cue reactivity measures. Results indicated that the relationship between cue reactivity and negative alcohol outcome expectancies differed for the two groups. Greater cue reactivity, assessed using HRV indices, was associated with more negative expectancies in the inpatient sample but with less negative expectancies in the mandated student sample, while an opposite trend was found for subjective arousal. The present findings highlight the importance of characterizing cue reactivity through multi-dimensional assessment modalities that include physiological markers such as HRV.
PMCID: PMC4454376  PMID: 23396175
Alcohol outcome expectancie; Heart rate variability; Cue reactivity; Alcohol use disorders
19.  Predictors of Motivation to Change in Mandated College Students Following a Referral Incident 
The purpose of present study was to understand factors that are related to a desire or motivation to change (MTC) alcohol use in a sample of college students mandated to receive an alcohol intervention. We examined characteristics of and reactions to the referral event, typical alcohol use involvement, and alcohol beliefs about the perceived importance of drinking in college (subsequently referred to as the “role of drinking”) assessed by the College Life Alcohol Salience Scale (CLASS; Osberg et al., 2010) as predictors of MTC following referral to an alcohol intervention. College students (N = 932) who presented for a mandatory alcohol intervention following a referral event (e.g., citation for underage drinking, medical attention for an alcohol-related incident, or driving under the influence) completed an assessment prior to receiving an alcohol intervention. Higher perceived aversiveness of the referral event and higher personal responsibility one felt for the occurrence of the event were positively related to higher MTC. Although alcohol beliefs about the role of drinking in college were not significantly related to either event aversiveness or responsibility, it was negatively related to MTC even after controlling for alcohol use involvement variables. Alcohol beliefs about the role of drinking in college represent an important construct that is related to increased alcohol use and alcohol-related problems and decreased MTC in a sample of college students. Interventions aimed at reducing alcohol beliefs about the role of drinking in college may be an effective strategy to reduce alcohol use and alcohol-related problems by college students.
PMCID: PMC4370338  PMID: 24750039
motivation to change; readiness to change; alcohol beliefs; mandated college students; alcohol use
20.  Magnitude and Prevention of College Drinking and Related Problems 
Alcohol Research & Health  2010;33(1-2):45-54.
In 2002, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) issued a report entitled A Call to Action: Changing the Culture of Drinking at U.S. Colleges. Data on the magnitude of college drinking problems in 1998 to 1999 were reported. From 1999 to 2005, the proportion of college students aged 18–24 who drank five or more drinks on a single occasion in the past month increased from 41.7 percent to 45.2 percent. The proportion who drove under the influence of alcohol increased from 26.1 percent to 29.2 percent. Higher percentages of 21- to 24-year-olds engaged in those behaviors than 18- to 20-year-olds, and between 1999 and 2005 the percentage increased among 21- to 24-year-olds but not among those aged 18–20. From 1998 to 2005, unintentional alcohol-related injury deaths increased 3 percent (from 1,442 to 1,825) per 100,000 college students aged 18–24. Alcohol misuse by college students often harms other people through traffic crashes and sexual/other assaults. Research regarding ways to reduce college drinking problems has shown that individual-oriented interventions, particularly screening and brief motivational counseling interventions, social norms interventions, environmental policy changes such as the minimum legal drinking age of 21 and drinking-and-driving laws, and comprehensive college–community programs, can reduce college drinking and related morbidity and mortality. There is a growing need for colleges and surrounding communities to implement interventions shown through research to reduce alcohol misuse among college-aged people.
PMCID: PMC3887494  PMID: 23579935
Underage drinking; college student; undergraduate student; problematic alcohol and other drug (AOD) use; AOD use (AODU) patterns; heavy episodic drinking; binge drinking; AOD-related (AODR) consequences; AODR injury; interventions; policy
21.  Brief Alcohol Interventions for Mandated College Students: Comparison of Face-to-Face Counseling and Computer-Delivered Interventions 
Addiction (Abingdon, England)  2010;106(3):528-537.
College students who violate alcohol policies are often mandated to participate in alcohol-related interventions. This study investigated (a) whether such interventions reduced drinking beyond the sanction alone, (b) whether a brief motivational intervention (BMI) was more efficacious than two computer-delivered interventions (CDIs), and (c) whether intervention response differed by gender.
Randomized controlled trial with four conditions (BMI, Alcohol 101 Plus™, Alcohol Edu for Sanctions, delayed control) and four assessments (baseline, 1, 6, and 12 months).
Private residential university in the USA.
Students (n = 677; 64% male) who had violated campus alcohol policies and were sanctioned to participate in a risk reduction program.
Consumption (drinks per heaviest and typical week, heavy drinking frequency, peak and typical blood alcohol concentration), alcohol problems, and recidivism.
Piecewise latent growth models characterized short-term (1-month) and longer-term (1–12 months) change. Female but not male students reduced drinking and problems in the control condition. Males reduced drinking and problems after all interventions relative to control, but did not maintain these gains. Females reduced drinking to a greater extent after a BMI than after either CDI, and maintained reductions relative to baseline across the follow-up year. No differences in recidivism were found.
Male and female students responded differently to sanctions for alcohol violations and to risk reduction interventions. BMIs optimized outcomes for both genders. Male students improved after all interventions, but female students improved less after CDIs than after BMI. Intervention effects decayed over time, especially for males.
PMCID: PMC3058775  PMID: 21059184
brief intervention; computer-delivered intervention; college drinking; alcohol abuse prevention; mandated students; gender
22.  Do Brief Personalized Feedback Interventions Work for Mandated Students or Is It Just Getting Caught That Works? 
Studies evaluating the efficacy of brief interventions with mandated college students have reported declines in drinking from baseline to short-term follow-up regardless of intervention condition. A key question is whether these observed changes are due to the intervention or to the incident and/or reprimand. This study evaluates a brief personal feedback intervention (PFI) for students (N = 230), who were referred to a student assistance program because of infractions of university rules regarding substance use, to determine whether observed changes in substance are attributable to the intervention. Half the students received immediate feedback (at baseline and after the 2-month follow-up) and half received delayed feedback (only after the 2 mo. follow-up). Students in both conditions generally reduced their drinking and alcohol-related problems from baseline to the 2 mo. follow-up and from the 2 mo. to the 7 mo. follow-up; however, there were no significant between-group differences at either follow-up. Therefore, it appears that the incident and/or reprimand are important instigators of mandated student change, and that written PFIs do not enhance these effects on a short-term basis, but may on a longer-term basis.
PMCID: PMC2804481  PMID: 18298236
College Students; Alcohol; Drugs; Brief Interventions; Mandated Students
23.  Extreme College Drinking and Alcohol-Related Injury Risk 
Despite the enormous burden of alcohol-related injuries, the direct connection between college drinking and physical injury has not been well understood. The goal of this study is to assess the connection between alcohol consumption levels and college alcohol-related injury risk.
12,900 college students seeking routine care in 5 college health clinics completed a general Health Screening Survey. 2,090 of these students exceeded at-risk alcohol use levels and participated in a face-to-face interview to determine eligibility for a brief alcohol intervention trial. The eligibility interview assessed past 28-day alcohol use and alcohol-related injuries in the past 6 months. Risk of alcohol-related injury was compared across daily drinking quantities and frequencies. Logistic regression analysis and the Bayesian Information Criterion were applied to compute the odds of alcohol-related injury based on daily drinking totals after adjusting for age, race, site, body weight and sensation seeking.
Male college students in the study were 19% more likely (95% CI: 1.12–1.26) to suffer an alcohol-related injury with each additional day of consuming 8 or more drinks. Injury risks among males increased marginally with each day of consuming 5–7 drinks (Odds ratio=1.03, 95% CI: 0.94–1.13). Female participants were 10% more likely (95% CI: 1.04–1.16) to suffer an alcohol-related injury with each additional day of drinking 5 or more drinks. Males (OR=1.69, 95% CI: 1.14–2.50) and females (OR=1.81, 95% CI: 1.27–2.57) with higher sensation seeking scores were more likely to suffer alcohol-related injuries.
College health clinics may want to focus limited alcohol injury prevention resources on students who frequently engage in extreme drinking, defined in this study as 8+M/5+F drinks per day, and score high on sensation seeking disposition.
PMCID: PMC2757258  PMID: 19485974
Alcohol; College drinking; Injury; Heavy drinking; Sensation-seeking
24.  How Does the Brief CEOA Match With Self-Generated Expectancies in Mandated Students? 
Addictive behaviors  2012;38(1):1414-1417.
Alcohol expectancies, defined as a person’s beliefs about the effects of drinking, can influence alcohol consumption and help predict problem drinking in college students. However, there are concerns that current expectancy measures do not adequately capture mandated student expectations about alcohol use. This study examined the correspondence of 412 self-generated expectancies from mandated students (n = 64) to items on the Brief Comprehensive Effects of Alcohol (B-CEOA; Ham, Stewart, Norton, & Hope, 2005). Self-generated expectancies were reviewed by raters who attempted to match each expectancy with a single B-CEOA item based on the qualitative essence of each statement. Most mandated student expectancies were not represented by the B-CEOA. All expectancies were then classified into 6 categories based on themes and categories from the alcohol expectancy literature. Mandated student expectancies emphasized the physiological aspects of drinking, whereas the B-CEOA assesses expectancies about intrapersonal factors. The findings suggest the B-CEOA may exclude alcohol expectancies that are important and relevant to this population. Self-generated alcohol expectancies from the target population should be considered when developing or administering expectancy questionnaires.
PMCID: PMC3493850  PMID: 23006244
alcohol; alcohol expectancies; college alcohol beliefs; college student drinking; mandated student
25.  Sustain Talk Predicts Poorer Outcomes among Mandated College Student Drinkers Receiving a Brief Motivational Intervention 
Within-session client language that represents a movement toward behavior change (change talk) has been linked to better treatment outcomes in the literature on motivational interviewing (MI). There has been somewhat less study of the impact of client language against change (sustain talk) on outcomes following an MI session. This study examined the role of both client change talk and sustain talk, as well as therapist language, occurring during a brief motivational intervention (BMI) session with college students who had violated college alcohol policy (N = 92). Audiotapes of these sessions were coded using a therapy process coding system. A series of hierarchical regressions were used to examine the relationships among therapist MI-consistent and MI-inconsistent language, client change talk and sustain talk, as well as global measures of relational variables, and drinking outcomes. Contrary to prior research, sustain talk, but not change talk, predicted poorer alcohol use outcomes following the BMI at 3- and 12-month follow-up assessments. Higher levels of client self-exploration during the session also predicted improved drinking outcomes. Therapist measures of MI-consistent and MI-inconsistent language, and global measures of therapist acceptance and MI spirit were unrelated to client drinking outcomes. Results suggest that client sustain talk and self-exploration during the session play an important role in determining drinking outcomes among mandated college students receiving a BMI addressing alcohol use.
PMCID: PMC4212208  PMID: 25222170
Motivational Interviewing; therapy process; alcohol use; brief intervention; change language; mandated students

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