(103) Adolescent and Caregiver Perspective on Substance Use Screening in the Emergency Department

Background & Introduction: Adolescent substance use poses significant challenges to public health, contributing to risky behaviors and a spectrum of adverse medical and mental health outcomes. These issues frequently result in emergency department (ED) visits, making this setting a crucial touchpoint for early identification and intervention. Existing literature highlights the ED as an underutilized opportunity for substance use screening, but prior research has predominantly focused on provider perspectives or specific populations, such as high-risk youth.

What remains underexplored is the comprehensive understanding of both adolescent and caregiver attitudes toward substance use screening within pediatric ED settings. Understanding these perceptions is essential to designing effective and culturally sensitive screening programs that address barriers and enhance engagement. This study aims to fill this gap by examining the experiences, perceived barriers, and facilitators to substance use screening from the perspectives of adolescents and their caregivers. By integrating both quantitative and qualitative methods, this research seeks to provide actionable insights into how substance use screening can be optimized in ED settings, ensuring both acceptability and effectiveness.

Methods: This study employed a cross-sectional design to explore adolescent and caregiver perspectives on substance use screening in pediatric emergency departments. A structured survey was developed and validated through expert review, cognitive interviews, and a pilot study. The final survey included 25 multiple-choice and four open-ended questions for adolescents, and 26 multiple-choice and four open-ended questions for caregivers. Topics covered demographic information, comfort with screening, perceived barriers, facilitators, and attitudes toward universal substance use screening.

Participants were recruited from a national online panel. Adolescents aged 13–17 years and their caregivers were eligible to participate. A total of 548 adolescents and 544 caregivers completed the survey. Quantitative data were analyzed descriptively, with proportions and frequencies calculated for each response. To identify significant trends, chi-square tests and logistic regression models were employed. For the qualitative data, thematic analysis was conducted to identify key themes, supported by illustrative quotes. This approach allowed for a comprehensive understanding of participant attitudes and experiences while ensuring methodological rigor.

Results: A total of 548 adolescents and 544 caregivers completed the survey, providing valuable insights into their perceptions of substance use screening in pediatric emergency departments. Quantitative findings revealed that 50.4% of adolescents and 38.0% of caregivers rated screening as "extremely" or "very" important. Support for universal screening was slightly higher among adolescents (43.8%) compared to caregivers (42.6%), although caregivers demonstrated greater hesitancy, with 38.2% expressing uncertainty about universal screening practices.

Adolescents reported varied comfort levels with screening, with 53.8% feeling "extremely" or "somewhat" comfortable discussing substance use with ED providers, while 26.7% expressed discomfort. Caregivers showed slightly higher comfort levels, with 71.2% reporting being "extremely" or "somewhat" comfortable discussing their child’s substance use. Most adolescents (71.8%) indicated they would respond honestly to screening questions, and 84.3% of caregivers stated they would encourage their child to answer truthfully. Attitudes toward sharing screening results revealed that 68.8% of adolescents supported sharing results with caregivers, but 17.2% opposed it.

Qualitative thematic analysis identified shared and unique barriers to screening. Privacy concerns were the most frequently cited barrier, reported by 75.5% of adolescents and 67.8% of caregivers. Adolescents expressed apprehension about unauthorized access to their information, with one noting, “I don’t want anyone outside the doctor’s office to know my answers.” Similarly, caregivers highlighted the importance of confidentiality, stating, “It’s critical that information stays private; otherwise, it may deter honesty.”

Fear of legal consequences was a significant concern for 62.0% of adolescents and 50.4% of caregivers, with adolescents worried about punitive outcomes. Trust in healthcare providers was also a barrier, with 57.0% of adolescents and 48.0% of caregivers expressing concerns about being judged or stigmatized. Facilitators included assurances of privacy and confidentiality (75.0% adolescents, 81.0% caregivers), clear communication (68.0% adolescents, 74.0% caregivers), and supportive healthcare providers (70.0% adolescents, 78.0% caregivers). Adolescents emphasized digital tools like apps for education and resources, while caregivers preferred follow-up services and professional consultations.

Overall, both adolescents and caregivers demonstrated support for substance use screening in the ED, though barriers such as privacy concerns and legal fears need to be addressed to enhance acceptability and effectiveness.

Conclusion & Discussion: This study provides critical insights into adolescent and caregiver perspectives on substance use screening in pediatric emergency departments. Both groups generally supported the practice, with adolescents demonstrating slightly higher endorsement for universal screening compared to caregivers. Privacy concerns emerged as the most significant barrier, with both adolescents and caregivers emphasizing the importance of confidentiality to encourage honesty during the screening process. Fear of legal consequences and a lack of trust in healthcare providers were additional challenges identified by both groups. Facilitators such as clear communication, empathetic healthcare providers, and access to follow-up resources were viewed as essential to improving screening acceptability.

An important finding was the divergence in preferences for follow-up support: adolescents favored digital tools like educational apps, while caregivers prioritized professional consultations and resource referrals. These distinctions underscore the need for tailored interventions that address the specific preferences and concerns of both groups.

The study's limitations include reliance on self-reported data, which may introduce response biases, and potential non-representativeness due to online recruitment. Future research should evaluate these findings in clinical settings to optimize screening protocols. Addressing identified barriers and leveraging facilitators will be pivotal in ensuring that ED-based substance use screening is effective, equitable, and widely accepted.

References: Friedman J, Godvin M, Shover CL, Gone JP, Hansen H, Schriger DL. Trends in Drug Overdose Deaths Among US Adolescents, January 2010 to June 2021. JAMA. 2022;327(14):1398-1400. doi:10.1001/jama.2022.2847

Friedman J, Hadland S. The Overdose Crisis among U.S. Adolescents | New England Journal of Medicine. N Engl J Med. 390(2). doi:10.1056/NEJMp2312084

Chun TH, Duffy SJ, Linakis JG. Emergency Department Screening for Adolescent Mental Health Disorders: The Who, What, When, Where, Why and How It Could and Should Be Done. Clin Pediatr Emerg Med. 2013;14(1):3-11. doi:10.1016/j.cpem.2013.01.003

Mello MJ, Baird J, Spirito A, et al. Adolescents’ Perceptions of Screening, Brief Intervention, and Referral to Treatment Service at Pediatric Trauma Centers. Subst Use Res Treat. 2024;18:29768357241272356. doi:10.1177/29768357241272356

Renny MH, Berger JC, Mei C, et al. Substance Use among Youth Presenting to the Pediatric Emergency Department. J Med Toxicol. Published online October 15, 2024. doi:10.1007/s13181-024-01032-x