Phone Apps & Adolescents: Ecological Momentary Assessment & Intervention

50 to 70% of all adolescents admitted to residential substance use disorder (SUD) treatment relapse within the first 90 days after discharge.

While continuing care and recovery support services have been shown to help reduce relapse rates, only 18% of youth receive continuing care and fewer access recovery support services after receiving treatment.

One potential way to address this gap, and to hopefully reduce relapse rates, is through the use of smart phones to help adolescents better monitor risk and protective factors associated with relapse.

Smart phones can also provide immediate interventions to reinforce motivation for recovery, to seek support from others and distract from cravings or urges and to connect with others. The Addiction Comprehensive Health Enhancement Support System (ACHESS) has been demonstrated to reduce risky drinking days among adults.

Dennis and colleagues aimed to determine the feasibility of adolescents completing ecological momentary assessments (EMA) and recovery support ecological momentary interventions (EMI) via smart phones, and to use EMA and EMI data to predict substance use in the subsequent week. EMAs are a variety of questions that reference the past 30 minutes: content is focused on adolescent’s feelings, activities and current location (see comparison table below).

Adolescents (n=29) were recruited from residential treatment and completed a 2-3 minute EMA 6 times per day for 6 weeks, met with study staff twice during a 7 day period, and were required to return study phones is good condition at the end of the 6 week study period. Abstinence was verified through urine samples. Primary outcomes included time to first alcohol or drug use in the first 7 days, and any use in the next 7 days following a given EMA.

100% of the adolescents accessed EMIs during the pilot study. The adolescents accessed EMIs on 78% of the days, and adolescent’s accessed 2 or more EMIs within one of an EMA an average of 28 times. This is important because adolescents using 2 or more EMI within an hour of the EMA were less likely compared to those who did not to use drugs or alcohol within the next 7 days (32% vs. 43%, Odds Ratio (OR)=0.62). One hundred percent of participants accessed the recovery support, recovery motivation and relaxation types of EMI with 90% accessing the social networking category of the EMI. The recovery support, recovery motivation, relaxation and social networking were accessed an average of 5, 3, 1 and 11 times per week respectfully.

EMA

EMI

References past 30 minutes
Current feelings, activities, location, and those persons present.
Internal and external factors made them want to use drugs or alcohol, supported their recovery or had no impact
Cravings and their exposure to drugs, alcohol or illegal activities

Available all of the time. Included:

Recovery support (listening to recovery stories, discussion groups, etc.)
Relaxation
Recovery motivation (motivational text messaging, recovery profiles, among others)
Social networking (Facebook, etc.)

Dennis and colleagues created a unidimensional scale ranging from 0-100 with higher scores representing greater perceived risk and less perceived support by combining negative (e.g. making you want to use alcohol or drugs) and positive ratings (supporting recovery).

Adolescents completed 89% of the total 5,460 EMAs that were sent out. The majority of adolescents reported that the EMA “was not too long” (95%), “very easy” or “easy to learn how to do” (100%), and that it was “very easy” or “easy to complete 6 EMAs per day (94%). Dennis and colleagues found that the single best predictor of any use in the next 7 days was substance use in the past 30 minutes when compared to no use. The scale was created to compare those who “Recognized” some risk or limitations in their support (score=1 to 100) compared to those with “Unrecognized” risks or limitations (score=0) was also found to be a good predictor of substance use. Those in the Unrecognized Risk and Recognized Risk groups reported a 50% and 31% reduced time to first use and rate of use over the next week after completing an EMA and reporting not using in the past 30 minutes.

Those who were reported currently using were 50.30 times more likely to report substance use in the next 7 days and those who were classified as having unrecognized risk were 2.08 times more likely to report substance us over the next 7 days. It also decreased the likelihood of using among the Unrecognized risk observation group (OR=0.69) and the Recognized risk observation group (0.54).

IN CONTEXT

Smart phones are growing in popularity among adolescents, especially as they become cheaper and increasing numbers of apps enable constant communication.

This pilot study by Dennis and colleagues, while small, showed that a smart phone-based application is a potentially beneficial continuing care support for adolescents after residential treatment.

As smart phones continue to decrease in cost and increase in availability, this may be an effective way to provide continuing care to adolescents.

LIMITATIONS: Further research is needed to examine the generalizability of using a smart phone for a longer follow up period, in order to evaluate whether the EMI and EMAs continue to be effective. Additionally, this cohort of individuals were all from residential programs in one state and a more diverse participant group is necessary to further measure generalizability. Dennis and colleagues were able to achieve high rates of success through training and also the changing nature of technology and the availability of smart phones to youth. Participants in this study were also compensated to complete the EMAs; it is unclear how acceptable this model will be in the real world with no financial incentive.