Alcohol Research Center, University of Connecticut Health Center, Farmington ... an average of 10.1 calls per subject. .... Each phone call of the IVR Study lasted.
The American Journal on Addictions, 15: 122–125, 2006 Copyright # American Academy of Addiction Psychiatry ISSN: 1055-0496 print / 1521-0391 online DOI: 10.1080/10550490601006121
An Interactive Voice Response (IVR) System for Adolescents with Alcohol Use Disorders: A Pilot Study Yifrah Kaminer, MD, Mark D. Litt, PhD, Rebecca H. Burke, MS, Joseph A. Burleson, PhD Alcohol Research Center, University of Connecticut Health Center, Farmington, Connecticut
In order to understand predictors of relapse among adolescents treated for alcohol use disorders (AUD), it is important to accurately assess the daily circumstances associated with use. This pilot study investigates the feasibility and acceptability of an interactive voice response (IVR) system in adolescents with AOSUD. Twenty-six adolescents 14 to 19 years old, with a mean age of 16.8, who were enrolled into an adolescent treatment program for AUD consented to make phone calls for 14 successive evenings to an IVR system and answer 14 questions pertaining to daily use of alcohol and other drugs. The subjects were compensated for their participation. A satisfaction questionnaire was administered at the end of the study. Participants completed 72% of scheduled recordings, with an average of 10.1 calls per subject. Most participants reported that they answered the questions honestly and accurately and were very much satisfied with the IVR system. The preliminary data presented here suggests that the use of IVR for the purpose of generating daily reports in youth is feasible and acceptable. The utilization of IVR systems should be explored to improve efficacy and attainment of generalizability to heterogeneous adolescent populations and lifestyles including for other psychiatric disorders. (Am J Addict 2006;15:122–125)
Although a significant number of youth diagnosed with alcohol and other substance use disorders (AOSUD) improve in treatment, relapse is common. Relapse rates of more than 60 percent 3–12 months after treatment completion have been recorded.1–3 The pivotal question has been why do adolescents relapse and what might be the predictors of relapse. Cognitive-behavioral models conceptualize substance use and related problems as learned behaviors that are initiated and maintained in the context of environmental factors.4–5 Cognitive-behavioral interventions often involve identiReceived February 27, 2006; revised May 24, 2006; accepted August 17, 2006. Address correspondence to Dr. Kaminer, Alcohol Research Center, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-2103. E-mail: kaminer@ psychiatry.uchc.edu. 122
fying the circumstances surrounding drug or alcohol use, such as the setting, time, or place, which may serve as potential triggers or stimulus cues. Strategies to manage urges and cravings, once stimulus cues have been identified, may involve techniques from different learning perspectives, such as self-control, reinforcement for competing behaviors, or other coping- skills training.6 However, alcohol treatment studies typically rely on outcome measures obtained weekly, monthly or at longer intervals. Although accepted practice, this approach does not adequately assess behaviors that characterize alcohol use and its precipitants and consequences on a daily basis. The most commonly used method of collecting data on alcohol and other substance use has been the Timeline Follow-Back (TLFB).7 This is a reliable and valid procedure, which elicits quantitative information regarding substance use for both short-term (30 days) and long-term (1 year) data collection by using an individualized calendar format that provides temporal cues to assist in recall of events. However, the TLFB tells us little about the circumstances surrounding alcohol or drug use. For the most part, measures pertaining to the processes of drug and alcohol use have been retrospective and infrequently administered. Unfortunately, infrequent measurements rely upon subjects’ capacity to recall events over comparatively long periods of time, which may result in significant recall error or potential bias.8 Other potential pitfalls for consideration include motivational issues, differing alcohol or drug use metrics, and even the distorting effects on memory of drug and alcohol use itself. Recently developed methods provide an opportunity to sample alcohol and drug use on a daily basis, providing more valid measures, and making it possible to examine moderators and mediators of observed treatment effects that cannot be ascertained through traditional treatment outcome indicators.9 Daily monitoring might help understand symptom covariation during early recovery and improved understanding of the relationship between comorbid psychiatric pathology.10–11
Interactive voice response (IVR) is a computer-based telephone response system in which callers respond to recorded questions using the telephone keypad. An extensive review of the literature on IVR concluded that this technique has numerous advantages, including economy, autonomy, confidentiality, improved data quality, standardized interviewing, and detailed longitudinal assessments.12 Frequent IVR monitoring might be useful for obtaining reliable daily reports about response to treatment.13 The validity of the data gathered through the IVR methodology was clearly established.14 The IVR system has been reported to be more accurate than the TLFB in adults with drinking history.15 Most studies utilizing a variety of frequent self-monitoring techniques report that compliance is very good when incentives are offered.11,16 In order to better understand predictors of relapse among adolescents treated for AOSUD it is important to accurately assess the circumstances associated with alcohol and other drug use. The long-term goal is to implement methodology that will facilitate the collection of more accurate and timely-data. Computer driven technology has been developed that can administer drug use survey questionnaires in an audio format and record adolescent respondents’ answers entered by pressing numbered keys on the keyboard.17 However, we are not aware of a published study of IVR technology in adolescents with alcohol or other substance use disorders (AOSUD) addressing these needs. Therefore, the objective of this pilot study was to investigate the feasibility and acceptability of a telephone based IVR system for data collection in adolescents treated for AOSUD.
METHODS Thirty-one prospective participants 14–19 years of age who had been diagnosed and treated for DSM-IV AOSUD were invited to participate in a study involving daily reporting of their alcohol and other substance use. Twenty-six consenting participants, (17 males and 9 females), enrolled in this trial for 14 days. Both the subject and parent=caretaker signed a consent form approved by the Institutional Review Board. Each adolescent was assigned to call a phone number at the University of Connecticut Health Center daily between 7–11PM. For each evening of recording he=she was asked to enter a confidential numeric code (i.e., a password) using the telephone keypad that prompted access to an IVR system. A recorded voice presented the same set of closed-ended questions every evening for 14 successive days. Participants were instructed to answer each question by using the phone keypad. Each evening’s data were thus entered directly into the database for subsequent evaluation and analysis. Each phone call of the IVR Study lasted approximately 2 minutes. (See appendix for IVR script). Kaminer et al.
The subjects were rewarded for their participation according to a contingency management protocol. A subject received $5.00 each time he=she completed a phone call. An additional $5.00 was earned for the fifth consecutive call, another $10.00 for the tenth consecutive call and another $15.00 for the last call, giving participants the opportunity to earn up to $100 if all 14 calls were completed. Responses to the IVR questions were evaluated using analyses of variance to assess each participant’s use of alcohol and drugs during the 14 days of daily monitoring. These analyses allowed us to evaluate whether there were differences in calling protocol compliance rates across gender and day type (weekday v. weekend). Descriptive findings are presented on recruitment and call completion rates to access the feasibility and acceptability of the questionnaire administered on the IVR system. Participants’ satisfaction ratings with the IVR study are also presented via frequency distributions of participants’ subjective experiences.
RESULTS Three components of the study are addressed in this section. First, the feasibility and acceptability of the questionnaire administered on the IVR system, second, the satisfaction questionnaire, and third the specific information provided by the participants regarding their potential alcohol and other substance use. Seventy two percent (262 calls) of the 364 potential calls (i.e., 26 subjects 14 evenings) were completed. The mean number of phone calls made per subject was 10.1 out of 14 possible calls. Fifty-one additional calls were also placed into the system. These calls were either made outside of the 4-hour calling window, incomplete due to an incorrect ID or password, placed outside of the 14 day window of time, or were made by a participant attempting to call into the system and complete the interview a second time that evening. The most common reasons for not calling were: 61% forgot to call, 11% night school; 11% no access to a phone, 4% at work during the calling period, and 4% forgot his=her ID or the IVR phone number. The average amount of compensation earned was $60 out of a potential total of $100. Fifty-four percent reported that the 4-hour window for making the call was long enough, did not interfere with evening activities, and was either very much or extremely convenient. However a similar percentage of participants also reported that it was more difficult to call within this time window on weekend compared to weekday nights. When calling rates were compared by type of day, somewhat better protocol compliance was seen on weekdays (77% of calls completed Monday through Thursday) than on weekends (65% of calls completed Friday through Sunday) [F(1,25) ¼ 1.88, p ¼ .072]. Supplement 1 2006
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A majority of participants (>70%) reported that the instructions given during the phone call were audible and the content clear, and that they were willing to participate again or recommend participation in a similar study to a friend. Eighty-nine percent of youth reported that they had answered the questions accurately and honestly every night. Fifty-three percent of males versus 44% of females reported drinking at least once during the 14-day period of the study. There was a significant effect for type of recording day (weekday v. weekend), such that the average number of drinks for any given weekday (M ¼ 0.35) was lower than that for weekend day (M ¼ 1.22) [F(1,23) ¼ 6.07, p ¼ .022]. Fifty-nine percent of males and 78% of females reported using an illicit drug at least once during the 14-day period of the study. Seventy-five percent of the females and 90% of the males who reported drinking at least once during that period also reported using an illicit drug at least once during the same time frame. Forty-six percent of participants who reported having drunk alcohol during the 14 days of recording also reported driving under the influence (DUI) at least once during that time. Finally, 41% of those reporting illicit drug use also reported driving under the influence of drugs.
DISCUSSION This pilot study reports the first evaluation of the feasibility and acceptability of daily telephone based IVR technology in youth with AUD. Our results indicate that youth can be engaged in IVR procedures and that adequate compliance can be achieved. The 72% compliance rate is within the same range reported in comparable studies in adults.11,16 This rate underestimates the potential compliance rate for this sample, in that additional calls were reported outside of the 4-hour calling window. The 29 additional calls into the system that were made outside of the calling window would constitute an addition of 12% of the volume of potential calls. This finding as well as the expressed inconvenience regarding the weekend calls need to be addressed by 1) expanding the time window for calls during weekdays and 2) having a day time opportunity to contact the IVR system to report use on the previous night, in particular during weekend (e.g., noon-6 PM), to better accommodate the adolescents’ sleep-wake cycle and life style. Treatment satisfaction has not been shown to correlate with treatment improvement of adolescents with substance use disorders.18 That is, adolescents who report that they are most happy with either their therapists and=or treatment experiences may not be the ones who are abstinent at follow-up. However, it is recommended that clinicians collect satisfaction data and review it on a regular basis to provide feedback as to how they are perceived by their service recipients.19 Moreover, it may be 124
predictive of patient loyalty, premature termination, and future help-seeking behavior.18 In general, participants were satisfied with their interaction with the IVR system. They also appear to be candid in their responses to alcohol and other substance use given the relatively high rate of use and driving under the influence (DUI) reported. It is plausible that the use of incentives increased the compliance in this study. It is unclear whether the same level of compliance would have been noted without these incentives. Since general clinical practice does not typically involve the use of incentives, it is unclear to what extent the results of this study generalize to clinical settings. This is an issue that merits further exploration. In summary, we found that most participants were able to comply adequately with the daily protocol with a minimum of inconvenience or indication of any adverse effects. This preliminary data suggest that the use of IVR for the purpose of generating daily reports in youth with AUD is feasible and acceptable. Future Directions Similarly to what was done in adults, there is a need to establish validity of the data gathered through the IVR methodology by comparing daily self-reports of consumption with daily breath and other pathophysiological measures as well as daily collateral reports.14 It is desirable to explore whether a higher compliance rate is associated with the use of a prompting system to alert participants that it was time to contact the IVR system to provide information.13,16 Finally, achieving optimal compliance with frequent monitoring may involve a combination of incentives, automatic prompts to call the system, and timely trouble-shooting following missed calls.11 Finally, it is of interest to replicate such a study in a clinical setting while considering who will be running such a system in the future (e.g., the program, third party). This research has been supported by Grants #AA012187-01A2 and K24AA013442 from the National Institute on Alcohol Abuse and Alcoholism, Bethesda, Md (Dr. Kaminer) and by grant M01-RR 06192 from the General Clinical Research Center of the National Institutes of Health, Bethesda, Md (Dr. Kaminer). The authors would like to acknowledge Dr. Khamis AbuHasaballah, who provided the programming for IVR assessment, and the contribution of Dr. Henry Kranzler to the development of the questionnaire. REFERENCES 1. Brown SA, Vik PN, Creamer V. Characteristics of relapse following adolescent substance abuse treatment. Addict Behaviors. 1989;14:291–300. 2. Dennis ML, Godley SH, Diamond G, et al. Main findings of the Cannabis Youth Treatment (CYT) randomized field experiment. J Subst Abuse Treatment. 2004;27:197–213.
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3. Kaminer Y, Burleson JA, Goldberger R. Psychotherapies for adolescent substance abusers: short- and long-term outcomes. J Nerv Ment Disease. 2002;190:737–745. 4. Dimeff LA, Marlatt GA. Relapse prevention. In: Hester RK, Miller WR, eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives. Boston, Mass: Allyn & Bacon;1995:176–194. 5. Monti PM, Rohsenow DJ, Colby S, et al. Coping and social skills training. In: Miller WR, Hester RK, eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 2nd ed. New York, NY: Allyn & Bacon;1995:221–241. 6. Waldron H, Kaminer Y. On the learning curve: Cognitive behavioral therapies for adolescent substance abuse. Addiction. 2004;99(Suppl 2):93–105. 7. Sobell LC, Sobell MB. Time-Line Follow-Back User’s Guide. Toronto, Canada: Addiction Research Foundation; 1996. 8. Searles JS, Perrine M, Mundt JS, et al. Self-report of drinking using touch-tone telephone. Extending the limits of reliable daily contacts. J Stud Alcohol. 1995;56:375–382. 9. Litt M, Kranzler H. Application of daily process measurement to alcohol treatment studies. Symposium conducted at the Annual Meeting of the Research Society on Alcoholism, Fort Lauderdale, FL. 2003. 10. Collins LM, Graham JW. The effects of timing and spacing of observations in longitudinal studies of tobacco and other drug use: temporal design considerations. Drug Alcohol Depend. 2002;68:S85–S96. 11. Simpson TL, Kivlahan DR, Bush KR, et al. Telephone selfmonitoring among alcohol use disorder patients in early recovery: a randomized study of feasibility and measurement reactivity. Drug Alcohol Depend. 2005;79:241–250. 12. Corkrey R, Parkinson L. Interactive voice response: Review of studies 1989–2000. Behavior Research Methods: Instruments & Computers. 2002;34:342–353. 13. Kranzler HR, Abu-Hasaballah K, Tennen H, et al. Using daily interactive voice response technology to measure drinking and related behaviors in a pharmacotherapy study. Alcohol Clin Exper Research. 2004;28:1060–1064. 14. Perrine MW, Mundt JC, Searles JS, et al. Validation of daily selfreported alcohol consumption using interactive voice response (IVR) technology. J Stud Alcohol. 1995;56:487–490. 15. Searles JS, Helzer JE, Rose GI, et al. Concurrent and retrospective reports of alcohol consumption across 30, 90, and 366 days: interactive voice response compared with the timeline follow back. J Stud Alcohol. 2002;63:352–362. 16. Carney MA, Tennen H, Affleck G, et al. Levels and patterns of alcohol consumption using Timeline Follow-Back, daily diaries, and real time ‘‘electronic interviews.’’ J Stud Alcohol. 1998;59:447–454.
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17. Turner CF, Ku L, Rogers SM, et al. Adolescent sexual behavior, drug use, and violence: Increased reporting with computer survey technology. Science. 1998;290:867–873. 18. Tetzlaff BT, Kahn JH, Godley SH, et al. Working alliance, treatment satisfaction, and patterns of post treatment use among adolescent substance users. Psychol Addict Behaviors. 2005;19:199–207. 19. Godley SH, Fiedler EM, Funk RR. Consumer satisfaction of parents and their children with child=adolescent mental health services. Eval Prog Planning. 1998;21:31–45.
APPENDIX: INTERACTIVE VOICE RESPONSE SCRIPT 1. How many alcoholic drinks did you consume in the last 24 hours? (enter answer using telephone keypad, from 0 drinks to 99 drinks. If #1 ¼ 0, then skip to #6 2. If you have been drinking did you drive under the influence (DUI)? 3. Did you drink alone? 4. Did you drink with other people? 5. If other people were present, did they pressure you to drink? 6. If you did not drink, is it because you had no opportunity to drink? 7. If you did not drink, is it because you resisted the opportunity to drink? 8. Did you use any illicit drugs (i.e., marijuana, cocaine, unprescribed medications etc.) in the past 24 hours? 9. If you have been using drugs did you drive under the influence (DUI)? 10. Did you use drugs alone? 11. Did you use drugs with other people? 12. If other people were present, did they pressure you to use? 13. If you did not use drugs, is it because you had no opportunity to use? 14. If you did not use drugs, is it because you resisted the opportunity to use?
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