Data-Driven Solutions to Risky Teen Behavior

Dr. Jennifer Salerno knows a lot about teens. She knows how often they're having sex, using contraception, eating well, carrying weapons, exercising and drinking alcohol. In fact, she's been able to find out so much about teen behavior that she's been able to assist adults in helping those teenagers stay healthier and safer. That's some powerful information from a demographic that often mystifies adults. You know how she found out so much about teens?

She asked them. 

"Teens, for the most part, are not listened to," Salerno says. "A lot of their complaints are that adults don't understand or aren't listening. Given the opportunity, they just spill."

Particularly when there is no judgement, and the questions are being asked in a neutral way. That's what Salerno's University of Michigan spin-out, Rapid Assessment for Adolescent Preventative Services, or RAAPS, does. By administering non-anonymous risk screenings on tablets to students in school based health centers, primary care and pediatrics offices, among other places where teens seek care, clinicians simply get better, more honest information about the risky behavior of teens. 

And that information is more than just nice to know. According to Salerno, three out of four serious injuries or premature deaths in teens are related to their behavior. 

"If three out of four teens were dying of tuberculosis, there would be an outcry," she says. "But people tend to say, even if I identify that behavior, what could I do about it it?" 

Questions without judgment

Salerno believes there's plenty to be done. That's why she, a nurse practitioner and doctor of nursing practice decided to start by asking the right questions in the right way. Salerno worked at the University of Michigan overseeing six school-based health centers, which function like primary care offices inside of schools. She estimates 100 of these centers exist across the state, including at Ann Arbor Technological High School, Lincoln High and Middle Schools and Ypsilanti Community High and Middle Schools, and while they administer important healthcare to teens, Salerno saw that something was missing.

"There were no tools that were time efficient enough to be used in a patient setting," she says. Left to ask awkward questions to teens directly, clinicians had no unbiased, reliable way to elicit honest responses from teens about their own behavior. 

Working with a team of practitioners and teens, Salerno developed scientifically validated questions that could not only assess risky behavior, but prompt students to answer honestly. Teens were involved in the development of the questions, web design and the health messages that are delivered to users as a result of their answers. 

"Teens themselves will tell you, 'I'm way more honest when I'm using a computer than I am face to face,'" says Salerno. "Computers don't have any non-verbal body langue. There is no implied judgement."

The tool turned into RAAPS, and with assistance from the university and SPARK, Salerno spun out into her own business. Now, about 50,000 surveys have been completed in about 160 offices nationwide. Not only is that data helping clinicians better serve the teen sitting in front of them, but collectively, RAAPS's data is unveiling larger trends in teen risk behaviors that can help drive policy, practices and general understanding of what's happening with our youth. 

Risky behavior

Salerno estimates about 80 percent of school based health centers in Michigan are now using RAAPS, and that percentage is even higher among southeast Michigan schools. What she's learning about risk behaviors in Michigan teens has even surprised her. 

"Girls are riskier than boys," she says. "Most people don't think that way."

Female teens, in fact, are at two times the risk of boys. A higher percentage of them - 39 percent in 2013 - fail to use protection during sex, they report more depression, abuse, bullying and suicidal thoughts or actions. Boys display troubling data as well, with one out of six of them carrying a weapon for protection, and half of those who do carry weapons report anger management issues. 

But it's not all bad news. RAAPS found that boys are drinking less and girls are engaging in less distracted driving than in the past. In general, all teens were found to be exercising more and wearing a helmet more often. Adolescents on state-subsidized insurance programs showed decreases in the use of cigarettes, alcohol and marijuana, and increases in healthy eating.

The even better news is that when negative behaviors are reported — such as carrying a weapons and having difficulty managing anger — teens are immediately receiving wellness messages related to that behavior through RAAPS, and their clinicians can act immediately. 

"It's not an anonymous survey," Salerno says. "The survey helps identify those boys."

And what happens next brings us to the best news RAAPS has to report yet. A year over year review of nearly 2,000 teens who took the risk assessment twice between 2011 and 2013 show that Michigan's school based health centers are making a significant difference in levels of exercise, distracted driving, contraception use, disordered eating, self-harm, being bullied or harassed, serious worry and sadness or depression.

"Their staff has been trained and they have a multidisciplinary approach," says Salerno. "They get physician time, and have access to a mental health therapist who can provide that mental health piece. When you have all of that as your intervention, you should have positive outcomes." 

The data trends are also helping inform clinicians as to how to address certain issues. When links between risky sexual behavior and depression are found, for instance, this broader view of the can help clinicians determine if talking about depression is more likely to resolve the issue than a lesson on how to use condoms.

Could those outcomes be even better? Sure they could, says Salerno. If, for instances, school based health clinicians could prescribe contraceptives, she believes their use would increase even more. Advocacy for more effective public policies is one way such a large data set can be put to use. Clinicians can also leverage the data to apply for grants that can bring resources to their centers to better address identified issues. 

Keeping up

RAAPS must work to keep up with trends in risk behaviors as well. Survey questions are reevaluated every other year to deal with new issues, such as texting and driving - something that didn't exist back in 2005 when the assessment was first being developed.

No matter how those questions evolve and how much public policy can develop to address identified issues, the effort to communicate with teens about risky behavior will be an ongoing and evolving one. But at the core of the very complicated endeavor will remain the same: continuing to ask teens what they're up to. 

"When I was practicing as a nurse practitioner, I would ask them, 'Who have you shared this with?'" Salerno says. "Nine out of ten times, they say no one had ever asked. No one was asking, so they weren't talking." 

Thanks to RAAPS that is changing for teens in Michigan, as well as nationwide. Salerno hopes to continue pushing the assessment out into the world for more clinicians to use and more teens to take. Sure, the data will help the world get a better grip on teen behavior, but most importantly, it will help each individual teen answering each question find a pathway to better health and safety. 

"It's really about getting it out to as many teens as possible so we can find these issues early," Salerno says, "before they impact their well-being."