A Trial of Telephone Services to Increase Adolescent Utilization of Health Care for Psychosocial Problems

Article Outline

• Abstract
• Method
  • Participants
  • Procedure
  • Description of the two study conditions
    • Experimental condition: TSS
    • Control condition: UC+
    • Outcome assessment procedures
  • Measures of subsequent healthcare utilization
    • Services for children and adolescents—Parent Interview (SCA-PI; [20]
    • Hospital administrative data
  • Statistical analyses
• Results
  • Impact of experimental condition on subsequent healthcare utilization
  • Post hoc analyses
• Discussion
• Acknowledgments
• References
• Copyright

Abstract 

Purpose

Adolescents identified in primary care clinics as experiencing psychosocial problems frequently do not receive recommended referral mental health care services. The purpose of the present study was to test whether a Telephone Support Services (TSS) intervention would increase subsequent healthcare utilization. Our TSS intervention featured a combination of case management and motivational interviewing.

Method

One hundred seventy-nine adolescents who screened positive for at least one of three psychosocial problems—depressive symptoms, suicidal ideation, or substance use—were randomly assigned to one of two study conditions. Eighty-nine participants were randomly assigned to TSS, and 90 participants were assigned to Enhanced Usual Care (UC+). Adolescents completed self-report interviews of medical and mental health utilization at 4 months. In addition, research staff queried our hospital's administrative data warehouse to obtain each participant's medical service and mental health service use at 6 months.

Results

TSS did not increase subsequent utilization of either medical or mental health services for adolescents screening positive for psychosocial problems in a primary care clinic. This finding held true whether service utilization was assessed through self-report or administrative data.

Discussion

The lack of experimental effect on healthcare utilization suggests that certain aspects of our TSS require modification in future work. On a positive note, given that each of the three TSS calls was completed by a strong majority of participants, TSS appears feasible and acceptable to adolescents with psychosocial problems.

Keywords: Adolescent, Mental healthcare, Telephone

Because more than 80% of youths are seen in primary care practices annually [1], these settings are attractive sites for identifying psychosocial problems and for initiating follow-up interventions. However, despite advances in the identification of psychosocial problems through computerized screening in waiting rooms [2] and training primary care providers [3], [4], further efforts are needed to engage adolescents in subsequent mental healthcare services. Using data from the national Child Behavior Study, Gardner and colleagues [5] found that less than 60% of newly identified and referred pediatric patients with psychosocial problems received any specialty care in the ensuing 6 months [5]. Using data from the National Longitudinal Study of Adolescent Health, Kodjo and Auinger [6] documented specialty mental health counseling rates of 8–19% for recognized emotionally distressed adolescents [6]. Because these studies likely represent the extreme range, roughly a third of identified adolescents get subsequent specialty mental healthcare.

Various primary care interventions (e.g., case management) have been proposed to increase adolescent engagement with subsequent specialty mental health services [7], [8]. Unfortunately, many youths may not receive or take to these interventions in busy clinics. An alternative avenue is Telephone Support Services (TSS). Developed from a disease management context for managed care companies, TSS involves nurses or other nonphysician clinicians providing structured contacts with patients to address challenges in obtaining or persisting with follow-up healthcare. Because these contacts occur outside of pediatric or adolescent clinic appointments, they may be more feasible than interventions that occur during brief and busy clinic encounters.

TSS increases adult adherence for depression treatment [9], [10]. However, it remains unclear if TSS can increase adolescent utilization of mental healthcare, in part because the few studies in this area have used multicomponent interventions and are thus unable to isolate the effects of telephone support. Asarnow and colleagues [11] found that telephone care managers improved service utilization for primary care adolescents with depression. However, care managers actually delivered treatment (e.g., cognitive–behavioral therapy) instead of just brief phone contacts to facilitate treatment in specialty mental health settings and were part of an in-clinic quality improvement team. Spirito and colleagues [12] similarly used a comprehensive intervention that featured a 1-hour face-to-face intervention to increase adolescent utilization of mental healthcare.

The present study's purpose was to test whether a less intensive TSS intervention focused on services and not on symptoms would increase subsequent healthcare utilization compared to usual care. We selected urban adolescents who screened positive for at least one of three psychosocial problems—depressive symptoms, suicidal ideation, and substance use—because of their high prevalence and serious health consequences. We hypothesized that adolescents in the TSS condition would have more medical and mental health visits than adolescents in our enhanced usual care condition for 4 to 6 months after identification of a psychosocial problem. It is important to assess the effects of TSS because these are often nonbillable services whose economic value must be judged by future service use.

A component of our TSS was brief motivational interviewing (MI), which has considerable empirical support for helping patients adhere to healthcare regimens [13]. The other component was case management—advising adolescents on transportation options, scheduling, and other barriers to care.

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Method 

Participants 

Youths ages 11 to 20 years seen in our hospital's adolescent medicine clinic were recruited. As standard of care in this clinic, adolescents completed 10 minutes of computerized psychosocial screening in its waiting room. Adolescents self-reported depressive symptoms (Center for Epidemiological Studies Depression Scale for Children—CES-DC; [14]), suicidal ideation (item from Patient Health Questionnaire-Adolescent; [15]), and types and frequency of substance use (items from Comprehensive Addiction Severity Index; [16]). To be eligible for our study, patients were required to meet criteria for at least one of four psychosocial problems: (a) a CES-DC score of greater than 35, (b) suicidal ideation within the past 30 days, (c) self-reported alcohol use of greater than two drinks in the past 30 days, or (d) self-reported use of any illegal substance within the past 30 days. Our stringent CES-DC cutoff score of 35 resulted in just 10% of adolescents screening positive for depression, a rate that did not overwhelm this clinic's limited behavioral health resources. This cutoff resulted in only youths with moderate to severe forms of depression screening positive.

In addition to having at least one psychosocial problem, youths were eligible only if their physician recommended a specific follow-up plan because the TSS' purpose was to increase adherence to recommended follow-up services. Physicians recommended specific plans for approximately 90% of youths with a psychosocial problem. The most common follow-up plans for enrolled youths were: (a) return to adolescent medicine clinic (n = 67), (b) obtain services from a mental health provider (n = 51), and (c) referral to this clinic's social worker (n = 37). We excluded a very small number of youths who were non-English speaking and/or who lacked regular telephone service.

Table 1 presents the baseline demographic and clinical characteristics of our sample. As with this clinic's population, roughly six out of seven participants were female. Participants were predominantly African American. Over 75% of participants had public health or no health insurance. Tobacco, alcohol, and marijuana were the most commonly endorsed substances. Our total enrolled sample had a mean CES-DC score of 27.2, indicating a moderate level of depressive symptoms. The intervention and control groups did not differ on any baseline demographic or clinical characteristic, suggesting successful randomization procedures.

Table 1. Baseline demographic and clinical characteristics by study condition (N = 179).

	Total sample	Control	Experiment	p-valuea
Sample size	179	90	89	N/A
Age group
<18 years	103	51.1%	64.0%	.080
18–20 years	76	48.9%	36.0%
Mean age	17.2	17.4	17.0	.231
Gender
Male	26	13.3%	15.7%	.649
Female	153	86.7%	84.3%
Race
Black	127	67.8%	74.2%	.506
White	46	28.9%	22.4%
Asian	3	2.2%	1.1%
Spanish surname	1	0	1.1%
Other	1	0	1.1%
Undetermined	1	1.1%	0
Payor
Private	41	22.2%	23.6%	.827
Public/self-pay	138	77.8%	76.4%
Substance use
Tobacco (yes)	48.0%	51.1%	44.9%	.409
Alcohol (yes)	40.2%	45.6%	34.8%	.143
Marijuana (yes)	41.3%	45.6%	37.1%	.250
Inhalants (yes)	0.6%	1.1%	0	1.000
Ecstasy (yes) b	0.9%	1.7%	0	1.000
Cocaine (yes) b	0.9%	1.7%	0	1.000
Amphetamines (yes)b	0.9%	1.7%	0	1.000
Heroin (yes)b	0	0	0	N/A
Barbiturates (yes)b	11.3%	12.1%	10.4%	1.000
Mean # Subst.	1.4	1.5	1.2	.092
Mean CES-DC score	27.2	26.7	27.7	.498
Suicidal thoughts (yes)	42.5%	38.9%	46.1%	.366
Mean # days substances usedc	8.2	8.9	7.5	.470

Procedure 

Five hundred twenty-seven youths screened positive for a psychosocial problem and were approached for participation. Two hundred seventy youths were deemed eligible for the study. The 257 ineligibles included 184 minors who did not have a parent to provide consent, 55 youths who had no recommended follow-up plan from the physician, and 18 youths who had already been enrolled.

Sixty-six percent of eligible patients consented to participate, yielding a total of 179 participants. Ninety-four percent of eligible patients over 18 years agreed to participate, while 54% of eligible patients under 18 years agreed (p < .01). Parents and patients over 18 years of age provided written consent, and patients under 18 years provided written assent. Participants were randomly assigned to one of two conditions by an administrative assistant based upon a predetermined random numbers table. The two arms of the study were our experimental condition (TSS) and our control condition (Enhanced Usual Care—UC+). All study procedures were approved by our Hospital's institutional review board.

Description of the two study conditions 

Eighty-nine participants were randomly assigned to TSS. Youths in this condition were scheduled to receive three brief phone calls. The first call was scheduled for 1 to 2 weeks after the visit to the adolescent medicine clinic. The second call was scheduled for the week before the first follow-up medical or mental health appointment to address the psychosocial problem. The third call was scheduled for 1 to 2 weeks after this first follow-up appointment. Because attrition from mental health services frequently occurs at the outset of recommended treatment, the phone calls were concentrated during this time period.

The TSS calls featured a combination of case management and brief motivational interviewing. Each phone call began with the telephone interventionist assessing the youth's understanding of the physician's recommendations, interest in those recommendations, and overall viewpoints on the particular psychosocial problem. If a youth struggled to find specialty mental healthcare or was unaware of the details of a future mental health appointment, the telephone interventionist provided case management by looking into the situation and reporting back to the youth. If a youth expressed ambivalence about obtaining follow-up care, then the telephone interventionist used brief MI techniques. MI features a provider offering empathy and nonjudgmental support as a patient explores reasons both for and against a particular health behavior, such as attending a future healthcare appointment [17].

Table 2 presents an overview of what occurred during the TSS calls. Each of the three calls lasted on average 7 to 9 minutes. The telephone interventionist coded the primary purpose of each call and her perceptions of the youth's intentions for the near future. MI techniques were used during 27% of the first calls, 28% of the second calls, and 15% of the third calls to either encourage youths to decrease substance use (with the hope that this insight might precipitate engagement in treatment services) or to use follow-up care.

Table 2. Call characteristics for youths enrolled in TSS condition (N = 89).

	Call 1 (%)	Call 2 (%)	Call 3 (%)
Phone call characteristics:
Participants completing call (%)	75 (84.3)	68 (76.4)	65 (73.0)
Mean duration of call (minutes)	9.3	9.2	6.5
Median duration of call (minutes)	7.0	8.5	5.0
Call purpose:
Referral assistance	8 (10.7)	7 (10.3)	6 (9.2)
MI call to decrease substance use	6 (8.0)	3 (4.4)	3 (4.6)
MI call to increase service use	14 (18.7)	16 (23.5)	7 (10.8)
Seek info for PCP	1 (1.3)	0	0
Youth in services now	14 (18.7)	14 (20.6)	17 (26.1)
MI not used—youth highly motivated to stop substance use	1 (1.3)	1 (1.5)	2 (3.1)
MI not used—youth highly motivated to go to services	20 (26.7)	21 (30.9)	12 (18.5)
MI not used—youth not using substances anymore	4 (5.3)	2 (2.9)	7 (10.8)
MI not used—youth is not depressed anymore	5 (6.7)	4 (5.9)	10 (15.4)
Youth choosing nonmedical strategies to deal with depression and/or drug use (pastoral assistance, family, etc.)	2 (2.7)	0	1 (1.5)
Total	75 (100)	68 (100)	65 (100)
Action plan:
Unaware—denies problem	8 (10.7)	5 (7.3)	5 (7.7)
Willing to think about problem	7 (9.3)	8 (11.8)	0
Planning to seek services	29 (38.7)	21 (30.9)	19 (29.2)
Planning to take care of problem on own	1 (1.3)	3 (4.4)	3 (4.6)
Has initiated care	4 (5.3)	8 (11.8)	4 (6.2)
Just started to take care of problem on own	5 (6.7)	2 (2.9)	3 (4.6)
Continues to be in services	16 (21.3)	16 (23.5)	19 (29.2)
Continues self-care	2 (2.7)	1 (1.5)	7 (10.8)
Services completed	0	0	0
Completed self-care/services on own	0	0	0
Unknown	3 (4.0)	4 (5.9)	5 (7.7)

TSS = Telephone Support Services.

Two female doctoral level clinicians served as the telephone interventionists, completing a 2-day training on MI before making calls. Calls were recorded and regularly supervised by a clinical psychologist. A sample of the TSS calls that featured MI was coded for intervention fidelity by an external MI expert. Their fidelity to the spirit of MI principles was coded as a 4.0 and a 5.25, respectively, on a seven-point scale using the Motivational Interviewing Treatment Integrity coding system [18]. These ratings indicate a neutral level and a proficient level of MI fidelity respectively. We did not gender match interventionists with our participants, given that such matching would unlikely have improved outcomes [19].

Ninety youths were randomly assigned UC+. The same telephone interventionists who delivered the TSS calls delivered a series of three brief UC+ calls at 1, 4, and 12 weeks postinitial screening. These calls were used only to gather the most recent contact information for participants to facilitate their location for the research assistant's 4-month telephone interviews. The telephone interventionists were instructed not to assess patient's understanding of physician recommendations or their interest in receiving additional services, offer referral assistance, or employ MI techniques.

Twenty UC+ calls were assessed for fidelity by the study team; none of the calls featured these contraindicated elements, with one slight exception. In this case, the youth inquired about making an appointment with the adolescent medicine clinic, and the telephone interventionist only told the youth to call that clinic. These calls' brevity (mean = 0.8 minutes, SD = 0.5) underscored that our interventionists did not have time to use contraindicated elements.

For both conditions, enrolled youths who screened positive for suicidal ideation in the adolescent medicine clinic were asked if they were currently experiencing suicidal ideation. If current suicidal ideation was endorsed, a separate provider from our hospital's mental health division conducted a lethality assessment to ensure safety.

After completion of the TSS and UC+ calls, a blinded research assistant conducted an evaluation telephone interview at 4 months after the initial screening date to obtain adolescents' self-report of recent healthcare utilization. Multiple steps were taken to blind the research assistant. She did not have access to the part of the study database containing condition assignment, and the telephone interventionists made their calls in separate rooms with closed doors. Youths received a $15 gift card for completing the telephone interview.

Measures of subsequent healthcare utilization 

Adolescents were asked about their utilization of primary care, emergency room care, psychiatric services, family therapy, other forms of psychotherapy, and residential/inpatient care for the 4-month period following the initial screening. According to the developers of the SCA-PI, adolescents are appropriate respondents for this interview.

After all study phone calls were completed, research staff queried our hospital's administrative data warehouse to obtain each participant's medical service and mental health service use for the 6-month period prior to the initial screening date and the 6-month period following the initial screening date. A strength of these administrative data is its freedom from the reporting biases inherent in interviews like the SCA-PI. A key limitation of these administrative data is its failure to capture outside healthcare visits.

Statistical analyses 

The TSS and UC+ groups were compared on baseline characteristics, 4-month service use according to telephone interviews, and 6-month service use according to hospital administrative data. Fisher's exact test or chi-square tests were used for all categoric comparisons. The Kolmogorov-Smirnov two-sample test for equal distributions was used for the CES-DC, as this variable was found to violate the assumption of normality for a t-test. Negative binomial regressions were conducted for all count data. Negative binomial regression is often preferred for analyzing count data over the Poisson regression model because most count data do not meet the strict assumptions required by the Poisson model and because the negative binomial regression model is superior when data like ours are highly variable [21].

Our total obtained sample of 179 provided 80% power at an alpha of 0.05, given our a priori assumptions that 55% of our intervention group would get subsequent healthcare while just 35% of our control group would. All analyses were conducted on an intent-to-treat basis.

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Results 

Impact of experimental condition on subsequent healthcare utilization 

Table 3 presents adolescent self-report data on healthcare utilization for the 4-month period following initial screening. The adolescent medicine clinic and the emergency room were the two most common sources of care. The TSS and UC+ groups did not differ on any index of self-reported healthcare utilization. One hundred twenty-seven out of 179 (71%) total participants completed the 4-month follow-up telephone interview.

Table 3. Results of 4-month self-report telephone interviews of service utilization by study condition (N = 127).

	Total sample	Control	Experiment	p-valuea
Call completed	127 (70.1%)	67 (74.4%)	60 (67.4%)	.327
Any visits (yes)
Teen clinic	52.8%	56.7%	48.3%	.377
ER	30.2%	26.9%	33.3%	.383
Psychiatristb	11.2%	10.4%	11.7%	1.000
Family therapy	7.1%	7.5%	6.7%	1.000
Other therapy	28.4%	32.8%	23.3%	.246
Overnight stay	7.8%	9.0%	6.7%	.748
Mean number of visits
Teen clinic	1.2	1.4	1.0	.218
ER	0.6	0.4	0.5	.672
Psychiatristb	1.7	1.1	2.3	.271
Family therapy	0.7	0.5	0.9	.662
Other therapy	3.4	4.1	2.6	.457

Table 4 demonstrates that those completing the 4-month interview in the TSS versus UC+ groups did not differ on baseline demographic and clinical characteristics. We also compared those who completed this interview (n = 127) with those who did not (n = 52). Completers had fewer numbers of substances used at baseline, more medical visits 6 months prior to study enrollment, and more mental health visits 6 months following study enrollment (all p < .05). There were no differences in demographic characteristics, CES-DC score, suicidal thoughts, total days of substance use, mental health visits prior to study enrollment, or medical visits following enrollment.

Table 4. Baseline sample characteristics of participants completing a 4-month telephone interview by study condition (N = 127)

	Total sample	Control	Experiment	p-valuea
Age (mean)	17.2	17.3	17.1	0.687
Sex
Male	15.0%	11.9%	18.3%	0.332
Female	85.0%	88.1%	81.7%
Race
White	22.1%	23.9%	20.0%	0.671
Nonwhite	77.9%	76.1%	80.0%
CES-DC score	27.1	25.6	28.7	0.220
Suicidal thoughts (yes)	40.2%	35.8%	45.0%	0.365
Number of substance used (mean)	1.3	1.3	1.2	0.606
Total daysb substances used (mean)	11.2	7.0	7.8	0.716
6 months prior to enrollment date:
Mental health visits (mean)	1.4	2.0	0.7	0.322
Medical visits (mean)	3.4	3.8	2.9	0.163
6 months following enrollment date:
Mental health visits (mean)	2.1	1.8	2.3	0.718
Medical visits (mean)	2.3	2.6	2.0	0.231

Table 5 presents hospital administrative data for healthcare utilization for the 6-month period following initial screening. Similar to the self-report data, the TSS and UC+ groups did not differ on any measure of medical or mental healthcare utilization. Two other interesting findings arose from Table 5. First, the two groups did not differ on healthcare use for the 6-month period prior to initial screening, again suggesting successful randomization procedures. Second, mental health use was somewhat lower according to administrative data versus adolescent self-reports.

Table 5. Service use according to hospital administrative data (N = 179).

	Total sample	Control	Experiment	p-valuea
6 months prior to enrollment date
Any medical service use (yes)	80.5%	83.3%	77.5%	.352
Any mental health service use (yes)	19.0%	20.0%	17.9%	.849
Mean medical visitsb	3.0	3.5	2.6	.057
Mean mental health visitsb	1.1	1.6	0.6	.360
6 months following enrollment date
Any medical service use (yes)	67.0%	71.1%	62.9%	.268
Any mental health service use (yes)	17.3%	16.7%	18.0%	.846
Mean medical visitsb	2.1	2.4	1.9	.198
Mean mental health visitsb	1.6	1.4	1.8	.646

Post hoc analyses 

Given this interesting second finding of lower rates of service for administrative data and the fact that we decided not to use MI for adolescents who endorsed high motivation to seek care, we explored the relationship between the youth's self-report on intentions to seek care and the youth's actual use of services according to the 6-month administrative data. To investigate this relationship, we split the TSS youths into two groups according to their action plans from the first call: Treatment Endorsers (who reported that they planned to seek services, had initiated care, or continued to be in services) and Treatment Nonendorsers (who endorsed other action plans). Regarding medical services, Treatment Endorsers and Treatment Nonendorsers did not differ on their use according to administrative data (68% vs. 52%, chi-square = 1.8, p = .18). Regarding mental health services, Treatment Endorsers did have higher levels of use according to administrative data relative to Treatment Nonendorsers (30% vs. 0%, chi-square = 9.3, p = .001). Nevertheless, it is noteworthy that 70% of self-identified Engagers had no subsequent mental health service use according to our hospital's 6-month administrative data.

In addition, given our lack of an experimental effect, we explored two possible moderating/mediating factors: patient's age and receipt of MI. Given that older adolescents may play larger decision making roles in seeking healthcare services relative to younger adolescents, we explored age by study condition interaction effects. No effects were found. Because MI might be a powerful engagement strategy, we analyzed service utilization for those youths who had at least one MI call versus those youths who did not. We did not find differences in service utilization between these two groups.

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Discussion 

Our major finding was that TSS did not increase subsequent utilization of either medical or mental health services for adolescents screening positive for psychosocial problems in a primary care clinic. This finding held true whether service utilization was assessed through self-report or administrative data. Our study was novel in that we employed routine computerized screening and telephone support that included some case management and brief amounts of telephone-delivered MI.

Multiple aspects regarding our TSS' brief MI component may have lead to null findings. Most importantly, few youths received MI because case management activities dominated most calls. We implemented MI over the phone, but Carey and colleagues [22] noted that face-to-face MI has resulted in optimal outcomes. Given that Grenard et al. [23] found that offering normative feedback on substance use led to more successful MI interventions, perhaps we should have include normative feedback to adolescents. Furthermore, the duration of TSS phone calls may have been insufficient to produce change. Although previous TSS research that did not feature MI has utilized similarly brief calls [6], Rubak and colleagues [24] found a positive relationship between MI dose and subsequent treatment adherence.

Other aspects of TSS may have attenuated treatment effects. We delivered TSS to just adolescents and not parents, given the difficulties in reaching multiple family members, the adolescent's expanding role in healthcare decision making, and the uncertainty regarding parental knowledge about or views on the adolescent's psychosocial problems. However, parental factors can play major roles in whether or not adolescents obtain mental healthcare [25], particularly for younger youths needing transportation to services. Hence, including parents as recipients of TSS calls may have led to greater service engagement.

Besides characteristics of our TSS intervention, demographic and clinical features of our sample may have contributed to our nonsignificant findings. Many adolescents may lack the insight and abstract thinking skills needed to take full advantage of various TSS components. In addition, our sample had moderate levels of depressive symptoms, and MI has been found to be more beneficial for adolescents with lower levels of depressive symptoms [26]. Depressive symptoms may interfere with both referral assistance and MI in diverse ways, such as decreasing an adolescent's ability to remember and attend appointments.

Five methodological limitations deserve closer scrutiny. First, our sample was recruited from a single primary care clinic and had fairly homogenous features (predominantly African American, female, and public insurance recipients). Therefore, although these populations have been historically underrepresented in clinical research, future work is needed to see if our results are generalizable to other demographic groups. Second, we did not assess characteristics of those who declined study participation; therefore, we cannot ascertain if participation biases might have limited our sample's representativeness to routine urban primary care practices. Third, one of our telephone interventionists' fidelity to MI principles was suboptimal, in part because of the considerable case management aspects of the calls. Fourth, interventionists were not blind to patient randomization status—a design feature common to all psychosocial intervention studies. Calls between experimental conditions might have differed systematically in nonspecific ways (e.g., degree of warmth offered to recipients) that might have influenced our findings. Fifth, the inability of our administrative data to capture services received outside of our hospital (e.g., church or community resources) may have led to an underestimate of actual utilization. Nevertheless, given that our hospital is the largest healthcare provider in our region and that we obtained comparable results through adolescent self-reports, we doubt that limitations of administrative data contributed significantly to our findings.

In summary, TSS did not produce the anticipated increases in service utilization for adolescents with psychosocial problems. Our study had numerous methodologic strengths, including apparently successful randomization in achieving equivalent groups at baseline and multiple approaches for assessing service utilization. Nevertheless, future research might benefit from more comprehensive assessment of participants' baseline psychological characteristics (e.g., interest and confidence in obtaining services) and careful modifications of our intervention's characteristics discussed earlier. Future investigations should also explore the dose of MI and/or case management needed to produce adolescent behavior change. On a positive note, given that each of the three TSS calls was completed by a strong majority of participants, TSS appears feasible and acceptable to adolescents with psychosocial problems. This finding is similar to Burleson and Kaminer (2007) [27] examination of a telephone intervention for adolescents. The next goal for TSS should be demonstrating not only social validity but also clinical utility for adolescents with psychosocial problems.

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Acknowledgments 

This research was funded by the National Institute of Drug Abuse grant R01DA018943-04 (PI: Kelly J. Kelleher).

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