Primary Connections for Youth and Families

All consented youth age 12-17 years complete a patient-facing, well-validated digital screening tool, the CRAFFT (Knight et al., 2003), which assesses number of days during the past year, and then the past 3 months, during which various formulations of AOD were used. If youth report 0 days of AOD use, the tool asks whether they have ridden in a car whose driver was intoxicated; if this response is negative, they are categorized Low Risk. If youth report \> 0 days of AOD use, the tool asks five additional questions assessing use risk and consequences; also, youth who report nicotine use in the past 30 days complete a nicotine dependence checklist (DiFranza et al., 2002). Screen data are then combined to sort youth into three risk categories: Riding Risk Only (no reported AOD use but indicated rode in car driven by intoxicated person), Distant Use (reported AOD use in past year but not past 3 months), or Recent Use (reported AOD use in past 3 months).

In the wait area, youth receive a tablet-delivered brief digital AOD education tutorial that includes advice to abstain from or reduce AOD use. The tutorial focuses on adolescent AOD prevalence rates and related behavioral symptoms; AOD use neurobiology and its relation to adolescent health; and common AOD impacts on developmental milestones (see Meredith et al., 2021). Psychoeducation for AOD has shown positive effects as both a universal and selective prevention strategy (Bröning et al., 2021; Das et al., 2016).

In primary care (PC) office, youth and providers together complete a tablet-supported brief negotiated interview (BNI; see Beaton et al., 2016). The BNI is informed by AOD use data gathered during youth screening (O'Grady et al., 2015). The BNI focuses on (a) education about AOD disorders, including youth and family factors that impact AOD use; (b) user-tailored feedback comparing the given youth's AOD use and related problems to national norms, along with information on neurobiological effects and developmental impacts of frequent use (Harris et al., 2012); (c) motivational tools (e.g., reduction readiness rulers) and decisional balance exercises (weighing positive versus negative personal impacts of AOD use) tailored to the youth's use levels (Slavet et al., 2006; King et al., 2009); and (d) AOD reduction goal-setting interventions tailored to the youth's readiness to change AOD use (Walton et al., 2013).

In primary care (PC) offices providers and youth discuss the value of attending counseling services to address AOD-related problems (Cucciare et al., 2015); counseling referral links that the PC site curates with local services; and the value of youth talking directly with caregivers about their AOD involvement as a first step toward support-seeking and behavior change (Gayes \& Steele, 2014). Providers directly recommend AOD counseling and facilitate a first appointment for youth who agree.

Screening procedures incorporate procedures for youth described for Standard Screening. They also incorporate two sources of caregiver-report data. First is an estimate of youth AOD use based on the Screening 2 Brief Intervention tool (Levy et al., 2016). Second is a 9-item checklist of youth mental health (MH) problems (Achenbach \& Rescorla, 2001). If both youth and caregiver report no AOD use or clinical-level MH problem, the family is categorized Low Risk. Otherwise, screen data are combined to sort families into three risk categories: Hidden SU Risk (youth reports AOD use in past year; caregiver reports no youth AOD use in past year), Named MH Risk (caregiver reports no youth AOD use in past year; caregiver reports clinical-level score for at least one youth MH domain), Named SU Risk (caregiver reports youth AOD use in past year).

Youth proceed as indicated in the SBIRT-A-Standard condition based on youth screen data. In the wait area, caregivers receive a tablet-delivered parenting tutorial that covers two AOD risk domains: education about adolescent AOD including prevalence rates, related behavior problems, neurobiological and health effects, and impacts on developmental milestones; and education and video modeling about parenting strategies that reduce or moderate AOD risk, including positive communication, fair and consistent discipline, and non-judgmental conversations about AOD use (Bo et al., 2018). Positive parenting education has been shown effective as a universal and selective prevention strategy in parent-focused AOD prevention trials (Kuntsche \& Kuntshce, 2016; Ladis et al., 2019; Van Ryzin et al., 2017). Tutorials are tailored for each risk category.

Youth proceed as indicated in the SBIRT-A-Standard condition based on youth screen data. In primary care (PC) offices, caregivers and providers together complete a tablet-supported parenting BNI informed by data from the caregiver screen only that parallels the youth BNI (e.g., AOD education, developmental risks) and also includes motivation, modeling, and goal-setting on positive parenting (e.g., non-judgmental conversations; see above) and effective parent-youth communication about AOD use (Carver et al., 2017).

In PC offices, providers meet separately with youth and caregivers to discuss the value of talking directly with the other family member about AOD risk while practicing positive communication strategies. Whenever both youth and caregiver agree to talk together, providers convene a brief facilitated conversation about AOD risk. In this conversation providers (a) emphasize that a positive youth-caregiver relationship is the strongest protective factor for youth development and (b) follow guidelines for brief triadic risk-reduction interventions focused on positive family communication about AOD risk (Guilamo-Ramos et al., 2020). When indicated, providers directly recommend AOD counseling and facilitate a first appointment for families who agree.