Dismantling the Effects of Normative Feedback for Adolescents: A Small Randomized Trial

Background and Purpose:  In contrast to the voluminous research among college drinkers, there is limited research on whether normative feedback interventions are beneficial for adolescent drinkers during post assessment Motivational Interviewing (MI) interventions.  Although many empirically supported interventions have included normative feedback in adolescent substance use disorder interventions, the effects of normative feedback have never been disentangled.  This is unfortunate, as therapists in major studies have raised anecdotal concerns about using normative feedback with adolescents.  The purpose of this study was to isolate the impact of normative feedback on adolescents’ readiness to change, perceptions of Motivational Interviewing (MI) quality, treatment engagement, and three month substance use outcomes. 

Methods: Adolescents referred for substance use disorder (SUD) assessments at two not-for profit agencies were randomized to MI with Normative Feedback (MI+NF, n=26) or MI only (MI, n=22).  Study participants were, on average, 16.3 years of age (SD = 1.4) and were mostly male (77.1%).  Participants self-reported their racial backgrounds as Bi- or multi-racial 36.2%, African-American 36.2%, White, non-Hispanic 23.4%, Hispanic/Latino 2.1%, or Other race 2.1%.   Overall, 85.4% of participants met DSM V (APA, 2013) criteria required for past year SUD, despite not being asked the full criteria set. Adolescents were assessed with the Global Appraisal of Individuals Needs Quick Version (Gain Q3; Titus et al., 2012), a reliable and valid substance use disorder assessment.  We compared the two groups on post-intervention measures of readiness to change and self-reported MI quality, as well as on three month follow up reports of treatment engagement, days of binge drinking, and the overall percent of days of abstinence across substances.  

Results:  There were no significant differences between the MI+NF or MI conditions on changes in readiness, and although not significant, there was a decline in readiness for the overall sample.  Treatment satisfaction and ratings of MI quality were generally high with no between-group differences. Post hoc analyses revealed a non-significant trend where race interacted with treatment condition in predicting readiness to change.  In terms of three month follow up outcomes, the entire sample significantly increased their percent of days abstinent by approximately 10% at follow up (d=.32, p =.03), but there were no statistically significant differences between groups on any outcomes.  Non-significant trends favored MI (55%) vs. MI+NF (41.7%) for treatment engagement (OR=.60, ns).  Further, another non-significant trend (d=.24, p = .47) was that teens who engaged in treatment had larger increases (14%) in PDA compared to those who did not engage (7.2 %). 

Conclusions and Implications.  Notwithstanding the limited sample size of this trial, this study raises questions about how effective normative feedback is for adolescents.  Furthermore, given the negative trend for treatment engagement (d = - .31) for the normative feedback condition, larger trials are needed to rule out potentially iatrogenic effects of NF interventions for adolescents.  Finally, future research with adolescents should determine the mechanisms through which this intervention may produce negative effects.