News & Updates — Grantee Spotlight

Leslie Walker-Harding, M.D., senior vice president, chief academic officer, and chair of the Department of Pediatrics at Seattle Children’s Hospital, recently led a FORE-supported workshop convened by the National Academies of Science, Engineering, and Medicine that explored ways pediatricians and other primary care providers can help prevent substance use disorder (SUD) among adolescents. The workshop brought together some 300 experts — researchers; clinicians; members of parent and family organizations; federal, state, and local health officials; and Capitol Hill staff — and resulted in a report and interactive website that compiles the evidence of what works to prevent SUD among adolescents, explores reasons why most primary care providers have not adopted evidence-based approaches, and outlines policies that could help. FORE asked Walker-Harding about what she’s learned about preventing SUDs among adolescents and what could encourage other providers to adopt evidence-based approaches.

How did you become interested in prevention and early intervention for adolescents?
Walker-Harding: I’m an adolescent medicine physician and became interested in youth violence while doing my specialty training and fellowship. As I began to practice, I really noticed violence is just a symptom of a lack of support. And if you take care of that, you won’t see kids who feel they need to respond with violence. As my career progressed, I got more interested in mental health and substance abuse. I found there’s some dialogue around mental health but very little around substance use. In pediatrics, it’s almost silent perhaps because most people don’t go into pediatrics to take care of teenagers. They go into pediatrics to take care of little kids. But substance use disorders are a pediatric disease with adult manifestations. Most people begin using substances during their adolescence. So if we actually prevented that, we’d have fewer people with disorders.

The National Academies report is titled Family-Focused Programs to Prevent Substance Use Disorders in Adolescence. Why focus on the family, rather than just teens?
Walker-Harding: Many people think teens start using substances because of peer pressure. What I saw very much is that parents and other caregivers are critical in determining whether a kid will initiate substance use and whether they’ll be able to express how they’re feeling. The kids who look like they don’t care and don’t want to be in the room with you are watching and wishing for their parents’ regard. And the research shows, if you’re an engaged parent, if you give boundaries, and you talk about what’s acceptable, your kid will still make their own choices, but they know where the borders are. Over the years, I’ve had parents who were on the run from the law or parents who were quite sophisticated drug dealers. Their teens were helped when their parents spoke up to say, ‘I don’t want this for you.’ Any parent can be impactful to their child.

How commonly do primary care providers screen for substance use problems among adolescents?
Walker-Harding: When polled, most primary care providers including some 70 percent to 80 percent of pediatricians say it’s important to screen, but few actually do because they don’t feel they have enough training and they don’t know what to do when they hear something that should be acted on. And so part of the message is getting providers to understand that anything you do — even saying this is not healthy for you, even a brief intervention — is helpful to kids versus doing nothing. If teens disclose substance use and you don’t respond, it can be devastating.

In terms of offering prevention programs within primary care, what’s practical?
Walker-Harding: We have half a century of evidence showing prevention programs are effective; the work now is to figure out how to implement them in health care. Given the time constraints, we cannot expect providers to lead programs themselves. They may not even be the right people to do it; it could be a community health worker, navigator, or someone else who’s been trained to do so. But a warm handoff from a provider can have a big impact. There’s been research showing that the uptake of prevention programs is higher when the primary care doctor or nurse practitioner says, ‘We have this program, would like you to go?’ Some parents don’t want to be told what to do in the school system. But people expect that their doctor is going tell them things about raising their child. Maybe it doesn’t feel as stigmatizing. Providers can also explain that there’s a need for universal prevention, that these programs benefit all families.

What options are there to help pay for prevention services in primary care?
Walker-Harding: Medicaid and other public health insurance programs cover about half of the kids in the country, so states could apply for waivers to pay for prevention programs. If they can demonstrate they work, others will come along. States could also direct some of their opioid settlement funds toward this kind of universal, primary prevention. So far, I’ve seen very little of that. There’s a big focus on preventing overdoses, preventing death. But to really make a difference, we need to go much further upstream.

Given the attention to the youth mental health crisis, what are your hopes that prevention programs will get more attention?
Walker-Harding: We’ve had the ability to change our society and change public health for many years. I think what we need is the will to do so. Long term, investment in prevention saves money. People need to know there are things we can do. We’re not helpless. It’s not a foregone conclusion that all these kids will have substance use disorders, have mental health problems. I hope that this report will get into not just health care spaces, but industry spaces and commercial space and other spaces that depend on us having a population that’s healthy to keep it going.