What parents of adolescents in residential substance use treatment want from continuing care: A content analysis of online forum posts

Parent SMART: Effects of residential treatment and an adjunctive parenting intervention on behavioral health services utilization

INTRODUCTION

Scant research has examined the impact of residential treatment on adolescent behavioral healthcare utilization post-discharge, even though behavioral healthcare utilization is major driver of healthcare costs. In the primary analyses of a pilot randomized trial, Parent SMART - a technology-assisted intervention for parents of adolescents in residential treatment - was found to improve parental monitoring and parent-adolescent communication, reduce adolescent drinking, and reduce adolescent school-related problems, relative to residential treatment as usual (TAU). The goal of this secondary analysis of the pilot randomized trial was to assess the effects of residential treatment and the adjunctive Parent SMART intervention on both the amount and type of subsequent behavioral healthcare utilization.

METHOD

The study randomized sixty-one parent-adolescent dyads to residential TAU (n = 31) or residential TAU plus Parent SMART (n = 30). Of the 61 dyads, 37 were recruited from a short-term residential facility and 24 were recruited from a long-term facility. Adolescents completed a structured clinical interview and self-reported their behavioral health-related visits to the emergency department, nights in residential/inpatient, and outpatient visits over the past 90 days, at baseline, 12-, and 24-weeks post-discharge. Generalized linear mixed models (GLMMs) examined both linear and non-linear (pre- to post- residential treatment) trends, pooled, and stratified by residential facility to examine behavioral health service utilization.

RESULTS

Both the linear and pre-post GLMMs revealed that behavioral health-related emergency department visits and residential/inpatient nights decreased across both residential facilities. GLMMs estimating change from the pre- to post period indicated that outpatient visits increased across both facilities. There were no significant effects of the Parent SMART adjunctive intervention in GLMMs, though bivariate tests and the direction of effects signaled that Parent SMART was associated with more nights of residential/inpatient utilization.

CONCLUSION

Residential substance use treatment may reduce adolescents' subsequent utilization of costly behavioral healthcare services such as emergency department visits and residential/inpatient nights, while increasing utilization of outpatient services. Parent SMART was not associated with significant changes in behavioral healthcare utilization, but the pattern of results was consistent with prior literature suggesting that stronger parenting skills are associated with greater utilization of non-emergency services.

Refining Parent SMART: User feedback to optimize a multi-modal intervention

INTRODUCTION

The continuing care period following residential substance use treatment is a time when adolescents are at especially high risk for relapse, yet few families engage in traditional office-based care. Parent SMART (Substance Misuse among Adolescents in Residential Treatment) is a multi-component continuing care intervention for parents that combines three digital health technologies - an "off the shelf" online parenting program, daily phone notifications, and an online parent networking forum - with support from a parent coach. The current study solicited both qualitative and quantitative user feedback about Parent SMART to ensure responsivity to user preferences, refinement, and continuous improvement of the intervention.

METHODS

Exit interviews were conducted with 30 parents who received Parent SMART, which includes (1) a parent networking forum; (2) daily text messages reminders of skills, (3) an "off-the-shelf" online parenting program; and (4) in-person or telehealth parent coaching sessions. The study collected qualitative feedback using semi-structured interviews and obtained quantitative feedback via a series of ratings of each Parent SMART component on a 5-point Likert scale administered at each follow-up assessment.

RESULTS

Quantitative feedback suggest that parents rated all four elements of Parent SMART as easy to use. Qualitative feedback revealed that parents valued several aspects of Parent SMART including the brevity and structure of the intervention elements, the reminders to use parenting skills, and the sense of social connectedness fostered by different components. Recommended refinements included a number of strategies to enhance personalization and ease of navigation.

CONCLUSIONS

Parent feedback informed enhancements to the Parent SMART intervention prior to implementation in a larger, ongoing pragmatic effectiveness trial. The current study serves as a model for applying a staged person-centered approach and eliciting both quantitative and qualitative feedback to refine digital health technologies.

The effects of neighborhood perceptions on response to a technology-assisted parenting intervention for adolescent substance use: protocol of a diversity supplement to parent SMART (Substance Misuse in Adolescents in Residential Treatment)

BACKGROUND

It is well established that an adolescent's neighborhood is associated with their likelihood of developing a substance use disorder. The availability of drugs, lack of access to resources, and exposure to violence are all associated with greater substance use among young people, leading to more pronounced health inequities. Technology assisted interventions (TAIs) have been touted to enhance the reach of substance use treatment and improve outcomes for high-need families living in underserved neighborhoods. A key question is whether neighborhood characteristics impact the effectiveness of TAIs, given these interventions are embedded within an adolescent's natural environment. This National Institute on Drug Abuse-funded Diversity Supplement will examine the role of perceived neighborhood characteristics on response to Parent SMART, a TAI for parents of adolescents in residential substance use treatment (R37DA052918; PI: Becker). Aim 1 will use both adolescent and parent self-report of multiple neighborhood dimensions (e.g., physical environment, social disorder, satisfaction with community resources) to identify indicators predictive of treatment response. Aim 2 will then explore the indirect relationship between neighborhood context and response to Parent SMART, via engagement.

METHODS

Participants include adolescent and parent dyads enrolled in an effectiveness trial evaluating Parent SMART, a TAI for parents of adolescents in residential substance youth treatment. Participants will complete self-report measures of neighborhood physical environment, social disorder, and satisfaction with community resources at baseline to predict parenting and youth substance outcomes at 6-, 12-, and 24-weeks post discharge.

DISCUSSION

To date, few studies have explicitly tested how neighborhood affects response to TAIs for adolescent substance use. Assessing adolescent and parent perceptions of neighborhood characteristics holds potential to pinpoint key contextual factors that affect TAI response and to promote consideration of multi-level health equity determinants in substance use research. Understanding neighborhood influences can advance public health by helping tailor TAIs to address the unique needs of adolescents living in underserved communities.

TRIAL REGISTRATION

This study extends the measurement and analysis plan of a pragmatic effectiveness trial. The pragmatic effectiveness trial is registered at ClinicalTrials.gov NCT05169385; https://clinicaltrials.gov/ct2/show/NCT05169385.

Juntos hacemos la diferencia [together we make the difference]: A network analysis of Latinx caregivers' use of youth support services

Latinx families face unique barriers to accessing traditional youth mental health services and may instead rely on a wide range of supports to meet youth emotional or behavioral concerns. Previous studies have typically focused on patterns of utilization for discrete services, classified by setting, specialization, or level of care (e.g., specialty outpatient, inpatient, informal supports), yet little is known about how youth support services might be accessed in tandem. This analysis used data from the Pathways to Latinx Mental Health study - a national sample of Latinx caregivers (N = 598) from across the United States collected at the start of the coronavirus pandemic (i.e., May-June 2020) - to describe the broad network of available supports that are used by Latinx caregivers. Using exploratory network analysis, we found that the use of youth psychological counseling, telepsychology, and online support groups was highly influential on support service utilization in the broader network. Specifically, Latinx caregivers who used one or more of these services for their child were more likely to report utilizing other related sources of support. We also identified five support clusters within the larger network that were interconnected through specific sources of support (i.e., outpatient counseling, crisis, religious, informal, and non-specialty). Findings offer a foundational look at the complex system of youth supports available to Latinx caregivers, highlighting areas for future study, opportunities to advance the implementation of evidence-based interventions, and channels through which to disseminate information about available services.

From parenting skills to adolescent treatment needs: Questions elicited by parents of adolescents discharged from residential treatment

Background

Despite the utility of parent involvement in continuing care following adolescent residential treatment, parent engagement in traditional office-based treatment is low. In our prior work, we found that parents who had access to a continuing care forum directed questions to a clinical expert and to other parents around five topics: parenting skills; parent support; managing the post-discharge transition; adolescent substance use; family functioning. The current qualitative study elicited questions from parents without access to a continuing care support forum to explore overlapping and new themes.

Methods

This study was embedded within the pilot trial of a technology-assisted intervention for parents of adolescents in residential treatment for substance use. Thirty-one parents randomized to residential treatment as usual were asked two prompts at follow-up assessments: what questions they would like to ask a clinical expert and what questions they would like to ask other parents of adolescents discharged from residential care. Thematic analysis identified major themes and subthemes.

Results

Twenty-nine parents generated 208 questions. Analyses revealed three themes identified in prior work: parenting skills; parent support; adolescent substance use. Three new themes emerged: adolescent mental health; treatment needs; socialization.

Conclusions

The current study identified several distinct needs among parents who did not receive access to a continuing care support forum. Needs identified in this study can inform resources to support parents of adolescents during the post-discharge period. Parents may benefit from convenient access to an experienced clinician for advice on skills and adolescent symptoms, paired with access to parental peer support.

Internet+Continuous Nursing Mode in Home Nursing of Patients with T-Tube after Hepatolithiasis Surgery

This study was to explore the effect of a continuous nursing model based on the mobile Internet in the home nursing of patients with T-tube after hepatolithiasis surgery. A continuous nursing system based on the mobile Internet was constructed, and 94 discharged patients with T-tube after biliary tract surgery were selected as the study subjects. The differences of complication rate, referral rate, nursing satisfaction, self-care ability, and quality of life score through the 36-item short form health survey (SF-36) after routine health education nursing (control group, n = 47) and continuous nursing mode based on the Internet (observation group, n = 47) were explored. The results showed that the success rate of the continuous nursing system based on mobile Internet in processing user requests was 96.2%. After nursing, the total complication rates of the control group and the observation group were 34.0% and 6.4%, the total satisfaction rates were 42.6% and 87.2%, and the referral rates were 23.4% and 6.4%, respectively, and the difference was statistically significant (P < 0.05). After nursing, the scores of self-care ability and SF-36 quality of life in the observation group were higher than those in the control group, and the difference was statistically significant (P < 0.05). In summary, the continuous nursing platform based on mobile Internet technology can meet the needs of users, and the nursing mode can significantly improve the home self-care ability of discharged patients with T-tube after surgery and improve the nursing effect, which is conducive to the rehabilitation of patients.

Parent SMART (Substance Misuse in Adolescents in Residential Treatment): Protocol of a Randomized Effectiveness Trial of a Technology-Assisted Parenting Intervention

BACKGROUND

Adolescents in residential substance use treatment are at extremely high risk for relapse following discharge to the community. Parenting practices, including parental monitoring and parent-adolescent communication, have been established as key predictors of adolescent substance use outcomes and relapse. However, traditional office-based therapy may not be feasible for parents who face structural and systemic barriers. There is a clear need for effective, accessible, and scalable interventions for parents of adolescents receiving residential substance use treatment. In a prior pilot randomized controlled trial, we tested Parent SMART (Substance Misuse among Adolescents in Residential Treatment)-a technology-assisted parenting intervention informed by extensive formative research-as an adjunct to residential treatment as usual (TAU). Parent SMART demonstrated high feasibility and acceptability, as well as evidence of effectiveness in improving parental monitoring and communication.

OBJECTIVE

This protocol paper describes a fully-powered randomized controlled pragmatic effectiveness trial of Parent SMART as an adjunct to residential TAU. We hypothesize that families who receive Parent SMART will demonstrate greater improvements in parenting skills, reductions in adolescent substance use, and reductions in adolescent problem behaviors relative to families that receive residential TAU. We will test the exploratory hypothesis that reductions in adolescent substance use will be partially mediated by improvements in parenting skills.

METHODS

Adolescent-parent dyads (n = 220 dyads; 440 total) will be randomized to either residential TAU only or Parent SMART+TAU. Parents randomized to Parent SMART will receive access to a networking forum, an off-the-shelf computer program called Parenting Wisely, and up to four telehealth coaching calls. Multimethod follow-up assessments consisting of self-reported parent and adolescent measures, a parent-adolescent in vivo interaction task, and 8-panel urine screens will be conducted 6, 12, and 24 weeks postdischarge from residential care. Measures will assess parenting skills, adolescent substance use, and adolescent problem behaviors. Analyses will be conducted using latent change score structural equation modeling.

RESULTS

The trial was funded in August 2021; ethics approval was obtained in August 2020, prior to funding. Due to concerns with the administrative interface in the pilot trial, the Parent SMART networking forum is currently being rebuilt by a different vendor. The programming is scheduled to be completed by December 2021, with recruitment beginning in February 2022.

CONCLUSIONS

The proposed research has the potential to advance the field by serving a high-need, underserved population during a vital treatment juncture; targeting parenting practices (putative mediators) that have been shown to predict adolescent substance use outcomes; addressing barriers to accessing continuing care; and testing a highly scalable intervention model.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05169385; https://clinicaltrials.gov/ct2/show/NCT05169385.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/35934.

Parent Smart: Effects of a Technology-Assisted Intervention for Parents of Adolescents in Residential Substance Use Treatment on Parental Monitoring and Communication

Promoting parent involvement in adolescent residential substance use treatment is an evidence-based principle, yet engaging parents is challenging. Parent SMART (Substance Misuse among Adolescents in Residential Treatment) is a technology-assisted intervention that was designed to engage parents of adolescents in residential SU treatment during the post-discharge transition period. A prior pilot randomized controlled trial (n=61 parent-adolescent dyads) established Parent SMART's feasibility, acceptability, and preliminary effectiveness in reducing adolescent substance use and substance-related problems across both a short- (i.e., acute stay) and long- (i.e., residential) term care facility. The current secondary analysis extends this prior work by examining whether Parent SMART was associated with improvements in putative mediators of change: parental monitoring and parent-adolescent communication. Multi-modal assessment consisting of participant-report questionnaires and a behavioral interaction task evaluated parenting processes over the 24 weeks following discharge. Generalized linear mixed models showed no significant time by condition interactions on the participant-report questionnaires, but found significant interactions on all five scales of the behavioral interaction task. Supplemental analyses by residential facility detected additional interaction effects favoring Parent SMART on the participant-report questionnaires. Plotting of the interaction effects indicated that Parent SMART was associated with improvements in parenting processes, whereas TAU was associated with relatively stable or worsening parenting scores. Parent SMART demonstrated preliminary effectiveness in improving key parenting processes among adolescents discharged from residential substance use treatment. Parent SMART warrants further testing in a fully-powered trial that evaluates parental monitoring and parent-adolescent communication as mediators of change.