Technology-assisted intervention for parents of adolescents in residential substance use treatment: protocol of an open trial and pilot randomized trial

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.

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.

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.

Online interventions for cannabis use among adolescents and young adults: Systematic review and meta-analysis

BACKGROUND

Young people present high rates of cannabis use, abuse, and dependence. The United Nations estimates that roughly 3.8% of the global population aged 15-64 years used cannabis at least once in 2017. Cannabis use in young people may impair cognitive skills, interfere with learning, impact relationships, and lead to long term behavioural and psychological consequences. Online cannabis interventions (OCI) are increasingly popular, but their dissemination is not often supported by empirical evidence.

AIM

To systematically compile and analyse the effectiveness of OCI for the reduction of cannabis use among adolescents and young adults (AYA).

METHODS

Pooled effect sizes of cannabis use between treatment and control groups were estimated. For each comparison, Hedge's g was calculated using a random effects model.

RESULTS

The search strategy yielded 4531 articles. Of those, a total of 411 articles were retrieved for detailed evaluation resulting in 17 eligible studies (n = 3525). Analyses revealed that online interventions did not significantly reduce cannabis consumption (Hedge's g = -0.061, 95% CI [-0.363] to [-0.242], p = .695) and high heterogeneity was noted (Q = 191.290). More recent studies using structured interventions, daily feedback, AYA centred designs, and peer support, specifically targeting CU seemed to have positive effects to address CU in this population.

CONCLUSIONS

The lack of positive outcomes suggests that more specific and targeted interventions may be necessary to promote cannabis-related behavioural change among young people. These targeted interventions may include structured CU modules, daily feedback, peer support for increased adherence, user-centred design procedures, and input from key stakeholders such as families and service providers.

Identifying alcohol misuse biotypes from neural connectivity markers and concurrent genetic associations

Alcohol use behaviors are highly heterogeneous, posing significant challenges to etiologic research of alcohol use disorder (AUD). Magnetic resonance imaging (MRI) provides intermediate endophenotypes in characterizing problem alcohol use and assessing the genetic architecture of addictive behavior. We used connectivity features derived from resting state functional MRI to subtype alcohol misuse (AM) behavior. With a machine learning pipeline of feature selection, dimension reduction, clustering, and classification we identified three AM biotypes-mild, comorbid, and moderate AM biotypes (MIA, COA, and MOA)-from a Human Connectome Project (HCP) discovery sample (194 drinkers). The three groups and controls (397 non-drinkers) demonstrated significant differences in alcohol use frequency during the heaviest 12-month drinking period (MOA > MIA; COA > non-drinkers) and were distinguished by connectivity features involving the frontal, parietal, subcortical and default mode networks. Further, COA relative to MIA, MOA and controls endorsed significantly higher scores in antisocial personality. A genetic association study identified that an alcohol use and antisocial behavior related variant rs16930842 from LINC01414 was significantly associated with COA. Using a replication HCP sample (28 drinkers and 46 non-drinkers), we found that subtyping helped in classifying AM from controls (area under the curve or AUC = 0.70, P < 0.005) in comparison to classifiers without subtyping (AUC = 0.60, not significant) and successfully reproduced the genetic association. Together, the results suggest functional connectivities as important features in classifying AM subgroups and the utility of reducing the heterogeneity in connectivity features among AM subgroups in advancing the research of etiological neural markers of AUD.

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.

Family involvement in treatment and recovery for substance use disorders among transition-age youth: Research bedrocks and opportunities

This article presents a narrative review and conceptual framework for research on family involvement across the continuum of substance use disorder (SUD) services for transition-age youth (ages 15-26). Though families are powerful resources for enhancing treatment and recovery success among youth with SUDs, they are not routinely included in clinical practice. This article summarizes youth SUD prevalence and service utilization rates and presents developmental and empirical rationale for increasing family involvement in services. It then describes key research issues on family involvement across the SUD services continuum: Problem Identification, Treatment Engagement, Active Treatment, Recovery Support. Within each phase, it highlights bedrock research findings and suggests promising opportunities for advancing the scientific knowledge base on family involvement. The main goals are to endorse family-oriented practices for immediate adoption in routine care and identify areas of research innovation that could significantly enhance the quality of youth SUD services.

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

BACKGROUND

Parents of adolescents in residential substance use (SU) treatment face a myriad of barriers to continuing care services. Growing research suggests that mobile health (mHealth) technologies can overcome common barriers to continuing care services, yet no work has addressed parents' needs. To gain insight into parents' continuing care needs, we analyzed online forum posts made by parents who received a novel mHealth intervention. Methods: Thirty parents received access to an online networking forum where they could connect with our adolescent SU expert or the community of parents also navigating their adolescent's post-discharge transition. In real-time, participants could ask questions and share information, experiences, and emotional support. Results: Twenty-one parents (70%) posted at least once; 12 parents made 15 posts to our expert, while 18 parents made 50 posts to the parent community. Thematic analysis uncovered five major themes: parenting skills; parent support; managing the post-discharge transition; adolescent SU; and family functioning. Conclusions: Parents discussed a range of topics directly and indirectly related to their adolescent's treatment. Incorporating networking forums into mHealth continuing care interventions offers parents a secure space to ask questions, share concerns, and gather information needed to support their adolescent's transition home.

Parent SMART (Substance Misuse in Adolescents in Residential Treatment): Pilot randomized trial of a technology-assisted parenting intervention

Adolescents in residential level of care for substance-related problems have high risk of relapse following discharge. Parent engagement lowers relapse risk, but there are myriad barriers to engaging parents in residential treatment and continuing care. Parent SMART (Substance Misuse in Adolescents in Residential Treatment) is a technology-assisted parenting intervention that was designed to circumvent barriers associated with traditional, office-based continuing care interventions to better engage parents. This pilot randomized trial assessed the acceptability, feasibility, and preliminary effectiveness of Parent SMART as an adjunctive intervention to adolescent residential treatment-as-usual (TAU). Sixty-one parent-adolescent dyads were randomized to Parent SMART+TAU or TAU-only. Thirty-seven dyads were recruited from a short-term facility and 24 dyads were recruited from a long-term facility. Those randomized to Parent SMART received a multi-component technology-assisted intervention combining an off-the-shelf online parenting program, coaching sessions, and a parent networking forum. Parent and adolescent assessments were conducted at baseline, 6, 12, and 24-weeks post-discharge. Feasibility (e.g., parental effectiveness) and acceptability (e.g., parental satisfaction, willingness to recommend the intervention) benchmarks were specified a priori as the primary hypotheses. Secondary effectiveness indicators were the proportion of days adolescent used alcohol, cannabis, and any substance. All acceptability and feasibility benchmarks were met or exceeded among dyads in both short- and long-term residential. Generalized linear mixed models showed no significant effects pooled across sites. Analyses by facility revealed two significant time by condition interactions. Adolescents in short-term residential whose parents received Parent SMART showed fewer drinking days and fewer school problems over time, relative to adolescents whose parents received TAU. Results indicate that Parent SMART was both acceptable and feasible, with preliminary indication of effectiveness among those in short-term residential. A fully-powered trial is warranted to reliably test the effectiveness of Parent SMART and understand possible mechanisms of improvement.

Conceptual framework for telehealth strategies to increase family involvement in treatment and recovery for youth opioid use disorder

With opioid use at crisis levels, it is imperative to support youth ages with opioid use disorders (OUD) in taking medication and accessing behavioral services over long periods. This article presents a conceptual framework for telehealth strategies that can be adopted to increase family involvement across a four-stage continuum of youth OUD treatment and recovery: Treatment Preparation, Treatment Initiation, Treatment Stabilization, OUD Recovery. It first identifies provider-delivered tele-interventions that can enhance OUD services in each of the four stages, including family outreach, family engagement, family-focused intervention, and family-focused recovery maintenance. It then introduces several types of direct-to-family tele-supports that can be used to supplement provider-delivered interventions. These include both synchronous tele-supports (remote interactions that occur in real time) such as helplines, peer-to-peer coaching, and online support groups; and asynchronous tele-supports (communications that occur without participants being simultaneously present) such as automated text messaging, self-directed internet-based courses, and digital web support.