The e-cigarette assessment for youth-Revised (EAsY-R): Preliminary results of a pilot study of measure refinement via cognitive interviewing.

The prevalence of youth vaping has, in a relatively short time, become an "epidemic." In the wake of such labeling by the Surgeon General, a number of important examinations of vaping have been conducted. These have largely focused on high school and college-age youth as this demographic shows the greatest prevalence of use. Nonetheless, no measure has been made available which might allow for the comprehensive assessment of quantity and frequency of vaping among this age group, thus aiding in standardization across settings. The current study utilized cognitive interviews with high school and college-age youth who use vaping devices to inform the preliminary development of such an assessment. The sample consists of eight students between the ages of 15 and 24 (Mage = 18.75, SD = 2.73, 62.5% female, 75.0% Hispanic/Latino/a/x, 100.0% White). Interviewing and measure refinement were conducted in a two-phase iterative fashion. Suggestions made during cognitive interviews resulted in the refinement of assessed content type, updated categories and pictures of vaping devices, as well as updated and age-relevant terminology. Further, instructions were streamlined, and assessment items and multiple-choice options were refined to maximize clarity and to minimize participant confusion. The result of this study, the E-Cigarette Assessment for Youth Revised, is a unique tool for standardizing examinations of the quantity and frequency of vaping behaviors among high school students and college-age youth.

Subjective norms as a mediator between exposure to online alcohol and marijuana content and offline use among adolescents.

INTRODUCTION: While adolescent substance use (SU) may be viewed as normative, SU can quickly escalate leading to consequences. Social media use may increase SU risk. Despite using social media to connect with others, adolescents also view depictions of glamorised SU by both peers and influential figures. Exposure to online alcohol and marijuana content may impact subjective norms (i.e., injunctive and descriptive) ultimately leading to increased offline SU. Data from a multi-wave project was collected to assess whether subjective norms-mediated associations between exposure to alcohol and marijuana content by peers and influential figures on Instagram and Snapchat and offline SU. METHODS: At Wave 1, participants were 264 adolescents (Mage  = 14.91, 51% female, 86% White, 85% Hispanic/Latino/a/x). RESULTS: Injunctive norms significantly mediated associations between exposure to alcohol content posted by peers and influential figures on Instagram and Snapchat and offline alcohol use. Injunctive norms significantly mediated associations between exposure to marijuana content posted by peers and influential figures on Instagram, and peers on Snapchat and offline marijuana use. Descriptive norms significantly mediated associations between exposure to alcohol content posted by peers on Instagram, as well as peers and influential figures on Snapchat and offline alcohol use. DISCUSSION AND CONCLUSION: Increased exposure to online SU content was more consistently associated with injunctive norms rather than descriptive norms. Future research should examine which social media features (e.g., the like button) contribute to increased subjective norms. Overall, findings suggest that social media may strongly convey approval of SU behaviours rather than actual use.

Remote Intensive Group Behavioral Treatment for Families of Children with Selective Mutism.

Selective mutism (SM) is a relatively rare, but highly interfering, child anxiety disorder characterized by a consistent failure to speak in certain situations, despite demonstrating fluent speech in other contexts. Exposure-based cognitive behavioral therapy and Parent-Child Interaction Therapy adapted for SM can be effective, but the broad availability and accessibility of such specialty care options remains limited. Stay-at-home guidelines to mitigate the spread of COVID-19 further limited the accessibility of office-based specialty care for SM. Building on separate lines of research supporting intensive treatments and telehealth service delivery models, this paper is the first to describe the development, preliminary feasibility, acceptability, and efficacy of a Remote Intensive Group Behavioral Treatment (IGBT) for families of young children with SM (N=9). Treatment leveraged videoconferencing technology to deliver caregiver training sessions, lead-in sessions, 5 consecutive daily IGBT sessions, and an individualized caregiver coaching session. Remote IGBT was found to be both feasible and acceptable. All families (100%) completed diagnostic assessments and caregiver-report questionnaires at four major study timepoints (i.e., intake, pre-treatment, post-treatment, 4-month follow-up) and participated in all treatment components. Caregivers reported high treatment satisfaction at post-treatment and 4-month follow-up and low levels of burden associated with treatment participation at post-treatment. Approximately half of participating children were classified as treatment responders by independent evaluators at post-treatment and 4-month follow-up. Although these pilot results should be interpreted with caution, the present work underscores the potential utility of using videoconferencing to remotely deliver IGBT to families in their natural environments.

The Role of Socialization Contexts on Adolescent Substance Use across Racial and Ethnic Groups.

Purpose of Review: This review summarizes theories and empirical work regarding socialization contexts contributing to substance use across marginalized adolescents. Future directions and recommendations to minimize the perpetuation of racial stereotypes are provided. Recent Findings: Neighborhoods high in social cohesion may offset substance use risk. Promoting school connectedness via increased support from teachers and peers could reduce school-based discrimination and enhance feelings of belongingness. The influence of peers on substance use engagement largely differs across racial groups and level of acculturation. Family cultural values emphasizing respect, obedience, and collectivism offer protection from substance use. Summary: Despite lower prevalence rates of adolescent substance use within racial/ethnic groups, rates of negative consequences due to substances are far greater compared to White adolescents. Transcultural factors (e.g., strong family ties), as well as culture-specific factors, should be leveraged to delay the onset of substance use and prevent negative sequelae resulting from substance use initiation.

The Impact of COVID-19 Experiences on Adolescent Internalizing Problems and Substance Use Among a Predominantly Latinx Sample.

Given the salience of socialization factors on adolescence and their role in vulnerability to disasters and trauma, this study examined whether COVID-19-associated fears and impacted quality of life mediated associations between pandemic-focused family conversations and media exposure and subsequent youth mental health. A primarily Latinx sample of adolescents (N = 167; Mage = 16.2 years, 44.9% female) participated in a longitudinal (summer 2020-winter 2020) COVID-19 study. COVID-19 media exposure predicted engagement in relevant safety behaviors, which negatively impacted quality of life, which in turn predicted increased internalizing problems. COVID-19 family conversations predicted social distancing fears, which negatively impacted quality of life, which then in turn also predicted increased internalizing problems. Targeting key socialization factors may minimize negative consequences following major community trauma among adolescents.

Recovery community centers: Characteristics of new attendees and longitudinal investigation of the predictors and effects of participation.

OBJECTIVE: Recovery community centers (RCCs) have expanded across the U.S., serving as social "recovery hubs" that increase recovery capital (e.g., employment, housing) by providing resources that clinical care does not provide. While research supports RCCs' general utility, little is known about new participants' characteristics, predictors of engagement, services used, and benefits derived. Greater knowledge would inform the field about RCCs' clinical and public health potential. METHOD: Prospective, single-group study of individuals (N = 275) starting at RCCs (k = 7) in the northeastern U.S. and reassessed 3 months later regarding the services these individuals used and the benefits they derived (e.g., reduced substance problems, enhanced quality of life [QOL]). Regression and longitudinal models tested theorized relationships. RESULTS: Participants were mostly young to middle-aged, racially diverse, single, unemployed, men and women, with low education and income, suffering from opioid or alcohol use disorder, with a history of psychiatric problems, low QOL, and prior treatment/mutual-help participation. Attendance varied greatly, but on average, was 1-2 times/week, with greater RCC engagement predicted by Hispanic ethnicity, shorter travel time, prior treatment, lower initial social support, and relatively greater baseline QOL (QOL was low overall). Commonly used and highly valued services included social support infrastructures (e.g., recovery coaching/meetings), and technological and employment assistance. In longitudinal analyses (n = 138), the study observed improvements in duration of abstinence, substance problems, psychological well-being, and QOL, but not in recovery assets. CONCLUSION: Findings generally are consistent with prior observations that RCCs engage and provide benefits for individuals facing the greatest challenges in terms of clinical pathology and low QOL and resources.

Message framing to inform cancer prevention pricing interventions in the UK and USA: a factorial experiment, 2019.

OBJECTIVES: To advance understanding of how message framing can be used to maximise public support across different pricing policies for alcohol, tobacco and sugary drinks/foods that prevent consumption of cancer-causing products. DESIGN: We designed a 3×4×3 randomised factorial experiment to test responses to messages with three pricing policies, four message frames and three products. SETTING: Online survey panel (Qualtrics) in 2019. PARTICIPANTS: Adults (N=1850) from the UK and USA. INTERVENTIONS: Participants randomly viewed one of 36 separate messages that varied by pricing policy (increasing taxes, getting rid of price discounts, getting rid of low-cost products), four frames and product (alcohol, tobacco, sugary drinks/foods). PRIMARY AND SECONDARY OUTCOME MEASURES: We assessed the relationship between the message characteristics and four dependent variables. Three were related to policy support: (1) increasing taxes on the product mentioned in the message, (2) getting rid of price discounts and special offers on the product mentioned in the message and (3) getting rid of low-cost versions of the product mentioned in the message. One was related to reactance, a psychological response to having one's freedom limited. RESULTS: We found no effect for pricing policy in the message. Frames regarding children and reducing cancer risk moderated some outcomes, showing promise for real-world use. We found differences in support by product and reactance with greatest support and least reactance for tobacco policies, less support and more reactance for alcohol policies, and the least support and most reactance for sugary drinks/foods policies. CONCLUSIONS: Cancer prevention efforts using policy interventions can be informed by the message framing literature. Our results offer insights for cancer prevention advocacy efforts across the UK and USA and highlight that tax versus non-tax approaches to increasing the cost of cancer-causing products result in similar responses from consumers.

Do Parents Still Matter? The Impact of Parents and Peers on Adolescent Electronic Cigarette Use.

PURPOSE: Vaping among adolescents has reached epidemic levels. Identifying factors associated with electronic cigarette (e-cigarette) use initiation could inform prevention programming. This study examined whether parental attitudes toward e-cigarettes impacted adolescent e-cigarette use intentions, positive expectancies of use, and actual use when accounting for adolescent attitudes and peer norms. Parents' negative attitudes toward e-cigarettes were expected to reduce teen e-cigarette use intentions. Low e-cigarette use intentions were expected to mediate the association between parental attitudes and teen e-cigarette use. Peer norms were expected to be associated with positive expectancies. Positive expectancies were expected to mediate the association between peer norms and teen e-cigarette use. METHODS: A sample of e-cigarette naïve adolescents (n = 176, aged 14-17 years, 52% female, 82% Latinx/Hispanic) and their parents were assessed. Parents and adolescents rated harm associated with e-cigarette use. Adolescents reported their perceptions of peer e-cigarette norms, intentions, positive expectancies, and e-cigarette use. Cross-sectional models were estimated for e-cigarette use intentions and positive expectancies. Prospective mediation models (n = 142) characterized pathways to e-cigarette use. RESULTS: Parents' attitudes toward e-cigarettes were associated with weaker intentions. Intentions mediated the association between parental attitudes and e-cigarette use. Adolescents reporting favorable e-cigarette peer norms endorsed more positive expectancies. Positive expectancies did not mediate the association between peer norms and e-cigarette use. CONCLUSIONS: Parents actively shape adolescent e-cigarette use even when accounting for peer norms and adolescent attitudes. Involving parents in prevention programming may help reduce vaping among teens. These associations should be examined with a larger and more diverse sample.

A preliminary validation of the adolescent e-cigarette consequences questionnaire.

INTRODUCTION: Given the recent dramatic increase among adolescents in the use of electronic nicotine delivery systems (ENDS) or electronic cigarettes (e-cigarettes), there is a growing need to identify outcome expectancies that influence the initiation or continued use of e-cigarettes. While a self-report measure exists for assessing adolescent outcome expectancies for cigarette use, there is currently not one available for e-cigarette use. Validation and use of such a measure would provide insight into the growing popularity of e-cigarettes. METHODS: The sample consisted of 264 (50.76 % female, 86.36 % White, 84.47 % Hispanic/Latinx) freshmen and sophomores from South Florida high schools who were identified as at-risk for e-cigarette use. The current study adapted the Adolescent Smoking Consequences Questionnaire (ASCQ) to derive the Adolescent E-Cigarette Consequences Questionnaire (AECQ) to characterize e-cigarette outcome expectancies. A confirmatory factor analysis was estimated to test the underlying factor structure. RESULTS: The confirmatory factor analysis provided support for a seven-factor structure (negative affect reduction, taste/sensorimotor manipulation, social facilitation, weight control, negative physical feelings, boredom reduction, and negative social impression) after removing two items with low factor loadings from the social facilitation subscale. After removing these items, factor loadings ranged from 0.46 to 0.86. CONCLUSION: The current study provides preliminary evidence to suggest that the Adolescent E-Cigarette Consequences Questionnaire is a psychometrically sound measure. Future work should continue to test this measure among diverse samples of adolescents (e.g., non-Latinx samples) with varying levels of use.

New kid on the block: An investigation of the physical, operational, personnel, and service characteristics of recovery community centers in the United States.

BACKGROUND: Professional treatment and non-professional mutual-help organizations (MHOs) play important roles in mitigating addiction relapse risk. More recently, a third tier of recovery support services has emerged that are neither treatment nor MHO that encompass an all-inclusive flexible approach combining professionals and volunteers. The most prominent of these is Recovery Community Centers (RCCs). RCC's goal is to provide an attractive central recovery hub facilitating the accrual of recovery capital by providing a variety of services (e.g., recovery coaching; medication assisted treatment [MAT] support, employment/educational linkages). Despite their growth, little is known formally about their structure and function. Greater knowledge would inform the field about their potential clinical and public health utility. METHOD: On-site visits (2015-2016) to RCCs across the northeastern U.S. (K = 32) with semi-structured interviews conducted with RCC directors and online surveys with staff assessing RCCs': physicality and locality; operations and budgets; leadership and staffing; membership; and services. RESULTS: Physicality and locality: RCCs were mostly in urban/suburban locations (90%) with very good to excellent Walk Scores reflecting easy accessibility. Ratings of environmental quality indicated neighborhood/grounds/buildings were moderate-good attractiveness and quality. Operations: RCCs had been operating for an average of 8.5 years (SD = 6.2; range 1-33 years) with budgets (mostly state-funded) ranging from $17,000-$760,000/year, serving anywhere from a dozen to more than two thousand visitors/month. Leadership and staffing: Center directors were mostly female (55%) with primary drug histories of alcohol (62%), cocaine (19%), or opioids (19%). Most, but not all, directors (90%) and staff (84%) were in recovery. Membership: A large proportion of RCC visitors were male (61%), White (72%), unemployed (50%), criminal-justice system-involved (43%) and reported opioids (35%) or alcohol (33%) as their primary substance. Roughly half were in their first year of recovery (49%), but about 20% had five or more years. Services: RCCs reported a range of services including social/recreational (100%), mutual-help (91%), recovery coaching (77%), and employment (83%) and education (63%) assistance. Medication-assisted treatment (MAT) support (43%) and overdose reversal training (57%) were less frequently offered, despite being rated as highly important by staff. CONCLUSIONS: RCCs are easily accessible, attractive, mostly state-funded, recovery support hubs providing an array of services to individuals in various recovery stages. They appear to play a valued role in facilitating the accrual of social, employment, housing, and other recovery capital. Research is needed to understand the relative lack of opioid-specific support and to determine their broader impact in initiating and sustaining remission and cost-effectiveness.

Exploring pathways to substance use: A longitudinal examination of adolescent sport involvement, aggression, and peer substance use.

The relationship between adolescent sport involvement and later substance use (SU) has been unclear. Understanding the pathways through which sport involvement influences SU may help identify targets for prevention. Using a sample of 535 adolescents from the Michigan Longitudinal Study (MLS; 67.29% male, 78.13% European American), this study prospectively examined whether aggression during late adolescence mediated the association between sport involvement during early adolescence and alcohol, marijuana, and cigarette use during early adulthood. In addition, perceived peer SU during early adolescence was tested as a potential moderator in the association between sport involvement on SU. High sport involvement was associated with more alcohol use. In contrast, the indirect effect of sport involvement on SU via aggression was significant for cigarette use, and marginally significant for marijuana use. Lastly, peer SU was a significant moderator in the cigarette model, indicating low peer SU was somewhat protective among high sport-involved adolescents. Prevention targeting alcohol use and associated consequences, as well as aggressive behaviors may help address future substance use.

Electronic Cigarette Use Among Youth: Understanding Unique Risks in a Vulnerable Population.

PURPOSE OF REVIEW: This review discusses prevalence rates of electronic (e-)cigarette use among youth and factors that likely contribute to their growing popularity among this population. Trends shaping the e-cigarette landscape, the appeal of e-cigarettes among youth, perceptions contributing to the initiation of e-cigarettes, available assessments capturing the usage of and attitudes towards e-cigarettes, and e-cigarette policies and regulations are reviewed. RECENT FINDINGS: E-cigarette use among this vulnerable group may relate to factors associated with the promotion of social status, individuality, and enjoyment, along with low perceptions of risk and harm. Measures assessing factors unique to e-cigarette use among youth (e.g., individuality) still need to be developed and validated. Effects of existing regulations to limit youth access to e-cigarettes may be limited, and shortcomings of current policy measures are discussed with recommendations. SUMMARY: The rise of e-cigarette use among youth culminated through a perfect storm of clever marketing targeting youth appeal, innovations in more effective nicotine delivery systems, capitalizing on increased susceptibility of the adolescent brain, and regulatory gaps. Understanding risk and protective factors specific to this vulnerable group, which can be gleaned in part by psychometrically valid assessments, could inform regulatory strategies and prevention programming efforts. Yet, few validated measures exist that assess attitudes, behaviors, and patterns of e-cigarette use that are specific to youth. Ultimately, it is incumbent upon policymakers to create comprehensive regulations that prioritize harm reduction and can evolve in lockstep with the constantly changing e-cigarette product landscape.

Validation of the electronic cigarette attitudes survey (ECAS) for youth.

Electronic cigarette (e-cigarette) use among adolescents has rapidly increased in recent years, especially among Latinx and non-Latinx Black adolescents. Yet, limited research exists on adolescent attitudes that may contribute to the popularity of these products. This is in part due to the lack of measures focused on assessing adolescent attitudes towards e-cigarette use. The aim of this study was to develop a measure of adolescent e-cigarette use attitudes. The sample consisted mainly of Latinx and non-Latinx Black adolescents. Data were collected from 247 youth (M age = 16.0, SD = 1.2), 63.6% were girls, a majority (69.2%) were non-Latinx Black, and 27.1% were Latinx. The Electronic Cigarette Attitudes Survey (ECAS) is comprised of 12 items reflecting attitudes associated with e-cigarettes, which were derived from prior theoretical, quantitative, and qualitative work with e-cigarette users. To determine the factor structure, a parallel analysis scree plot and an exploratory factor analysis (EFA) of the ECAS was conducted using half of the sample chosen at random (n = 113). Results supported a one-factor solution. A confirmatory factory analysis (CFA) was conducted on the other randomly chosen half of participants (n = 121). Results confirm a one-factor solution. No significant differences were found on ECAS scores based on race/ethnicity or e-cigarette use status (lifetime e-cigarette use vs. no use). The ECAS represents a viable measure for assessing e-cigarette attitudes among youth.

A pilot randomized clinical trial testing integrated 12-Step facilitation (iTSF) treatment for adolescent substance use disorder.

BACKGROUND AND AIMS: The integration of 12-Step philosophy and practices is common in adolescent substance use disorder (SUD) treatment programs, particularly in North America. However, although numerous experimental studies have tested 12-Step facilitation (TSF) treatments among adults, no studies have tested TSF-specific treatments for adolescents. We tested the efficacy of a novel integrated TSF. DESIGN: Explanatory, parallel-group, randomized clinical trial comparing 10 sessions of either motivational enhancement therapy/cognitive-behavioral therapy (MET/CBT; n = 30) or a novel integrated TSF (iTSF; n = 29), with follow-up assessments at 3, 6 and 9 months following treatment entry. SETTING: Out-patient addiction clinic in the United States. PARTICIPANTS: Adolescents [n = 59; mean age = 16.8 (1.7) years; range = 14-21; 27% female; 78% white]. INTERVENTION AND COMPARATOR: The iTSF integrated 12-Step with motivational and cognitive-behavioral strategies, and was compared with state-of-the-art MET/CBT for SUD. MEASUREMENTS: Primary outcome: percentage days abstinent (PDA); secondary outcomes: 12-Step attendance, substance-related consequences, longest period of abstinence, proportion abstinent/mostly abstinent, psychiatric symptoms. FINDINGS: Primary outcome: PDA was not significantly different across treatments [b = 0.08, 95% confidence interval (CI) = -0.08 to 0.24, P = 0.33; Bayes' factor = 0.28). SECONDARY OUTCOMES: during treatment, iTSF patients had substantially greater 12-Step attendance, but this advantage declined thereafter (b = -0.87; 95% CI = -1.67 to 0.07, P = 0.03). iTSF did show a significant advantage at all follow-up points for substance-related consequences (b = -0.42; 95% CI = -0.80 to -0.04, P < 0.05; effect size range d = 0.26-0.71). Other secondary outcomes did not differ significantly between treatments, but effect sizes tended to favor iTSF. Throughout the entire sample, greater 12-Step meeting attendance was associated significantly with longer abstinence during (r = 0.39, P = 0.008), and early following (r = 0.30, P = 0.049), treatment. CONCLUSION: Compared with motivational enhancement therapy/cognitive-behavioral therapy (MET/CBT), in terms of abstinence, a novel integrated 12-Step facilitation treatment for adolescent substance use disorder (iTSF) showed no greater benefits, but showed benefits in terms of 12-Step attendance and consequences. Given widespread use of combinations of 12-Step, MET and CBT in adolescent community out-patient settings in North America, iTSF may provide an integrated evidence-based option that is compatible with existing practices.

Coping with the enduring unpredictability of opioid addiction: An investigation of a novel family-focused peer-support organization.

BACKGROUND: Opioid overdose deaths have become a major public health crisis. While efforts have focused mostly on helping opioid-addicted individuals directly, family members suffer also from the grave and enduring unpredictability associated with opioid addiction and often play a vital role in helping addicted loved ones access care. Little is known, however, about resources to help affected family members. Here we describe results from the first quantitative and qualitative investigation of a free and growing support organization for family members of addicted individuals ("Learn to Cope" [LTC]; www.learn2cope.org), organized around three key questions: 1. Who participates, how often, and in what ways? 2. What are the demographic and clinical histories of their addicted loved-ones? 3. How do participants benefit? METHOD: Survey with LTC members at meetings and online (N=509; 95% participation rate). RESULTS: 1. Participants were primarily middle-aged mothers (77%) of opioid-addicted adult male children, attending LTC meetings several times per month, using LTC online resources several times a week, and meeting with LTC members between meetings. 2. Their addicted loved-ones were mostly male (73%), addicted to opioids (88%), with a criminal history (70%), with just under half (41%) having suffered at least one prior overdose. Almost three-quarters (71%), however, reported their loved one was "in recovery", with 30% having a year or more. 3. Benefits since beginning participation included gains in understanding and coping with addiction, feeling better able to help and communicate with their loved-one, and reductions in self-blame and stress. Of members trained in Narcan administration (66%), 86% had received training at LTC meetings; LTC members reported having deployed Narcan for over 44 overdose reversals. CONCLUSION: The growing availability of LTC may provide a needed source of support and information for family members of opioid-addicted loved-ones and may help reduce overdose deaths through Narcan training and distribution.

Alcoholics Anonymous and other mutual help organizations: Impact of a 45-minute didactic for primary care and categorical internal medicine residents.

BACKGROUND: Substance use disorders (SUDs) are highly prevalent among primary care patients. One evidence-based, cost-effective referral option is ubiquitous mutual help organizations (MHOs) such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and SMART Recovery; however, little is known about how to effectively increase trainee knowledge and confidence with these referrals. The primary aim of this study was to evaluate whether a single 45-minute combined lecture and role play-based didactic for primary care residents could enhance knowledge, improve attitudes, and bolster confidence in referring patients with addictions to community MHOs. METHODS: The authors developed a 45-minute lecture and role play addressing the evidence for MHOs, their respective background/content, and how to make effective referrals. Participants were administered a brief survey of their MHO-related knowledge, attitudes, and confidence before and after the session to evaluate the didactic impact. RESULTS: Participants were 55 primary care and categorical internal medicine residents divided among postgraduate year 1 (PGY1; 27.3%), PGY2 (38.2%), and PGY3 (34.5%). They had a mean age of 29 (SD = 2.62); 49% were female, 69% were Caucasian, and 78% reported some religious affiliation. Participants' subjective knowledge about MHOs increased significantly (P < .001), as did their confidence in making referrals (P < .001). Changes in participants' attitudes about the importance of MHOs in aiding successful addiction recovery approached significance (P = .058). The proportion of participants with correct responses to each of 4 knowledge-based questions increased substantially. CONCLUSIONS: Primary care and internal medicine residents reported variable baseline knowledge of MHOs and confidence in making referrals, both of which were improved in response to a 45-minute didactic. Role play may be a useful supplementary tool in enhancing residents' knowledge and skill in treating patients with SUD.

Developing and Testing Twelve-Step Facilitation for Adolescents with Substance Use Disorder: Manual Development and Preliminary Outcomes.

Adolescent substance use disorder treatment programs are often based on the 12-step philosophy of Alcoholics Anonymous and/or link adolescents to these free resources. Despite this, no studies have developed and rigorously tested a twelve-step facilitation (TSF) intervention for young people, leaving a significant evidence gap. This study describes the first systematic development of an outpatient adolescent TSF treatment. An integrated twelve-step facilitation (iTSF) treatment incorporated TSF, motivational enhancement therapy, and cognitive behavioral therapy elements and was developed in an iterative manner with weekly feedback provided by 36 adolescents (M age 17 years [SD = 1.4]; 52.8% white) with DSM-IV substance use disorder recruited from the community. Assessments were conducted at baseline and at three and six months. Participants completed 6 of 10 sessions on average (8 participants completed all 10). Notable treatment developments were the inclusion of "in-services" led by Marijuana Anonymous members, including parents in a portion of individual sessions to provide a rationale for TSF, and use of a Socratic therapeutic interaction style. Acceptability and feasibility of the treatment were excellent (treatment satisfaction was 4.29 [SD = 0.59] out of 5). In keeping with TSF theory, the intervention substantially increased 12-step participation, and greater participation related to greater abstinence. iTSF is a replicable manualized treatment that can be implemented and tested in outpatient settings. Given the widespread compatibility of iTSF with the current adolescent treatment, if found efficacious, iTSF could be relatively easily adopted, implemented, and sustained and could provide an evidence-based option that could undergird current practice.