Investigating Substance Use as a Coping Strategy Among Adolescent Psychiatric Inpatients: A Comparative Analysis Before and During the COVID-19 Pandemic.

The COVID-19 pandemic resulted in significant changes in daily life, potentially impacting mental health and substance use behavior. Research on COVID-related changes in adolescent substance use have yielded mixed findings. The current cross-sectional chart review study compared rates of past-year substance use before and during COVID-19 among adolescent psychiatric inpatients, and investigated how motives for coping with COVID-19 changes were related to psychiatric acuity, and past-year substance use. Count models assessed if the number of past-year days of alcohol and cannabis use was higher among adolescents (n = 491, 11-18 years, 61% female) hospitalized during COVID-19 (3/14/20 to 4/5/21) versus adolescents hospitalized before COVID-19 (8/30/2019 to 3/13/20). For a subsample of COVID-19 inpatients (n = 124; 75% female), we evaluated psychiatric correlates of endorsing substances to cope with COVID-19 changes/rules. Results indicated adolescents admitted during COVID-19 reported significantly more past-year alcohol and cannabis use days than adolescents admitted before COVID-19. Adolescents endorsed using alcohol (19%), cannabis (33%), and e-cigarettes/vaping (25%) to cope with COVID-19. E-cigarette/vaping to cope with COVID-19 was significantly related to lifetime suicide attempt. Endorsing alcohol or cannabis to cope with COVID-19 was associated with a significantly greater number of past-year use days for each respective substance. Adolescent psychiatric inpatients admitted during COVID-19 reported more substance use days than adolescents admitted before COVID-19. Using substances to cope was linked to psychiatric correlates (e.g., suicidality). Assessing the presence and function of substance use in this population may be important to identify, treat, and prevent compounding negative outcomes during times of community stress.

Improving Social Recovery Capital Research To Enhance Clinical Utility: A Proposed Agenda.

Social recovery capital (SRC) is the combination of social resources that can be used to initiate and sustain addiction recovery through friends, family, and peers. Broadly, understanding one's SRC allows us to get a sense of where one has social support for recovery and where there may be social barriers to their recovery process. SRC is often a vital component of many people's recovery journey, yet our understanding of how best to use this concept in research and practice remains underdeveloped. To improve understanding of the role of social recovery capital and strategies to measure and increase it, we present a roadmap involving a five-pronged research agenda to: (1) Refine the measurement of social recovery capital; (2) Model the complexity of social recovery capital empirically; (3) Integrate personality science with social recovery capital research; (4) Optimize evidence-based behavior change techniques of social recovery capital; and (5) Incorporate an intersectional framework when examining or applying social recovery capital. Overall, this five-pronged research agenda seeks to enhance the clinical utility of SRC research to maximize the impact of SRC on one's recovery.

Naltrexone moderates the association of alcohol use and affect among adolescent drinkers in daily life.

BACKGROUND: Naltrexone is an efficacious medication for the treatment of alcohol use disorder in adults. As an opioid receptor antagonist, naltrexone blocks activation of the endogenous opioid system, which is involved in the affectively reinforcing properties of substance use. Few studies, however, have examined the moderating effect of naltrexone on the association between affect and alcohol use. Additionally, most existing research on naltrexone has been with adults in the human laboratory. METHOD: We conducted a secondary analysis of ecological momentary assessment data from a randomized, double-blinded, placebo-controlled cross-over study that compared naltrexone (50 mg/daily) and placebo in 26 adolescents (15 to 19 years old) who exhibited problematic drinking patterns. Multilevel models tested whether naltrexone moderated associations of alcohol use with both positive and negative affect (PA, NA). RESULTS: Results indicated that, during naltrexone treatment, greater estimated blood alcohol concentration (eBAC) levels were associated with greater NA further into drinking episodes. In turn, greater NA after the first drink of an episode was associated with reduced subsequent eBAC values during naltrexone treatment. Low PA was also associated with lower subsequent eBAC levels in the naltrexone condition after the first drink. CONCLUSIONS: These findings support the idea that naltrexone can disrupt the association between affect and alcohol use, effects that emerge later in drinking episodes. Greater attention to the effects of naltrexone on affect and reinforcement may help to tailor psychotherapy to maximize the benefits of naltrexone. However, in the present study, as most drink reports were in the first 2 h of the drinking episode and participants reported affect only at the first three end-drink reports of a drinking episode (limiting the number of drinks reported), we had reduced power to detect effects in the continuation phase. Thus, replication of the findings is needed using a design that assesses the impact of naltrexone across the entire episode.

Adolescent (mis)perceptions of peer alcohol posts on social media: Prospective associations with alcohol attitudes and use.

BACKGROUND: Social media is a central context in which teens interact with their peers, creating opportunities for them to view, post, and engage with alcohol content. Because adolescent peer interactions largely occur on social media, perceptions of peer alcohol content posting may act as potent risk factors for adolescent alcohol use. Accordingly, the preregistered aims of this study were to (1) compare perceived friend, typical person, and an adolescent's own posting of alcohol content to social media and (2) examine how these perceptions prospectively relate to alcohol willingness, expectancies, and use after accounting for offline perceived peer alcohol use. METHODS: This longitudinal study included 435 adolescents (Mage  = 16.91) in 11th (48%) and 12th grade (52%). Participants completed measures of alcohol content social media posts, perceived peer alcohol use, willingness to drink alcohol, alcohol expectancies, and alcohol use at two time points, 3 months apart. RESULTS: Consistent with preregistered hypotheses, adolescents reported that 60.3% of the typical person their age and 30.6% of their friends post alcohol content on social media. By contrast, only 7% of participants reported that they themselves posted such content to social media. After accounting for offline perceived peer drinking norms, neither perceived friend nor typical person alcohol content social media posts were prospectively associated with willingness to drink or positive or negative alcohol expectancies. Perceived friend alcohol content posts were prospectively positively associated with past 30-day alcohol consumption even after controlling for offline perceived peer drinking norms. CONCLUSIONS: Adolescents misperceived the frequency of alcohol-related posting to social media among their peers, and perceptions of friend alcohol content posts prospectively predicted alcohol use. Given the results from the current study and the ubiquity of social media among adolescents, prevention efforts may benefit from addressing misperceptions of alcohol-related posting to social media.

Computational modeling reveals strategic and developmental differences in the behavioral impact of reward across adolescence.

Studies of reward effects on behavior in adolescence typically rely on performance metrics that confound myriad cognitive and non-cognitive processes, making it challenging to determine which process is impacted by reward. The present longitudinal study applied the diffusion decision model to a reward task to isolate the influence of reward on response caution from influences of processing and motor speed. Participants completed three annual assessments from early to middle adolescence (N = 387, 55% female, Mage  = 12.1 at Wave 1; Mage  = 13.1 at Wave 2, Mage  = 14.1 at Wave 3) and three annual assessments in late adolescence (Mages  = 17.8, 18.9, 19.9). At each assessment, participants completed a two-choice reaction time task under conditions of no-reward and a block in which points were awarded for speeded accuracy. Reward reduced response caution at all waves, as expected, but had a greater impact as teens moved from early to middle adolescence. Simulations to identify optimal response caution showed that teens were overly cautious in early adolescence but became too focused on speed over accuracy by middle adolescence. By late adolescence, participants adopted response styles that maximized reward. Further, response style was associated with both internalizing and externalizing symptoms in early-to-middle adolescence, providing evidence for the construct validity of a diffusion model approach in this developmental period.

An examination of the joint effects of adolescent interpersonal styles and parenting styles on substance use.

The current study examined how parenting and adolescent interpersonal styles jointly influence youths' abilities to form close relationships - a central developmental milestone - yet avoid substance use, which predominantly occurs in the presence of peers. Nine annual waves from an adolescent sample (N = 387) were used to assess (a) combinations of interpersonal and parenting styles from early to middle adolescence using longitudinal latent profile analysis, (b) the validity of these profiles on indicators of adjustment, and (c) the relationships between the profiles and growth in substance use across adolescence as well as substance-related consequences in late adolescence. The results supported five distinct combinations of interpersonal and parenting styles, and validity analyses identified both risk and protective profiles. The protective profile submissive-communal interpersonal style + high-warmth-authoritative parenting style was associated with indicators of positive social adjustment (e.g., friendship quality, resistance to peer influence) as well as lower levels of substance use. Significant differences also emerged with respect to substance-related consequences. The findings of this study highlight how combinations of adolescent interpersonal style and parenting render adolescents more or less successful at navigating peer relationships while avoiding substance use behaviors.

Adolescent Sibling Associations among Alcohol, Cannabis, and Sexual Risk Behavior: A Test of Interdependence.

BACKGROUND: Although siblings are conceptualized as a salient social influence during adolescence, few studies have examined how adolescent siblings influence each other's substance use and risky sexual behavior. Objectives: In this study, we investigated the influence of alcohol use days, cannabis use days, and cannabis and alcohol co-use days on the sexual risk behavior of siblings while accounting for dyadic influence. METHODS: At the baseline visit for a randomized controlled trial for adolescents referred due to parents' concerns about their substance use ("referred adolescents"; n = 99; Mage=15.95; 38.38% female), we assessed alcohol and cannabis use days as well as sexual risk behavior of the referred adolescents and their sibling (Mage=15.03; 51.52% female). We computed the number of days in the 30 days prior to the baseline that alcohol and cannabis use occurred on the same day. Using a cross-sectional actor partner interdependence model, we tested two models of how adolescents' substance use is associated with their own ("actor effect") and their siblings' ("partner effect") sexual risk behavior-one model for alcohol and cannabis use, and one model for daily co-use. RESULTS: For referred adolescents and their siblings, within an individual, greater alcohol, cannabis, and daily co-use was significantly associated with sexual risk behavior (actor effects). Furthermore, more sibling co-use days was positively associated with referred adolescent sexual risk behavior (partner effect), representing interdependence. CONCLUSION: These findings confirm the influence siblings have on one another's risky behavior in adolescence and have implications for prevention and intervention efforts for adolescent substance use.

Assessing Parent-Adolescent Substance Use Discussions Using the Continuous Assessment of Interpersonal Dynamics.

Assessing parent-child interactions is critical for understanding family dynamics, however tools available for capturing these dynamics are limited. The current study sought to examine the validity of the Continuous Assessment of Interpersonal Dynamics (CAID) for understanding the dynamics of parent-adolescent substance use discussions. Specifically, we examined how CAID parameters were related to indicators of parenting and substance use. Sixty-one parent-adolescent dyads (M adolescent age = 14.02, 57% female; M parent age = 46.40; 98% female) completed three 9-minute video-taped conflict, alcohol, and cannabis discussions as well as self-report measures of parenting (e.g., monitoring, psychological control) and substance use behaviors (e.g., intentions, use with parental permission). Interactions were coded using the CAID which provides continuous assessments of parent and adolescent warmth and dominance. Parental warmth, adolescent warmth, and dominance complementarity CAID parameters were positively associated with adaptive parenting and negatively associated with maladaptive parenting factors. Parental warmth in the cannabis discussion was negatively associated with the substance use and intentions factor. These findings support CAID as a reliable and valid assessment of interpersonal dynamics that characterize parent-adolescent substance use discussions and suggest that substance use conversations may be most effective when parents and adolescents act warmly throughout the discussion and exhibit dominance complementarity.

Parsing apart affective dimensions of withdrawal: Longitudinal relations with peer victimization.

The current study examined a bifactor model of affective dimensions of withdrawal. Specifically, a model which specified a general factor of anxious-avoidant withdrawal (i.e., withdrawal with negative affect), a specific factor of unsociability (i.e., withdrawal without negative affect), and a specific factor of negative affect without withdrawal was specified in the primary sample (n = 238, 56.3% boys, M age = 44.92 months, SD = 5.32 months) and a validation sample (n = 332, 52.6% boys, M age = 47.11 months, SD = 7.32 months). The model provided a good fit to the data in both samples. In the primary sample, longitudinal relations between the bifactor model and peer victimization were examined across three time points (Time 1 in the spring, Time 2 in the fall, and Time 3 in the spring). Results showed that negative affect without withdrawal was concurrently associated with higher levels of relational and physical victimization at T1, unsociability predicted reductions in relational victimization from T1 to T2 as children entered a new classroom, and anxious-avoidant withdrawal predicted reductions in relational and physical victimization from T2 to T3 as children acclimated to the new classroom. Developmental considerations and clinical implications are discussed.

An examination of reciprocal associations between substance use and effortful control across adolescence using a bifactor model of externalizing symptoms.

Early adolescence is thought to represent a window of vulnerability when exposure to substances is particularly harmful, partly because the neurotoxic effects of adolescent substance use may derail self-regulation development. However, previous studies fail to account for externalizing symptoms, such as aggression and delinquency, that accompany adolescent substance use and may also derail the development of self-regulation. The current study aims to clarify whether the neurotoxic effects of adolescent substance use are associated with deficits in effortful control (EC) after accounting for externalizing symptoms and to examine reciprocal relationships between EC, externalizing symptoms, and substance use. A longitudinal sample of adolescents (N = 387) was used to estimate bifactor models of externalizing symptoms across five assessments (Mage = 11.6 to 19.9). The broad general externalizing factors were prospectively associated with declines in EC across adolescence and emerging adulthood. However, the narrow substance use specific factors were not prospectively associated with EC. Findings suggest that the broader externalizing context, but not the specific neurotoxic effects of substance use, may hamper self-regulation development. It is critical to account for the hierarchical structure of psychopathology, namely externalizing symptoms, when considering development of EC.

Agency, communion, and pubertal status: Separating between- and within-person associations to examine social goals development.

OBJECTIVES: Agentic (status/independence) and communal (acceptance/connectedness) social goals are thought to shape how adolescents transact with their social environments. Despite their theoretical importance, little work has focused on the development of these higher order personality dimensions. Informed by developmental neuroscience and evolutionary psychology theoretical frameworks, the current study examined associations between pubertal status, a person's level of pubertal development at a single point in time, and agentic and communal social goals across early to middle adolescence. METHODS: This longitudinal study consisted of 387 (55% female) adolescents (Wave 1 M age = 12.1) who were assessed annually across three waves. Hierarchical linear modeling was used to examine growth in pubertal status and agentic and communal goals and to distinguish between- and within-person associations between pubertal status and social goals. RESULTS: Within-person pubertal status was concurrently associated with higher levels of agentic and communal goals. In the cross-sectional and longitudinal models, between-person pubertal status was associated with higher levels of agentic social goals. No support was found for social goals prospectively predicting pubertal status. CONCLUSIONS: These findings provide support for the hypothesis that puberty, in part, may drive developmental shifts in the value adolescents place on close peer relationships and obtaining status and independence.

Adolescent Social Norms and Alcohol Use: Separating Between- and Within-Person Associations to Test Reciprocal Determinism.

Despite perceived drinking norms being robust predictors of adolescent alcohol use, few studies have assessed the development of perceived norms across adolescence and processes accounting for the strong associations between perceived norms and drinking. Using reciprocal determinism as a theoretical basis for understanding the development of adolescent drinking norms, this study examined reciprocal associations across nine waves of data spanning early to late adolescence. Bivariate latent curve models with structured residuals demonstrated consistent within-person reciprocal associations between descriptive and injunctive norms and alcohol use after accounting for growth in norms and alcohol use. Results suggest the need for developmentally informed intervention efforts targeting perceived drinking norms during early and middle adolescence.

The development of inhibitory control in adolescence and prospective relations with delinquency.

INTRODUCTION: Despite the central role of inhibitory control in models of adolescent development, few studies have examined the longitudinal development of inhibitory control within adolescence and its prospective association with maladaptive outcomes. The current study evaluated: 1) growth in inhibitory control from early- to middle-adolescence, and 2) the relation between inhibitory control and later delinquency. METHODS: Participants included 387 parent-child dyads (11-13 years old at Wave 1; 55% female; USA). Across three annual assessments, teens completed the Stop Signal Task (SST), and parents completed the Inhibitory Control subscale of the Early Adolescent Temperament Questionnaire-Revised. Teens self-reported their delinquent behaviors in early (Mage = 12.1) and middle adolescence (Mage = 14.1) and emerging adulthood (Mage = 18.2). RESULTS: Latent growth curve models indicated that SST performance improved curvilinearly from early to middle adolescence (ages 11-15), with growth slowing around middle adolescence. However, no growth in parent-reported inhibitory control was observed. Lower task-based and parent-reported inhibitory control in early adolescence predicted greater increases in delinquency from middle adolescence to emerging adulthood. However, rate of growth in task-based inhibitory control was unrelated to later delinquency. CONCLUSIONS: This longitudinal study provides a novel examination of the development of inhibitory control across early and middle adolescence. Results suggest that the degree to which inhibitory control confers risk for later delinquency may be captured in early adolescence, consistent with neurodevelopmental accounts of delinquency risk. Differences across assessment tools also highlight the need for careful measurement considerations in future work, as task-based measures may be better suited to capture within-person changes over time.

Dyadic and Group-Level Positive Friendship Characteristics and Susceptibility to Perceived Delinquent Peer Substance Use.

Peer relations researchers have suggested that dyadic and peer group relationship characteristics may interact with each other to affect behavior. Building on prior work that has pitted the relative effects of dyadic and peer group relationship characteristics on susceptibility to peer influence, the present study sought to integrate dyadic and group characteristics into a moderational model by testing whether friendship quality and peer group identification together exacerbate risk for conforming to peer norms for substance use. This longitudinal study included 387 early adolescents assessed annually for 4 years. Participants completed measures of perceived peer delinquency, friendship quality, peer group identification, and substance use frequency. Results indicated that perceived peer delinquency had the strongest association with substance use for adolescents characterized by high friendship quality and high peer group identification. These findings highlight the importance of considering the joint effects of multiple peer relationship characteristics on susceptibility to peer influence.

Social Goals Impact Adolescent Substance Use through Influencing Adolescents' Connectedness to Their Schools.

Although developmental models of risk behavior highlight the role of school connectedness in the etiology of adolescent substance use, no studies to our knowledge have assessed longitudinal mediational models examining how adolescents form bonds to their school, and how the quality of those bonds relate to substance use. To address this gap, the current study used four waves of data, spanning ages 11-16 (grades 5-11), to examine the association between individual differences in agentic (Dominance/Power) and communal (Nurturance/Affiliation) social goals and school connectedness, and in turn, whether levels of school connectedness are associated with substance use. The community sample (N = 387, 55% female) was assessed annually and included non-Hispanic Caucasian (83.1%), African American (9.1%), Hispanic (2.1%), and Asian (1.0%), as well as youth of mixed ethnicity (4.7%). The results supported a mediational pathway whereby agentic goals were associated with low levels of school connectedness, which, in turn, were associated with high levels of substance use. Counter to our hypotheses, no association was found between communal goals and school connectedness. These findings provided initial evidence for the important role social goals play in shaping an adolescent's connectedness to their school and risk for substance use.

Addressing Inconsistencies in the Social Norms Drinking Literature: Development of the Injunctive Norms Drinking and Abstaining Behaviors Questionnaire.

BACKGROUND: Informed by inconsistent findings regarding the association between injunctive norms (IN) and drinking behaviors, the current study developed a new measure of IN, the Injunctive Norms Drinking and Abstaining Behaviors Questionnaire (IN-DABQ). This measure addressed several psychometric weaknesses of prior assessment of this construct, specifically, reliance on single-item measures, and assessment of a limited range of drinking behaviors. The new measure also assessed norms for reasons for abstaining from drinking as college students often have simultaneous motives to use and inhibit their drug use. A parallel measure of descriptive norms (DN), the Descriptive Norms Drinking and Abstaining Behaviors Questionnaire (DN-DABQ), was created to allow for a comparison of the relative predictive effects of descriptive and IN in relation to different drinking outcomes. METHODS: A college sample (N = 254, female = 50.42%) was recruited using Amazon's Mechanical Turk. Participants completed an online survey assessing demographic characteristics, social norms for 3 referents, weekly alcohol use, and alcohol-related consequences. RESULTS: Exploratory factor analyses indicated 2 factors for the DN-DABQ and 3 factors for the IN-DABQ. The IN Drinking Behaviors factor consistently predicted weekly consumption and alcohol-related consequences across 3 reference groups (typical college student at your school, friends, and closest friends). CONCLUSIONS: These findings suggest that prior inconsistencies in the relationship between IN and drinking behaviors are likely a function of poor measurement of this construct. Implications for normative feedback interventions are discussed.

Social Goals and Grade as Moderators of Social Normative Influences on Adolescent Alcohol Use.

BACKGROUND: The literature distinguishes 2 types of social normative influences on adolescent alcohol use, descriptive norms (perceived peer alcohol use) and injunctive norms (perceived approval of drinking). Although theoretical formulations suggest variability in the salience and influence of descriptive and injunctive norms, little is understood regarding for whom and when social norms influence adolescent drinking. Strong agentic and communal social goals were hypothesized to moderate the influence of descriptive and injunctive norms on early adolescent alcohol use, respectively. Developmental changes were also expected, such that these moderating effects were expected to get stronger at later grades. METHODS: This longitudinal study included 387 adolescents and 4 annual assessments (spanning 6th to 10th grade). Participants completed questionnaire measures of social goals, social norms, and alcohol use at each wave. RESULTS: Multilevel logistic regressions were used to test prospective associations. As hypothesized, descriptive norms predicted increases in the probability of alcohol use for adolescents with strong agentic goals, but only in later grades. Injunctive norms were associated with increases in the probability of drinking for adolescents with low communal goals at earlier grades, whereas injunctive norms were associated with an increased probability of drinking for adolescents with either low or high communal goals at later grades. Although not hypothesized, descriptive norms predicted increases in the probability of drinking for adolescents high in communal goals in earlier grades, whereas descriptive norms predicted drinking for adolescents characterized by low communal goals in later grades. CONCLUSIONS: The current study highlights the importance of social goals when considering social normative influences on alcohol use in early and middle adolescence. These findings have implications for whom and when normative feedback interventions might be most effective during this developmental period.

The moderating role of cognitive capacities in the association between social norms and drinking behaviors.

BACKGROUND: The literature documents 2 related yet distinct social normative influences on adolescent drinking. Descriptive norms refer to perceptions of how much others engage in a particular behavior, whereas injunctive norms refer to the extent to which others approve of a particular behavior. Theoretical formulations suggest that whether descriptive or injunctive norms guide drinking behavior depends on cognitive factors related to executive functioning. Cognitive capacities, specifically inhibitory control (IC) and preplanning, were tested as moderators of the association between social norms and alcohol use using a longitudinal design and community sample of adolescents. METHODS: This longitudinal study included 387 adolescents and 3 annual waves of data. Behavioral tasks assessed IC (Stop Signal Task) and preplanning (Tower of London) and social norms and drinking were assessed using self-report measures. RESULTS: Significant interactions were found for descriptive and injunctive norms with preplanning and descriptive norms with IC. As hypothesized, descriptive norms were stronger prospective predictors of alcohol use at low levels of cognitive preplanning, whereas injunctive norms were stronger prospective predictors at high levels of cognitive preplanning. Descriptive norms prospectively predicted alcohol use at high, but not at low levels of IC. CONCLUSIONS: These findings highlight the complexity of normative influences and suggest that descriptive and injunctive norms have differential effects on future drinking for individuals with different cognitive capacities.

Beyond mediators: A critical review and methodological path forward for studying mechanisms in alcohol use treatment research.

Understanding how treatments for alcohol use disorder (AUD) facilitate behavior change has long been recognized as an important area of research for advancing clinical care. However, despite decades of research, the specific mechanisms of change for most AUD treatments remain largely unknown because most prior work in the field has focused only on statistical mediation. Statistical mediation is a necessary but not sufficient condition to establish evidence for a mechanism of change. Mediators are intermediate variables that account statistically for the relationship between independent and dependent variables, whereas mechanisms provide more detailed explanations of how an intervention leads to a desired outcome. Thus, mediators and mechanisms are not equivalent. To advance mechanisms of behavior change research, in this critical review we provide an overview of methodological shortfalls of existing AUD treatment mechanism research and introduce an etiologically informed precision medicine approach that facilitates the testing of mechanisms of behavior change rather than treatment mediators. We propose a framework for studying mechanisms in alcohol treatment research that promises to facilitate our understanding of behavior change and precision medicine (i.e., for whom a given mechanism of behavior change operates and under what conditions). The framework presented in this review has several overarching goals, one of which is to provide a methodological roadmap for testing AUD recovery mechanisms. We provide two examples of our framework, one pharmacological and one behavioral, to facilitate future efforts to implement this methodological approach to mechanism research. The framework proposed in this critical review facilitates the alignment of AUD treatment mechanism research with current theories of etiologic mechanisms, precision medicine efforts, and cross-disciplinary approaches to testing mechanisms. Although no framework can address all the challenges related to mechanisms research, our goal is to help facilitate a shift toward more rigorous and falsifiable behavior change research.

Mechanisms of Behavior Change in Adolescent Substance Use Treatment: A Systematic Review of Treatment Mediators and Recommendations for Advancing Future Research.

Substance use disorders commonly onset during adolescence, yet the best available treatments yield only modest and transient effects. Elucidating treatment mediators is essential for improving treatment options. This review summarizes over 20 years of research on mediators of adolescent substance use treatment; k = 17 studies assessing both treatment or treatment ingredient to mediator (a path) and mediator to treatment outcome (b path) paths were included. Mediators were categorized using the Science of Behavior Change target class framework. Overall, mediation tests supported four of eight self-regulation, two of 10 stress resilience and reactivity, six of 19 interpersonal and social process, and two of four treatment engagement and adherence mediators. To enhance the capacity of this work to inform clinical practice, we recommend future research examine theoretically informed mechanisms using temporally sequenced data among other methodological guidelines.