Integrating Tobacco Prevention Strategies into Behavioral Parent Training for Adolescents with ADHD Rosalie Corona, Ph.D. Associate Professor of Psychology February 16, 2016

Our Team Tobacco & ADHD Experts Rosalie Corona Joshua Langberg Albert Farrell Randy Koch Maggie Sibley Cathy Hockaday Charles McLaughlin Graduate Students Efren Velazquez Nadia Islam Anh-Thuy Le Many Students in Josh’s Lab Community Partner Chesterfield Public School

Why Focus Tobacco Prevention Efforts on Youth with ADHD? Compared to youth without ADHD, youth with ADHD initiate tobacco use at younger ages have higher rates of use high risk of progression to a substance use disorder are likely to escalate to heavier tobacco use after trying tobacco only once

Why Focus Tobacco Prevention Efforts on Youth with ADHD (cont.)? Many evidence-based treatments for youth with ADHD exist Pharmacological treatments and behavioral parent training are effective at reducing ADHD symptoms None specifically target or are sufficiently effective at preventing tobacco use

Integrating Tobacco Prevention into ADHD Treatment Although family-based prevention programs for tobacco prevention exist most families of youth with ADHD initiate treatments to address educational impairments Likelihood of families attending multiple programs is not high An alternative approach is to integrate tobacco prevention into an evidence-based ADHD treatment ADHD interventions are widely available in community

Current Project Integrate evidence-based tobacco prevention skills into an evidence- based behavioral training program for ADHD Phase I – Experts meeting to develop integrated curriculum & training in ADHD intervention Phase II – Pilot RCT to determine feasibility and provide preliminary efficacy

Evidence-Based Interventions Strengthening Families Program (SFP 10-14) Content is theoretically and clinically relevant to risk factors experienced by families of youth with ADHD Targets parent-child conflict, poor monitoring of risk behaviors, inconsistent discipline 7 sessions Supporting Teens Academic Daily Needs – Group (STAND-G) Targets empirically identified adolescent (e.g., deficits in academic skills such as organizational skills) and parent (e.g., using consistency management appropriately) mechanisms that predict positive long- term outcomes 8 group sessions 90 minutes

Specific Aims Aim 1: Integrate evidence-based tobacco use prevention skills into an evidence-based parent-teen behavioral treatment program for ADHD (STAND-G). Aim 2: Examine the impact of STAND-G+TPS* on factors that are associated with reduced adolescent tobacco use: (a) adolescent skills; (b) parenting skills; and the (b) family relationship. Hypothesis 2a. STAND-G+TPS adolescents (compared to STAND-G alone) will report increased tobacco use refusal self-efficacy and intentions, and peer pressure resistance. Hypothesis 2b. STAND-G+TPS parents and adolescents (compared to STAND-G alone) will report increased parental monitoring of adolescents’ tobacco risk related behaviors. Hypothesis 2c. STAND-G+TPS parents and adolescents will report increased communication about tobacco use compared to STAND-G alone. We do not expect differences between the groups on outcomes that are targeted with both interventions (e.g., homework problems, adolescent-parent conflict). *TPS = tobacco prevention skills

Specific Aims (cont.) Aim 3: Assess whether the STAND-G+TPS intervention has an impact on adolescent tobacco and other substance use. Hypothesis 3. STAND-G+TPS adolescents (compared to STAND-G alone) will report less tobacco (e.g., cigarettes, e-cigarettes), alcohol, marijuana, and non- medical prescription drug use. Aim 4: Explore whether theoretically important components of our behavior change model mediate the intervention’s impact on tobacco and other substance use. Hypothesis 4. We expect that for STAND-G+TPS participants increased parental monitoring of adolescents’ tobacco risk related behaviors and communication about tobacco use will mediate the intervention’s impact on subsequent decreases in adolescent tobacco and other substance use.

Phase I Experts Meeting (October 22-23) Day 1: Dr. Sibley trained graduate students and team members on the STAND-G intervention Day 2: ADHD and SFP/Tobacco experts discussed how best to integrate SFP tobacco prevention skills into STAND

Phase II Pilot Efficacy RCT 80 families randomized to STAND-G or STAND-G+TPS* Adolescents (13-18 years) with ADHD and a primary caregiver 10 families per group Year 1 = 2 groups Year 2 = 6 groups Recruitment from public high schools, prior research participants, community settings *TPS = tobacco prevention skills

Phase II (cont.) Overview of Procedures Baseline measures, diagnostic assessment Randomization (families will be blind to condition) Group implementation Graduate student therapists from VCU ADHD Clinic Audio-tapes and forms to assess fidelity Follow-up measures post-intervention, and 3- and 9-months after program completion

Logic Model Parent Sessions Goal: Enhance parenting skills and promote effective parenting styles. Adolescent Sessions Goal: Build adolescent life skills Family Sessions Goal: Strengthen family bonds, promote positive communication, and enhance joint problem solving. Decrease Risk Factors Increase Protective Factors Improved Parent Skills (e.g., monitoring, discipline) Improved Adolescent Skills (e.g., refusal self-efficacy, peer resistance) Improved Family Relationship Skills (e.g., cohesion, communication) Reduced Adolescent Substance Use Reduced Adolescent Problem Behavior Program Components Targets Proximal Outcomes Distal Outcomes

Measures Adolescents Only mental health symptoms tobacco and other substance refusal skills and intentions general peer resistance skills intervention targeted behaviors tobacco and other substance use (e.g., marijuana, ATP, alcohol, e-cig)

Measures (cont.) Parents Only Diagnostic rating scales Homework problems checklist Child’s grades Mental health services Child mental health symptoms Parent mental health symptoms Intervention targeted parenting behavior

Measures (cont.) Parents and Adolescents Parental monitoring Parent-child communication about tobacco and alcohol use Parent-child conflict Family cohesion

Project Innovation A focus on adolescents with ADHD who have not been targeted in tobacco use prevention trials but who are at high risk of tobacco use. A focus on the use of alternative tobacco products (ATPs) among adolescents with ADHD. Teaching tobacco use prevention skills to adolescents with ADHD and their parents by integrating them into an existing evidence-based treatment for ADHD. The intervention’s theory of change will be tested in a sample of adolescents with a primary diagnosis of ADHD. Fidelity tools for the combined STAND-G+TPS intervention will be developed, refined, and tested during this project.

Year 1 Progress to Date IRB approval (hooray!) STAND-G Training Integrated manual (nearly) completed Training in STAND-G+SFP scheduled for 3/15/ families assessed to date; 3 scheduled for assessment this week Two groups scheduled to begin the week of April 4, 2016