Family-Based Protocol for Medication Integration in Treatment of Comorbid ASU/ADHD in Routine Care

The goal of this proposal is to develop and pilot a brief protocol designed to
systematically integrate pharmacological interventions for attention deficit hyperactivity
disorder (ADHD) into behavioral treatment services for adolescent substance users with
comorbid ADHD in everyday care. ADHD is a prevalent co-occurring condition for adolescent
substance use (ASU) that can significantly impede successful ASU treatment but is vastly
under-diagnosed and undertreated among ASU clients in agency settings. Moreover, ADHD
medication acceptance and compliance is particularly difficult to achieve in high-risk
adolescent populations. The proposed R21 study will use an interrupted time series design to
test a brief protocol designed to promote integration of evidence-based ADHD pharmacotherapy
into routine behavioral services for ASU: Medication Integration Protocol (MIP). MIP is a
5-session family-based protocol delivered during the early portion of ASU treatment that
contains three research-based elements: (1) standardized psychiatric assessment and
family-focused psychoeducation about adolescent ADHD; (2) an approved ADHD medication
regimen (OROS-MPH) with demonstrated efficacy for ASU/ADHD clients; (3) family-based
interventions to support medication acceptance (as indicated) and coordination of care
between psychiatric and behavioral services. MIP will be integrated into existing
family-based services at one partnering clinical site: 20 ASU/ADHD cases will be treated by
site family therapists who will be newly trained and monitored in MIP. The partnering clinic
provides family therapy as the routine standard of care for outpatient behavioral health and
offers on-site child psychiatry services. Primary study aims will yield proof-of-concept
data on MIP feasibility and fidelity in usual care and evidence of MIP impact on psychiatric
and behavioral services utilization, medication acceptance and compliance, and satisfaction
with treatment services. Exploratory analyses will generate effect sizes for the short-term
impact of MIP on the main targets of ADHD medication: ADHD symptoms and executive cognitive
functioning. New study products would include a standardized and piloted MIP protocol,
clinician training and fidelity monitoring procedures, and an observational fidelity
instrument. If validated, MIP could be utilized as a stand-alone intervention in everyday
care, or, be combined with existing manualized treatments for ASU in an effort to develop
fully integrated treatment models for ASU/ADHD. Also, MIP could be delivered in conjunction
with either family-based treatments or individual treatments that can flexibly include
caregivers in early sessions.

Inclusion Criteria:

- age 13-17, (2) caregiver able to participate in treatment,

- one day of alcohol use to intoxication or illegal drug use in the past 30 days (or 30
days prior to living in a controlled environment),

- endorsement of one or more DSM-IV symptoms of Substance Use or Alcohol
Dependence/Abuse,

- meet ASAM criteria for outpatient substance use treatment,

- meet DSM-IV criteria for ADHD (with or without onset prior to age 7),

- not enrolled in any behavioral treatment.

Exclusion Criteria:

- MDD

- Bipolar Disorder

- mental retardation

- PDD

- medical or psychiatric illness requiring hospitalization

- current psychotic features

- current suicidality