Behavioral Treatment of Adolescent Substance Use

The study will test two novel strategies to enhance outcomes. Working Memory Training (WMT),
an efficacious method for strengthening specific cognitive processes, aims to improve factors
(e.g., delay discounting / impulsive decision-making) that have shown a strong relation to
substance use and treatment response. Second, more intensive and higher magnitude CM (ICM)
will be used to motivate abstinence among teens who are not abstinent by Week 6. The
investigators hypothesize that these strategies will improve outcomes by modifying a
fundamental cognitive system involved in making choices to engage in risky behavior and by
increasing motivation to abstain in early nonresponders. Aim 1 will pilot and refine the new
procedures in a community clinic in preparation for the randomized trial. A sequential,
multiple assignment randomized trial (SMART) will allow the study to determine the most
effective first-line treatment and the most effective adaptive strategy (Aim 2). All teens
will begin treatment with CM or CM/WMT. After 4 weeks, responders will continue in their
first-line treatments, while nonresponders will be randomized to ICM or to continue with
first-line treatment. Aim 3 will conduct mechanistic analyses to assess whether cognitive
changes related to WMT engender increased abstinence, and whether specific tailoring
variables moderate treatment effects. Aim 4 will gather formative data on implementation
factors to inform future large-scale studies and dissemination efforts. Primary hypotheses
are: (1) first-line treatment with WMT will improve abstinence outcomes and reduce relapse;
(2) strategies with ICM for nonresponders will result in better outcomes than those without;
(3) WMT will reduce delay discounting, which will predict outcome. The unique approach holds
promise for reducing multiple types of risky behaviors by affecting basic mechanisms that
determine impulsive decision-making.

Inclusion Criteria:

Participants must be 12 to 18 years of age, must live at home with the parent who will
participate, report using marijuana during the previous 30 days or provide a
marijuana-positive urine test, meet criteria for cannabis abuse or dependence, and have a
parent who can participate.

Exclusion Criteria: DSM criteria for dependence (likely to be adjusted for DSM-5 Use
Disorder) on alcohol or other drugs other than marijuana (use of or meeting criteria for
abuse of other substances will not be an exclusion criterion), active psychosis, severe
medical or psychiatric illness limiting participation, or pregnant or breast-feeding.