Perceived burdensomeness and thwarted belongingness as mediators of the relation between anxiety and suicidal ideation among adolescents.

INTRODUCTION: Anxiety and suicidal ideation have been shown to be positively related in adolescents. However, less is known about the strength of this association across different types of anxiety or the mechanisms through which this relation exists. Joiner's interpersonal theory of suicide suggests that thwarted belongingness (TB) and perceived burdensomeness (PB) lead to suicidal ideation; these constructs may explain a pathway through which anxiety and suicidal ideation are related. It was hypothesized that TB would mediate the relation between social anxiety disorder (SAD) symptoms and suicidal ideation, and PB would mediate the relation between generalized anxiety disorder (GAD) symptoms and suicidal ideation. METHODS: These longitudinal mediation models were assessed using data collected from 147 depressed adolescents, who were recently hospitalized for suicidal ideation or behavior, enrolled in a randomized controlled trial (RCT). RESULTS: Consistent with study hypotheses, PB mediated the relation between GAD symptoms and suicidal ideation severity. However, TB did not mediate the relation between SAD symptoms and suicidal ideation severity. CONCLUSION: These results suggest that screening for and addressing PB among youth with GAD may help reduce risk for suicidal behavior.

Relations between discrimination, rejection sensitivity, negative affect, and decrements in problem-solving ability following social rejection: An experimental investigation.

INTRODUCTION: While negative affect and problem-solving deficits have been consistently linked to suicidal thoughts and behaviors, the latter are often conceptualized and studied as time- and/or context-invariant. Though requiring additional empirical support, theory suggests that discrimination may strengthen the relation between rejection sensitivity and increases in negative affect as well as declines in problem-solving abilities following rejection. The aim of the current study was to test this claim using a social rejection paradigm (i.e., Cyberball) with young adults experiencing past-month suicidal ideation. METHODS: The sample consisted of 50 participants. Lifetime discrimination and rejection sensitivity were assessed prior to Cyberball. Negative affect and problem-solving abilities were assessed pre- and post-Cyberball. SPSS and the PROCESS macro were used to test relations among variables of interest. RESULTS: Rejection sensitivity predicted greater problem-solving decrements, but not negative affect, following rejection among individuals who had experienced higher (vs. lower) levels of lifetime discrimination. CONCLUSION: Addressing rejection sensitivity and sources of discrimination within the context of treatment may reduce the impact of social rejection on problem-solving abilities among young adults at risk for suicide.

Impact of a Virtual Suicide Safety Planning Training on Clinician Knowledge, Self-Efficacy, and Use of Safety Plans in Community Mental Health Clinics.

OBJECTIVE: Safety planning is a critical evidence-based intervention used to prevent suicide among individuals who report suicidal ideation or behavior. There is a dearth of research on optimal ways to disseminate and implement safety plans in community settings. The present study examined one implementation strategy, a 1-hour virtual pre-implementation training, designed to teach clinicians to effectively use an electronic safety plan template (ESPT), integrated with suicide risk assessment tools, in the context of a measurement feedback system. We examined the effect of this training on clinician knowledge and self-efficacy in use of safety planning as well as ESPT completion rates. METHOD: Thirty-six clinicians across two community-based clinical psychology training clinics completed the virtual pre-implementation training as well as pre- and post-training knowledge and self-efficacy assessments. Twenty-six clinicians completed a 6-month follow-up term. RESULTS: Clinicians reported significant improvements in self-efficacy and knowledge from pre- to post-training. They retained significant improvements in self-efficacy and a trend toward greater knowledge at the 6-month follow-up. Of the clinicians who worked with suicidal youth, 81% attempted to use an ESPT and 63% successfully completed all sections of the ESPT. Reasons for partial completion included technological difficulties and time constraints. CONCLUSION: A brief virtual pre-implementation training can improve clinician knowledge and self-efficacy in use of an ESPT with youth at risk for suicide. This strategy also holds the potential to improve the adoption of this novel evidence-based intervention in community-based settings.

Facets of social problem-solving as moderators of the real-time relation between social rejection and negative affect in an at-risk sample.

Social rejection predicts negative affect, and theoretical work suggests that problem-solving deficits strengthen this relation in real-time. Nevertheless, few studies have explicitly tested this relation, particularly in samples at risk for suicide. This may be particularly important as social rejection and negative affect are significant predictors of suicide. The aim of the current study was to examine whether cognitive (i.e., perceiving problems as threats) and behavioral (i.e., avoidance) facets of problem-solving deficits moderated the real-time relation between social rejection and negative affect. The sample consisted of 49 young adults with past-month suicidal ideation. Demographic information, social problem-solving deficits, as well as depressive/anxiety symptoms and stress levels were assessed at baseline. Social rejection and negative affect were assessed using ecological momentary assessment over the following 28 days. Dynamic structural equation modeling was used to assess relations among study variables. After accounting for depressive/anxiety symptoms, stress levels, sex, and age, only avoidance of problems bolstered the real-time positive relation between social rejection severity and negative affect (b = 0.04, 95% credibility interval [0.003, 0.072]). Individuals with suicidal ideation who possess an avoidant problem-solving style may be particularly likely to experience heightened negative affect following social rejection and may benefit from instruction in problem-solving skills.

Interpersonal stress and proinflammatory activity in emerging adults with a history of suicide risk: A pilot study.

Interpersonal stress during adolescence and young adulthood can threaten healthy developmental trajectories. A "primed" proinflammatory response to acute stress may serve as an underlying process that results in negative outcomes for youth. The present pilot study examined the relation between interpersonal stress and two proinflammatory cytokines in a sample of 42 university-recruited emerging adults with recent suicidal thoughts and behaviors. Participants completed self-report measures of mood, suicidal thoughts and behaviors, recent peer-related stressors, and interpersonal sensitivity. They also participated in an acute laboratory social stress task and provided three saliva samples to measure their proinflammatory responses (IL-6 and TNF-α) to the stressor. Participants reported significant increases in sadness and exclusion, and significant decreases in inclusion, following task participation. Importantly, no participants reported an increase in or onset of suicidal thoughts. No significant associations between interpersonal stress and proinflammatory cytokines were found. Changes in affect during the task coupled with lack of increased suicidal thoughts indicate it is acceptable to use this exclusion and rejection paradigm with this population, with proper debriefing and positive mood induction procedures. Given all other nonsignificant associations, future research considerations are discussed, including impact of COVID-19 on task potency and incorporation of multiple stress response systems.

Trajectories of adolescent suicidal ideation and depressive symptoms during partial hospitalization: Clinical and demographic characteristics as predictors of change.

Partial hospital programs (PHPs) are a vital mental health service for youth at risk for suicide. Yet, few studies have examined trajectories of suicidal ideation and depressive symptoms, two important risk factors for suicidal behavior, over the course of care. Moreover, little is known about factors that may impact these trajectories among youth in PHPs. The present study examined trajectories of suicidal ideation and depressive symptoms, as well as clinical and demographic predictors of these changes, among youth enrolled in two PHPs. A sample of 253 youth (Mage = 15.3; SD = 1.4; range = 12-18; 68.8% female; 63.2% White; 75.1% non-Hispanic/Latino/a/x) completed repeated measures of suicidal ideation severity and depressive symptoms during treatment. Trajectories of these outcomes were examined using two separate latent growth models. Recent history of self-injurious behaviors and demographics were tested as predictors of trajectories using a taxonomic approach. Overall, suicidal ideation and depressive symptoms declined over the course of care. Sex, history of self-injury, and sexual identity were associated with variability in one or both trajectories of change. Results suggest individual variability in the rate of change among youth in PHPs. Such information may be used to aid in treatment planning and quality improvement efforts within PHPs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Examination of proinflammatory activity as a moderator of the relation between momentary interpersonal stress and suicidal ideation.

INTRODUCTION: Peer-related interpersonal stress can increase risk for suicidal thoughts among adolescents and young adults. However, not all individuals who undergo peer-related interpersonal stressors experience suicidal thoughts. Heightened proinflammatory activity is one factor that may amplify the relation between interpersonal stress and suicidal thinking. METHODS: This pilot study examined the relation between interpersonal stress and suicidal ideation in real time, as well as whether proinflammatory cytokine (IL-6 and TNF-α) activity across a laboratory social stressor moderated this association in a sample of 42 emerging adults with recent suicidal ideation. Participants completed 28 days of 6×/daily ecological momentary assessment that assessed for suicidal ideation (presence vs. absence, ideation intensity), occurrence of negative peer events, and feelings of exclusion. RESULTS: There was a trend for within-person increases in feelings of exclusion to be associated with increases in concurrent suicidal ideation intensity. Additionally, within-person increases in negative peer events were associated with increased odds of subsequent suicidal ideation among individuals with very low IL-6 activity. However, this finding is considered preliminary. CONCLUSION: Interventions targeting perceptions of exclusion and increasing social support may be of benefit. However, findings require replication in larger samples, and thus must be interpreted with caution.

Longitudinal Relations Between Parenting Practices and Adolescent Suicidal Ideation in a High-Risk Clinical Sample: A Moderated Mediation Model.

Parenting behaviors are associated with adolescent suicidal ideation (SI), but few studies have examined this relation longitudinally or investigated underlying mechanisms. We investigated a moderated mediation model to evaluate perceived burdensomeness as a mediator in the longitudinal relation between parenting behavior (warmth and verbal hostility) and adolescent SI. We hypothesized that this association would be particularly strong among adolescents with greater functional impairment. The sample included 147 adolescents (Mage = 14.9, Age Range = 12-18 years, 76.2% female) and a primary caregiver (Mage = 43.5, Age Range = 27-60 years, 81.4% female) enrolled in a clinical trial. Caregivers completed measures of warmth and verbal hostility (PCPR) and adolescents completed measures of functional impairment (CDI-2), perceived burdensomeness (INQ), and SI (SIQ-JR) at baseline, 12 and 18 months. Two moderated mediation path analyses, one for each parenting behavior, were conducted. Age, sex, treatment condition, baseline and 12-month SI, baseline perceived burdensomeness, and the alternate baseline parenting behavior were included as covariates. Neither model yielded a significant direct effect between baseline parental verbal hostility or warmth and 18-month SI. However, lower warmth and higher verbal hostility were positively associated with 18-month SI indirectly through greater 12-month perceived burdensomeness among youth with relatively higher levels of functional impairment. Perceptions of burdensomeness are a mechanism by which low parental warmth and high parental verbal hostility contribute to SI, but only among youth with greater functional impairment. Interventions to address youth perceptions of burdensomeness may be beneficial, particularly for the most highly impaired youth.

The Role of Family Factors in the Outcomes of Court-Involved Youth.

Court-involved youth (CIY) comprise a significant portion of the U.S. population and have a high prevalence of psychiatric illness and substance use. Youth delinquency has also been associated with family variables and parenting practices. However, it is not known which family factors are most relevant to behavioral outcomes in CIY mandated to outpatient mental health treatment. Self-report measures from 163 CIY (M = 15.19 years; 58.3% male) starting psychiatric care in two U.S. cities were utilized in a cross-sectional analysis to examine the association of parental monitoring and family functioning with the severity and variety of delinquent acts. Results demonstrate that parental monitoring is significantly associated with the delinquent behavior of CIY in mental health treatment, beyond that of psychiatric symptoms and substance use. Improved understanding of influential family factors can enhance tailoring of existing interventions to ensure that they are relevant to the needs of CIY, especially those in psychiatric treatment.

Cognitive Flexibility and Impulsivity Deficits in Suicidal Adolescents.

Although neurocognitive deficits have been documented in adolescents with suicidal ideation (SI) and suicide attempts (SA), it is unclear whether certain impairments differentiate these groups, potentially suggesting heightened risk for SA. Focus on specific facets of impulsivity and cognitive control may indicate distinctions between adolescents with SA vs. SI. The current study examined dimensions of impulsivity and cognitive control in 141 adolescents with SA (n = 41) vs. SI without SA (n = 49) vs. typically-developing controls (TDCs; n = 51). Adolescents completed cross-sectional neurocognitive tasks via the Cambridge Neuropsychological Testing Automated Battery, in addition to demographic and clinical measures. Analyses involved ANOVAs and ANCOVAs. Results indicated that adolescents with SA demonstrated less set shifting/cognitive flexibility (reduced ability to adapt to/disengage from stimuli) and greater impulsive decision making (reduced ability to collect/evaluate information before making decisions) compared to TDCs. In addition, both TDCs and adolescents with SA had greater response inhibition (increased ability to stop motor responses that have begun/become prepotent) than those with SI. Similar results were found when analyzing female adolescents separately. There were no significant differences for male adolescents, potentially due to the small subsample (n = 40). There were no significant findings for spatial planning/problem solving or visuospatial working memory. Findings suggest: 1) less set shifting/cognitive flexibility and greater impulsive decision making for adolescents with SA vs. TDCs; and 2) greater response inhibition for TDCs and adolescents with SA vs. SI. Such information may be useful for improving risk assessments (adding neurocognitive tasks) and targeted treatments (incorporating cognitive remediation) for this impaired population.

A prospective investigation of the relation between dysfunctional family communication and suicidal ideation severity in a clinical adolescent sample: A serial mediation model.

BACKGROUND: Extant research has documented a relation between the quality of family communication and adolescent suicidal ideation. However, few studies have examined this relation longitudinally or explored potential mechanisms of this effect. In the present study, unhealthy family communication was hypothesized to be associated with suicidal ideation severity over 18 months via a serial mediation pathway through emotion regulation difficulties and depressive symptom severity. METHODS: The sample consisted of 147 adolescents (Mage = 14.91, SD = 1.51, range = 12-18 years; 76.2% female, 85.5% White) enrolled in a randomized clinical trial. Family communication quality was assessed at baseline using the Family Assessment Device. Emotion regulation difficulties and depressive symptoms were assessed using the Difficulties in Emotion Regulation Scale and Children's Depression Inventory-2, respectively, at baseline, 6-, and 12-months. Suicidal ideation was assessed using the Suicidal Ideation Questionnaire-JR at baseline and 18-months. Path analysis was used to analyze temporal relations between constructs. RESULTS: After accounting for participant's age, sex, treatment condition, and baseline levels of variables of interest, analyses supported the indirect relation between baseline family communication and 18-month suicidal ideation severity through 6-month emotion regulation difficulties and 12-month depressive symptom severity. LIMITATIONS: Data were exclusively collected via self-report, and the sample was racially homogenous. CONCLUSIONS: Treatment aimed at improving family communication may help bolster emotion regulation abilities, lower depressive symptoms, and subsequently, suicide risk.

Posttraumatic stress disorder symptom clusters, suicidal ideation, and social support in a clinical adolescent sample.

Posttraumatic stress disorder (PTSD) is a risk factor for adolescent suicidal ideation (SI). This study explored the relation between PTSD symptom clusters and SI, and whether social support moderates this association, in a cross-sectional, adolescent, clinical sample (N = 125). We hypothesized that each cluster would be positively associated with SI severity and that social support would buffer these associations. Only the persistent avoidance cluster was significantly associated with SI severity. Further, social support moderated this association. Results highlight the positive association between persistent avoidance symptoms of PTSD and SI and suggest that bolstering social support serves a protective function.

Sexual Identity and its Association with Trajectories of Depressive Symptoms and Emotion Regulation Difficulties from Early to Middle Adolescence.

Few studies have examined how changes in sexual identity impact trajectories of depressive symptoms and emotion regulation difficulties. The current study addresses this gap in the literature by examining these associations over a three-year period in a community sample of adolescents (N = 177; Mage = 12.56; SD = 0.60; nmale = 95). Multilevel modeling revealed that youth who consistently held sexual minority identities from early to middle adolescence-but not youth with inconsistent sexual identity-demonstrated increases in depressive symptoms and emotion regulation difficulties relative to their heterosexual peers. Findings suggest that treatments that bolster emotion regulation abilities and address depressive symptoms may be of particular benefit to youth with consistent sexual minority identities from early to middle adolescence.

Depression-related emotional problems mediate the relation between hopelessness and suicidal ideation severity.

OBJECTIVE: Cross-sectional research with adult samples suggests that hopelessness may indirectly affect suicidal ideation (SI) through overall depressive symptom severity. However, particular depressive symptom constellations, rather than overall symptoms, may underlie the association between hopelessness and SI. Yet, the cross-sectional nature of these studies precludes examination of the temporal associations among these constructs. METHODS: Using path analysis, the present study examined whether depression-related emotional problems mediate the relation between hopelessness and SI in a clinical sample of 110 adolescents over a 6-month period. The specificity of depression-related emotional problems as a mediator was also evaluated. RESULTS: After accounting for covariates, results supported the specificity of 3-month depression-related emotional problems as a mediator of the association between baseline levels of hopelessness and 6-month SI. CONCLUSION: Results suggest that treatment targeted specifically at hopelessness may help reduce depression-related emotional problems and lower SI, and ultimately, adolescent suicide risk.

Predictors and moderators of marijuana and heavy alcohol use outcomes in adolescents treated for co-occurring substance use and psychiatric disorders in a randomized controlled trial.

BACKGROUND: The current study identifies predictors and moderators of substance use outcomes for 111 adolescents with co-occurring substance use and psychiatric disorders who participated in a randomized controlled trial that compared the effectiveness of two home-based treatments: an integrated cognitive behavioral therapy (I-CBT) protocol, in which masters-level clinic staff received intensive training and ongoing supervision in the use of this protocol versus a treatment-as-usual (TAU) comparison condition in which therapists received a continuing education-style CBT workshop in the same protocol. METHOD: The study conducted exploratory predictor and moderator analyses of marijuana and heavy alcohol use outcomes using candidate variables across four domains of psychological characteristics: adolescent substance use, adolescent psychiatric symptoms, parent, and family. RESULTS: Regardless of treatment condition, low parental monitoring at baseline, as assessed by a videotaped interaction task, but not self-report, predicted greater percentage of marijuana use and heavy alcohol use days over the 6-month follow-up period. If parents entered treatment with low levels of parental monitoring, adolescents in the I-CBT condition reduced their percentage of heavy alcohol use days significantly more than adolescents in TAU over the 6-month follow-up period. Greater adolescent aggression and parental emotion dysregulation at baseline also predicted greater percentage of marijuana use days over the 6-month follow-up period for the sample as a whole. Adolescents in the I-CBT condition who reported low positive urgency at baseline reduced their percentage of heavy alcohol use days significantly more than adolescents in TAU care over the 6-month follow-up period. CONCLUSION: The article discusses implications for clinical decision-making, improving treatment effectiveness, and tailoring interventions for adolescents with co-occurring substance use and psychiatric disorders.

Adolescent depressed mood and difficulties with emotion regulation: Concurrent trajectories of change.

INTRODUCTION: Adolescent depression is a significant mental health concern. Emotion regulation difficulties have been associated with subsequent depressive symptoms, though different facets of emotion regulation are rarely compared. This study examined the degree to which trajectories of change in different facets of emotion regulation (goal-directed behavior, impulse control, and regulation strategies) and depressive symptoms were associated across twelve months in a clinical adolescent sample. METHODS: Participants included 110 adolescents from the US who were enrolled in a randomized trial that tested a cognitive-behavioral treatment for youth with co-occurring mental health and substance use concerns (Mage = 15.71 years; 57.3% male). Assessments were conducted at baseline, 3-, 6-, and 12-month follow-ups. Three separate bivariate latent basis growth curve analyses were conducted. Correlations between latent intercepts and latent slopes, as well as overall model fit, were examined. RESULTS: Impulse control and goal-directed behavior were each associated with depressive symptoms at baseline. Additionally, change in impulse control over time was significantly associated with change in depressive symptoms. However, the same was not true for goal-directed behavior. Overall fit indices for models of emotion regulation strategies were below acceptable levels and thus could not be interpreted. CONCLUSIONS: Findings from the present study indicate that adolescents' depressive symptoms appear to improve as their perceived ability to control impulses improves. These results suggest that addressing impulse control difficulties may be an important step in treating adolescent depression and co-occurring disorders.

Parental Monitoring Predicts Depressive Symptom and Suicidal Ideation Outcomes in Adolescents Being Treated for Co-Occurring Substance Use and Psychiatric Disorders.

BACKGROUND: Comorbidity of substance use disorders (SUDs) with mood disorders and other psychiatric conditions is common. Parenting processes and family functioning are impaired in adolescents with SUDs and mood disorders, and parent/family factors predict intervention response. However, limited research has examined the relationship between parent/family factors and mood symptom treatment response in adolescents with comorbid SUDs and psychiatric conditions. METHOD: This study examined the predictive effects of parenting processes and family functioning on depressive symptoms and suicidal ideation (SI) in a randomized controlled trial of integrated cognitive-behavioral therapy vs. treatment as usual for 111 adolescents with comorbid SUDs and psychiatric disorders. Measures of parenting processes, family functioning, depressive symptoms, and SI were completed at baseline and 3-, 6-, and 12-month follow-ups. Exploratory analyses involved mixed-effects regression models. RESULTS: Across treatment conditions, depressive symptoms and SI improved over 12 months. Family functioning domains of family roles (d=0.47) and affective involvement (d=0.39) significantly improved across treatment conditions over 12 months. Higher baseline parental monitoring predicted improved trajectory of depressive symptoms (d=0.44) and SI (d=0.46). There were no significant predictive effects for baseline family functioning or other parenting processes (listening, limit setting). LIMITATIONS: Limitations include the modest sample, attrition over follow-up, and generalizability to samples with higher rates of mood disorders and/or uncomplicated mood disorders. CONCLUSIONS: Parental monitoring may be an important prognostic indicator of depressive symptoms and SI in adolescents with co-occurring SUDs and psychiatric conditions, and therefore may be useful to assess and target in treatment, in addition to family functioning.

Feasibility of an Integrated Treatment Approach for Youth with Depression, Suicide Attempts, and Substance Use Problems.

Depression, suicidal behaviors and substance use problems frequently co-occur, and treatment for youth with these co-occurring problems is often fragmented and challenging. An integrated cognitive-behavioral treatment approach that builds upon a relapse prevention framework and applies common core skills, language, and approach for treating these related problems may be clinically beneficial. Following a description of the integrated approach, we present results of a pilot trial (n = 13) to examine the acceptability and feasibility of the Cognitive-Behavioral Therapy - Relapse Prevention (CBT-RP) intervention plus enhanced treatment as usual (TAU) compared to enhanced TAU alone. The feasibility of the CBT-RP + TAU intervention was reflected by high rates of retention (86%). The acceptability was reflected in positive evaluations regarding the helpfulness of the intervention by adolescents and families. The majority of youth in both CBT-RP + TAU and TAU alone groups evidenced reductions in depression and suicide ideation from study entry to Week 20. Patterns of reduction were more consistent, however, for youth receiving CBT-RP + TAU, and reductions were slower to emerge for some youth receiving TAU alone. Reductions in alcohol and marijuana problems were similar, but half of the youth in TAU alone (and none in the CBT-RP + TAU group) had emergency department visits related to psychiatric crises or substance related problems. These findings, although based on a small sample, underscore the feasibility and acceptability of an integrated cognitive-behavioral relapse prevention approach for youth with depression, suicide attempt histories, and substance use problems.

Parent-adolescent relationship characteristics and adolescent cannabis use: A growth curve analysis.

Background: Adolescent cannabis misuse may be associated with serious academic, conduct, and health problems. Identifying factors associated with adolescent cannabis misuse over time may provide insight to address these factors in interventions. Parent-adolescent relationship characteristics (i.e., attachment, discipline) have been linked to adolescent cannabis misuse and may be important factors to study. Objectives: We investigated time-varying associations between parent-adolescent relationship domains and weekly adolescent-reported cannabis misuse. We hypothesized that during times when parents reported less positive aspects of their relationship with their adolescents, adolescents would report higher levels of cannabis misuse. Methods: Data were drawn from a community clinic treatment study for adolescents with substance use and co-occurring psychiatric disorders (n=110; average age=15.71; 57.3% male). Latent growth modeling with time-varying predictors (parent-adolescent relationship characteristics) was used to examine if the associations between adolescent cannabis misuse and relational frustration, discipline, and attachment varied across the study period (baseline, 3-, 6-, and 12-months). Results: Weekly cannabis misuse significantly increased over time, even after accounting for parental relationship characteristics. When parents rated higher levels of relational frustration relative to their average level of frustration, adolescents reported higher cannabis misuse at all study periods except 12-month follow-up. Conclusion: Results support the importance of considering how specific aspects of the parentadolescent relationship, in this case elevated parental frustration, are associated with adolescent cannabis misuse during treatment and after its completion. Findings suggest parental relationship frustration is a key factor to assess and address within individually tailored interventions for co-occurring cannabis misuse and psychiatric disorders.

A randomized trial of an integrated cognitive behavioral treatment protocol for adolescents receiving home-based services for co-occurring disorders.

The current study conducted a preliminary test of whether community mental health clinic staff could implement a multicomponent cognitive behavioral treatment, developed for adolescents with substance misuse (alcohol and/or marijuana) and comorbid psychiatric symptoms. We randomized a total of 111 families, with an adolescent 12-18 years old, referred to a home-based services program for youth with co-occurring substance use and mental health problems, to receive treatment from either masters-level therapists who received intensive cognitive behavioral therapy (I-CBT) training or from masters-level therapists who took part in a typical brief continuing education-style CBT workshop (treatment as usual, or TAU). Each family's therapist and insurance company determined the frequency and intensity of treatment. We administered follow-up assessments at 3, 6, and 12 months. There was a small, but not statistically significant, reduction in the percent days of heavy drinking and marijuana use over time for both conditions, with the overall effect across the three follow-up points favoring the I-CBT condition. There were no differences on alcohol use days or other drug use. There was also a small, but nonsignificant, positive effect over time on externalizing symptoms, depressed mood, and anxiety, favoring the I-CBT condition. Youth in the I-CBT condition relative to TAU had significantly fewer juvenile justice contacts, while the pattern of costly service use varied, with higher rates at 6-month and lower rates at 12-month follow-ups. If therapists pay greater attention to parent training and provide more parent-adolescent communication sessions, outcomes may improve above standard community care. Training enhancements, to better meet the needs of community therapists and their clinic settings, may also produce better overall results for parents and adolescents.