Cannabis use is common among court-involved, nonincarcerated (CINI) youth, who comprise 74% of justice-involved youth [1]—of those who test positive for a substance at the time of their arrest, 92% test positive for cannabis [2]. Early-onset cannabis use has been linked to many negative long-term outcomes, including violent behavior [3], criminal justice involvement [4,5], and substance use (SU) disorders [6]. In addition, cannabis use is a risk factor for subsequent rearrest and detention among CINI youth, perpetuating their involvement in the juvenile justice system [7]. The synergistic, maladaptive relationship between early cannabis use and juvenile justice involvement [8] highlights the need for early interventions targeting cannabis use in CINI youth [9]. Unlike detained youth who can be funneled directly into treatment on-site [10], CINI youth are typically referred to community providers, shifting treatment-seeking responsibilities to CINI youth and their families. Families involved with the legal system often face multiple competing demands that can make it difficult to engage in treatment [11], even when court-mandated, placing CINI youth at risk for escalating legal consequences and SU problems. Recent research indicates that only 28% of detained youth [12] and <30% of CINI youth [13] in need of SU services ultimately receive any treatment. Given that many court agencies were not designed to deliver SU treatments, on-site services need to minimize resource demands, maximize accessibility, and above all, be effective.

Although research on effective interventions to reduce cannabis use among CINI youth is in its infancy, theory and evidence from the broader adolescent SU literature may offer valuable insight. To date, theories of adolescent SU [14] have centered on several key intrapersonal and interpersonal mechanisms of SU behavior. Intrapersonal mechanisms, including one’s attitudes, self-efficacy, beliefs, and SU expectancies, are thought to be informed via didactic (eg, SU education [15]) and social (witnessing parent [16-18] or peer [19] SU) learning and later refined by direct experiences. Theorized interpersonal mechanisms of SU behavior encompass both direct influence from others, such as social reinforcement or modeling [20,21], and indirect influences, including perceived norms of peers’ SU [14,22].

Recent systematic and meta-analytic reviews of SU treatments for youth [23-25] indicate that cognitive-behavioral, family-based, and motivation-enhancing approaches are most effective at decreasing SU behaviors and problems in adolescents. Established intervention approaches primarily target intrapersonal mechanisms of SU. Cognitive-behavioral and family-based approaches can take 12 to 16 sessions [26], whereas motivation-enhancing models require fewer sessions and organizational resources, suggesting they could potentially be more cost-effective [27-29] and disseminable [30] in justice settings. Although brief motivation-enhancing approaches have shown promise among justice-involved youth [31,32], such interventions could be strengthened by incorporating components that also target interpersonal mechanisms of SU. For example, a recent randomized controlled trial (RCT) of a motivation-enhancing intervention incorporating accurate peer cannabis use norms found that participants reported more accurate peer norms after treatment [33]. In turn, changes in peer norms and one’s own approval of cannabis use were linked to posttreatment improvements in cannabis use and related outcomes. Finding new ways to foster peer engagement and build supportive communities in adolescent treatment contexts akin to SU recovery (eg, 12-step programs, peer recovery specialists, and online support groups) could prove to be a powerful means of promoting SU behavior change among youth.

Digital health interventions that combine motivation-enhancement and accurate peer norms may be especially well-suited to treat CINI youth in justice settings because they are accessible, customizable, portable, and show evidence of reducing cannabis use [34-39]. Among adolescents who receive brief computerized SU treatments [40], effects appear to fade over time [41], suggesting that adjunct treatments may be needed to help sustain gains. Smartphone apps are an especially appealing means of providing youth ongoing, on-demand care as an adjunct to concurrent or recently completed services (eg, continuing care and recovery support). More than 91% of US youth have their own smartphones [42], which they use for everything from schoolwork to seeking support from peers during challenging times [43]. Overwhelming evidence shows that teens find mobile apps to be a confidential and acceptable intervention platform, one with which they engage much more frequently than adults [44,45].

Most publicly available smartphone apps for SU do not incorporate evidence-based practices or resources related to SU treatment [46,47], but the availability of empirically-supported apps is increasing. A 2021 systematic review of smartphone apps for SU [48] identified 2 adjunctive smartphone apps specifically for youth with cannabis use. Although studies of both apps established the feasibility and potential efficacy of adjunctive smartphone apps for cannabis use [44,49-52], these apps were built for older, heavy cannabis users who were also receiving in-person therapy from skilled clinicians, and neither was designed for youth in low-resource settings like the juvenile justice system. Critically, no existing apps built to help youth reduce cannabis or other SU have any peer networking features. In other words, no currently available app designed for youth who use substances leverages interpersonal mechanisms of change. This represents a significant limitation to existing apps as well as an opportunity to advance the field. Therefore, new research is needed to establish the feasibility, acceptability, and effectiveness of an adjunct smartphone app targeting intrapersonal and interpersonal mechanisms to reduce cannabis use among high-risk teens in low-resource settings.

This protocol aims to develop, feasibility test, and evaluate the preliminary effectiveness of Teen Empowerment through Computerized Health (TECH) app as an adjunct to standard family court services (ie, treatment-as-usual [TAU]) to reduce cannabis and other SU among CINI youth. We conceptualize TECH as a peer-facilitated adjunct to brief, motivation-enhancing treatments for cannabis use—a virtual community where CINI youth can give and receive ongoing support around SU-related behavior change. Study activities will address three scientific aims and two hypotheses:

The study aims will be achieved across 3 distinct study phases. Phase I will consist of qualitative interviews with CINI youth (n=14-18), their caregivers (n=6-8), and behavioral health app developers (n=6-8) to determine how, why, and when CINI youth would most prefer to engage with a smartphone app to reduce cannabis use. Qualitative results will guide decision-making on the key features and overall design of the TECH app, in partnership with our software developer. Phase II will beta test the TECH app with CINI youth (n=10) to guide decision-making to refine the app. Phase III will encompass a pilot RCT with CINI youth (n=60) to compare the treatment effects of TAU-only and TAU+TECH.

The study will be guided by 2 frameworks. First, the research approach will follow principles of user-centered design [53] for accelerating digital health research [54]. In this context, the user-centered design approach will engage key stakeholders in all aspects of TECH development and refinement, to ensure the resulting app is tailored to the specific needs and preferences of CINI youth who use cannabis. Second, the Behavior Intervention Technology (BIT) model will guide the research team’s efforts to build the TECH app prototype [55]. The BIT model helps researchers clarify why a digital health product is needed (eg, clinical and usage aims for the TECH app), how it is expected to change users’ behavior (eg, interpersonal and intrapersonal mechanisms), and what technical components will achieve the desired effects (eg, elements, characteristics, and workflow of the TECH app features).

This research will be done in partnership with a state-wide family court in the Northeastern United States. The partner family court has jurisdiction over all delinquent, wayward, dependent, psychiatrically disordered, and diverted youth aged <18 years.

All CINI youth who participate in any phase of this study will receive standard services from the family court, including juvenile intake and any indicated referrals. In the juvenile intake, court staff workers screen youth for mental health and SU problems. Intake workers then make referrals; options for continued system involvement include formal delinquency charges, diversion programs (eg, mandated community service, mental health services, or SU services), ongoing supervision, or probation.

In 2017, the family court began recommending the eCHECKUP-TO-GO (ECTG) program for cannabis [56] as their standard of care for CINI youth who present with a history of cannabis use. ECTG is a computerized single-session, motivation-enhancing intervention that generates personalized behavior change goals related to cannabis and SU across personal, academic, and social domains and has shown positive outcomes among cannabis-using [37,57] and abstinent [58] college students. All CINI youth who participate in any phase of this study will receive the computerized ECTG program for cannabis use.

Three types of participants will be recruited: CINI youth, their caregivers, and behavioral app developers. Notably, caregivers of CINI youth and CINI youth will participate independently in the study (ie, we are not enrolling caregiver+CINI youth dyads). CINI youth will be recruited for all study phases and must be (1) aged 14-18 years, (2) able to speak and read English, (3) have access to a smartphone, (4) report past-year cannabis use and screen positive on either the CRAFFT (car, relax, alone, forget, friends, trouble) [59] or the Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2 [60])—the family court’s preferred evidence-based SU screening measures, and (5) have a caregiver willing and able to provide consent for their participation. In phases II and III, eligible CINI youth must also be (6) willing to adhere to the TECH app’s user safety agreement during the consent process. Importantly, caregivers providing consent for CINI youth to participate must be able to complete the consent process in English or Spanish. Caregivers and behavioral health app developers will only participate in phase I interviews. Caregiver participants must (1) speak in English and (2) be a legal guardian and primary caregiver of an eligible CINI youth. Behavioral health app developers must (1) speak and read in English and (2) be lead developers of a research-based smartphone app targeting behavioral health outcomes. Exclusion criteria are limited to enhance generalizability and only include conditions that preclude CINI youth from actively participating in an interview or using the proposed app (eg, psychosis, cognitive impairment, no smartphone access, or non-English speaking).

CINI youth (phase I, n=14-18; phase II, n=10; and phase III, n=60; in total, n=84-88) will be recruited through the family court’s juvenile intake department. Court intake staff will receive a brief training on the study objectives, eligibility criteria, and referral procedures. Upon screening a study-eligible adolescent, intake staff will describe whichever phase of the study is actively recruiting participants; CINI youth aged >18 years and caregivers of interested minors will sign a consent-to-contact form allowing contact with the investigators. The phase I consent-to-contact form allows families to indicate whether the CINI youth, the caregiver, or both would be interested in interviewing. When recruiting CINI youth who are minors, the research team will initiate contact with their caregivers.

Caregivers of CINI youth (phase I only; n=6-8) will be recruited through the family court’s juvenile intake department via the same methods used to recruit CINI youth. Following receipt of the consent-to-contact form, the principal investigator will contact eligible caregivers to describe the study interviews.

Behavioral health app developers (phase I only; n=6-8) will be identified via searches of the literature and repositories of federally funded grants to ensure they were a lead developer of a research-based smartphone app targeting behavioral health outcomes. Given TECH’s focus, preference will be given to developers of youth- or SU-focused apps. The principal investigator will contact eligible individuals to describe the study and invite them to reply if interested.

All participants will receive financial compensation for their participation in the study. Phase I participants will receive a US $50 gift card upon completion of the study interview. Phase II and III CINI youth will receive up to US $90 and US $200 in gift cards, respectively.

To promote retention of phase II and III CINI youth at follow-up, we will collect multiple sources of contact information at baseline, including social media handles [61]. Participants will also receive gift cards escalating in value for each completed assessment (ie, US $40 at baseline, US $50 at 1 and 3 months, and US $60 at 6 months).

We aim to recruit 84 to 88 CINI youths throughout the 5-year, multiphase protocol. Approximately 1500 youths are referred to the family court annually. In a recent study of a sample of youth screened by the family court, 173 (50%) of 348 youths screened positive for problematic cannabis use [63], indicating that the recruitment pool is sufficiently robust to support the proposed recruitment targets.

The proposed study activities will be reviewed and approved by the institutional review board at Brown University. The research team has extensive experience conducting intervention research with CINI youth who use cannabis and addressing emergent safety concerns. Study activities will include several safeguards to ensure that the proposed research presents minimal risks of psychological discomfort, coercion, legal, and loss of privacy or confidentiality to CINI youth participants. Psychological discomfort will be minimized by (1) emphasizing that youth will not be obligated to answer distressing questions and can withdraw from the study at their discretion; (2) avoiding direct questions about parental neglect, abuse, or suicidal ideation; and (3) conducting a thorough safety assessment if youth spontaneously disclose these concerns. The risk of coercion will be minimized by (1) reminding CINI youth their participation is voluntary; (2) ensuring that they receive multiple referral options for substance misuse from their court intake worker, of which the study will be one; and (3) offering compensation rates consistent with previous studies and commensurate with the level of effort required. Legal risks will be minimized by obtaining a certificate of confidentiality from the National Institutes of Health and explaining its limitations. Potential loss of privacy or confidentiality will be minimized by (1) using electronic consent and assent forms instead of needing to store and/or transport hard copies from the family court to the university; (2) deidentifying participant data; (3) storing all electronic data, including audio recordings, on a password-protected, secure shared drive; (4) allowing only the principal investigator, coinvestigators, and research team members to access data files; and (5) destroying all audio recordings and any other identifiable information within 6 months of the study’s conclusion.

Our pilot RCT will be submitted for registration to the ClinicalTrials.gov website within 21 days of enrolling the first phase III participant (anticipated in summer 2023).

This multiphase research aims to develop and pilot test an adjunctive smartphone app to reduce cannabis and other SU among CINI youth. Given the high prevalence of cannabis use in this population [2] and well-documented associations with health and legal consequences later in life [3-6], preventive and early interventions are vital to disrupt the cycle of SU and criminal justice involvement among CINI youth. We believe that the proposed TECH app will be the first designed specifically for CINI youth, who represent nearly 75% of all youth involved in the juvenile justice system [1]. Although a handful of smartphone apps have been developed to support adolescents in treatment for cannabis use [44,49-52], TECH will be one of the first apps designed for youth who are not currently receiving traditional SU treatment. Treatment rates are generally low across the juvenile justice system: only 28% of detained youth [12] and <30% of CINI youth [13] in need of SU services receive any treatment.

Brief, computerized interventions such as the ECTG program [56] can deliver evidence-based content with high fidelity, making them ideal for self-administration or delivery by a workforce without behavioral health training. However, similar to most brief approaches, gains achieved through brief computerized interventions can fade over time, including in samples of adolescents who use substances [40,41]. Digital adjuncts, like the TECH app, could provide a light touch of ongoing support to help bolster treatment gains. Although this app will be tailored to address the unique needs and preferences of CINI youth who use substances, evidence supporting the feasibility and acceptability of our multimodal digital approach could have broader implications. Fully digital approaches represent a promising, if untested, solution for high-need, low-resource settings, especially those with the existing infrastructure to identify individuals at risk but lacking the workforce, capacity, or overarching mission to deliver behavioral health services, such as juvenile-court settings. Finally, despite overwhelming evidence indicating that peers play a key role in the development of adolescent SU, this study marks one of the first efforts to leverage interpersonal mechanisms of change through a peer networking forum. The proposed platform will connect youth in a monitored, virtual community that limits risky peer behavior so that they can engage and support each other’s cannabis-related behavior changes.

We note the following limitations to the proposed work. First, although caregiver- and family-based interventions for adolescent SU are well-established [24], this study will intervene solely on CINI youth. If TECH shows promise as an adjunct to brief computerized treatments (ie, the ECTG program for cannabis use [56]), an appropriate next step could be to deliver TECH alongside family-focused digital approaches [96]. Second, all CINI youth will receive TAU, which includes the computerized ECTG program for cannabis use [56] that has been shown to reduce cannabis use among young adults [37,57,58]. This ensures that CINI youth in-need would not be denied standard services. Although this may impact our ability to detect preliminary intervention effects specific to the TECH app, it is also the only way to assess whether the adjunctive TECH app can help sustain cannabis and other SU behavior change among CINI youth. Third, CINI youth and caregivers may be hesitant to disclose youth SU and delinquent behavior in qualitative interviews and surveys. To address this issue, our consent procedures will explain our protocols to maintain confidentiality and how study data will not lead to reprisals from family courts. Finally, although sufficient to achieve the proposed aims, the small sample in the pilot RCT may provide limited opportunities for in-app peer engagement, which may hinder interpersonal mechanisms of behavior change. We will take several steps to maximize peer presence on the TECH app, including randomizing youth 2:1 to receive the TECH app, phasing recruitment so that multiple participants receive the app concurrently, and populating the app with content collected from previous participants.