Transcript Family functioning, HIV risk and substance use in detained

Family Functioning,
HIV Risk and Substance Use
in Detained Adolescents
Evan Elkin, MA
Director, Adolescent Portable Therapy
Vera Institute of Justice
Katherine Elkington, PhD
Postdoctoral Research Fellow
HIV Center for Clinical and Behavioral Sciences
Columbia University and NYSPI
Background and Context
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Vera Institute of Justice
The Adolescent Portable Therapy (APT)
treatment model
Mission and impetus behind the program
 Overview of the program and the treatment model
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3-year program evaluation and the dataset we
will discuss today
Adolescent Portable Therapy
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APT emerged from conversations with Juvenile justice
system stakeholders in 1999
The push for evidence-supported, manualized
interventions
The challenge of maintaining continuity of care for
system-involved youth
Lack of interventions tailored for adolescents
The challenge of addressing treatment need in settings
where intervention philosophies are punitive
Designed as an alternative to institutional intervention
for youth who contact multiple systems but don’t
typically get treatment
APT Treatment Model
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Portability across systems
At its core, a family therapy intervention
Blends CBT with family therapy
Short term, intensive, delivered in-home and in the field
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4-months
2x/weekly in home contact
Blends individual and family sessions
Between session contact and contact with other “system”
players
Captured in manual form
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Uniform training and supervision
Replicability
APT Office
APT Highlights
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A finalist for the 2005 Innovations in American
Government Award from Harvard’s Ash Institute
OJJDP and Drug Strategies listed Model Program
The only program in New York State licensed by
OASAS to provide home based substance abuse
treatment for adolescents
Publication of APT treatment manual: available at
Chestnut.org or www.vera.org/aptmanual
Replications underway: NH, Buffalo, Winnipeg
Longitudinal Evaluation
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Robert Wood Johnson Foundation funded a 3-year
randomized, controlled program evaluation
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Roughly 500 youth and families assessed at baseline, 3, 9 and
15 months
Youth recruited for heavy substance use
More than 80% had significant co-occurring mental health
symptoms
More than 50% were first time, misdemeanor offenders
More than 80% had no prior history of drug treatment
More than 60% had no prior history of MH treatment
Introduction
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Juvenile detainees are at high risk HIV
 Higher
rates of HIV risk behaviors and earlier
sexual debut
 ~66%
engaged in 10+ HIV risk behaviors in past 3
months
 Higher
rates of STIs
 Higher
rates of substance use and disorder
 Alcohol
and drug use associated with numerous
sexual risk behaviors among adolescents
(Teplin et al., 2002; Teplin et al., 2003; Malow et al., 2006; Bachanas et al., 2002; Lowry et al., 1994; Shrer et al., 1997)
Introduction cont’d
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Interventions focused on individual level factors,
while efficacious, do not sustain HIV risk
behavior change over time for adolescents
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Greater attention is now being paid to the
important role of the family in either promoting
or reducing HIV risk behavior
Protective: family cohesion and connectedness;
positive parent-child relationships; parental
monitoring of behavior
 Risky: Overt family conflict; impoverished
nurturing; lack of structure; hostile, unsupportive
and neglectful family relationships
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(DiClemente et al., 2007; Malow et al., 2007; Repetti et al., 2002)
Introduction cont’d
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Much is known about the effect of family functioning
(FamF) on substance use and abuse among detainees
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Little is known about FamF on HIV risk behaviors
among juvenile detainees
Hard to reach population, once in treatment for
substance abuse, opportune time to intervene to reduce
HIV risk behaviors
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Family therapy (i.e. APT) is the state-of-the-science for
treatment of substance abuse in adolescents
Are the same FamF characteristics associated with both HIV
and substance abuse?
Understanding the role FamF plays in HIV sex risk
behaviors and substance use/abuse is important in
informing the development of interventions that can
target both problems in these high-risk youth.
(Liddle, 2004; Donenberg et al. 2006)
Research Questions:
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To understand the association between FamF
and HIV sexual risk behaviors and frequency
and type of substance use we asked the
following:
1)
2)
What is the association between FamF and HIV
sexual risk behaviors?
What is the association between FamF and type
and frequency of substance use?
Methods
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Procedures/recruitment
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N= 477 youth screened and recruited on intake
 Inclusion Criteria: age 12-16; use of any substance at
least 30 times in past 30 days; or meet criteria for SUD
 Exclusion Criteria: Unwilling family involvement; acute
psychosis or suicidality; requiring psychiatric medication
Assent/consent obtained and baseline interview occurred
within 24hrs of intake
Measures
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Global Appraisal of Individual Needs (GAIN-I):
Substance use and disorder; HIV sexual risk behaviors
Family Adaptability and Cohesion Scales (FACES II):
Family Functioning (n=232)
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Cohesion: Emotional bonding that family members have towards one
another
Adaptability: Amount of change in leadership/control, roles and
relationship rules, how systems balance versus change.
Family Functioning
(N=232)
A
d
a
p
t
a
b
i
l
i
t
y
Chaotic
Chaotically disengaged
(n=24; 10%)
Chaotically enmeshed
(n=31; 13%)
Balanced
(n=108; 47%)
Flexible
Structured
Rigid
Rigidly disengaged
(n=62; 27%)
Disengaged
Rigidly enmeshed
(n=7; 3%)
Separated
Connected
Cohesion
Enmeshed
Definitions of FACES
Family Functioning
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Chaotically Disengaged: Erratic leadership; roles are unclear;
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Chaotically Enmeshed: Erratic leadership; decisions are
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Rigidly Enmeshed: One individual is in charge and is highly
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Rigidly Disengaged: One individual is in charge and is highly
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Balanced: Some emotional separateness and time apart but
little involvement among family members; poor support
impulsive; extreme amount of emotional closeness; individuals
are very dependent on one another
controlling; limited negotiations; roles are strictly defined;
extreme amount of emotional closeness; no personal space
controlling; limited negotiations; great deal of personal
separateness/independence; limited support from family
members
there is emphasis on togetherness and support; egalitarian
leadership; joint decision-making and open negotiations; rules
maybe changed but are enforced; roles are relatively stable
Sample Characteristics of Pre-adjudicated Juvenile
Detainees (n=232)
Table 1. Sample Characteristics of Pre-adjudicated Juvenile
Detainees (n=232)a
Characteristic
N
%
Gender
Male
182
78
Female
50
22
Age
Mean (sd)
14.8 (0.8)
Median
15
Race/ethnicity*
African American
109
47
Latino
74
32
Other
33
14
Education
8th grade or less
160
69
Grade 9-12
72
31
Primary Caregiver
Parents living together
20
9
Parents separated
2
1
Single parent
157
68
Other family members
38
16
County/State
4
2
Other
11
5
Self identified Orientation
2
Bi-sexual
1
4
Lesbian
2
0
Gay
0
3
Celibate
1
Substance use related variables
Youth used at home
42
18
Youth used with a family member
70
30
Family members ever trouble w/alcohol
78
34
Family members ever trouble w/drugs
84
36
Family members get drunk weekly
39
17
Family members used drugs weekly
56
24
Family members ever been in treatment
31
13
*
% may not total 100% due to missing data
Prevalence of HIV Sexual Risk
Behaviors
Table 2. Prevalence of HIV sexual risk behaviors among detained youth by
gender (n=232)
Male
Female
Total
(n=182) (n=50)
Sexual risk behavior in past 12 months
N
%
%
%
p
Injected drugs
2
1
1
2
ns
Sexually active
207
90
90
90
ns
Sex while you or partner was drunk or high
Sex with IDU
Anal sex
Sex with MSM
Sex exchange for drugs, money etc
Exchanged drugs, money, etc for sex
2+ sex partners
Sex without a condom
114
1
28
4
4
0
153
100
50
0
12
2
2
0
67
44
50
1
15
1
0
0
69
43
51
0
4
4
8
0
61
49
ns
ns
0.05
ns
ns
ns
ns
ns
Use alchol or drugs to make sex last longer
Past three months (n=186)
Sexually active
Sex with a condom
Sex without a condom
24
11
12
4
ns
186
56
148
95
41
79
95
40
78
95
44
81
ns
ns
ns
Prevalence of Substance Use
Table 3. Prevalence of drug and alcohol use in past 30 days
among detained youth, by gender (n=232)
Total Male Female
Substance use in past 30 days
%
%
%
p
Any alcohol use
76
76
75
ns
Any marijuana use
85
84
88
ns
Any hard drug use
10
8
20
0.03
Both alcohol and marijuana use
67
67
69
ns
≥ 30 times use of alcohol
4
4
4
ns
≥ 30 times use of marijuana
54
55
49
ns
≥ 30 times use of marijuana and any
alcohol
56
56
58
ns
Substance dependence
(past 6 months)
19
20
15
ns
Substance abuse (past 6 months)
59
55
71
0.053
What is the Association between Family
Functioning and HIV Sexual Risk Behavior?
Table 4. Sexual risk behaviors by family functioning - Balanced family functioning is the comparison group
Chaotically
Rigidly
Rigidly
Chaotically
disengaged
disengaged
enmeshed
enmeshed
(95%CI)
(95%CI)
(95%CI)
Sexual risk behavior
AORa
AORa
AORa (95%CI) AORa
(Past 12 mos)
Sexually active
Sex while high
Anal sex
2+ sex partners
Unprotected sex
Use drugs to make sex last
1.1
0.5
0.7
0.8
0.5
2.0
(0.2-5.3)
(0.2-1.4)
(0.1-3.3)
(0.3-2.2)
(0.2-1.3)
(0.6-7.3)
1.3
1.1
0.9
1.6
0.8
0.6
0.2
1.9
(0.1-0.6)*** 0.3
(0.7-5.6)
1.7
(0.4-4.6)
(0.6-2.2)
(0.3-2.7)
(0.8-3.3)
(0.4-1.5)
(0.1-2.1)
------1.3
0.2
---
------(0.2-7.5)
(0.0-1.7)
---
2.8
1.1
0.8
5.2
1.0
0.3
(0.3-23.0)
(0.5-2.7)
(0.2-3.1)
(1.5-18.6)**
(0.4-2.3)
(0.0-2.4)
(0.1-0.8)** 0.5
(0.8-3.8)
0.9
(0.1-6.1)
(0.1-9.5)
0.6
1.8
(0.2-2.0)
(0.7-4.7)
SE
1.1
1.2
β
0.5
0.2
SE
0.2*
0.3**
(Past 3 mos n=186)
Unprotected sex
Condom use
Frequency of sex occasions
Frequency of unprotected sex
β
-0.3
-1.1
SE
0.4
0.6
*p<0.1, **p<0.05; ***p<0.01
a Adjusted for gender, race/ethnicity and age
β
0.2
0.1
SE
0.2
0.2
β
-1.3
-1.3
What is the Association between Family
Functioning and Substance Use?
Table 5. Substance use by family functioning; Balanced family functioning is the comparison group
Chaotically
Rigidly
Rigidly
Chaotically
disengaged
disengaged
enmeshed
enmeshed
a
(95%CI)
(95%CI) AORa (95%CI)
Substance use in past 30 days AORa (95%CI) AORa
AOR
Any alcohol use
≥ 30 times use of marijuana
≥ 30 times use of marijuana
and alcohol
Substance dependence
(past 6 months)
Substance abuse
(past 6 months)
0.8
1.8
(0.3-2.4)
(0.7-4.6)
1.6
2.5
(0.7-3.9)
(1.2-5.0)**
1.8
2.4
(0.2-16.3)
(0.4-14.2)
0.7
1.4
(0.3-1.7)
(0.6-3.4)
0.9
(0.3-2.9)
2.1
(0.9-4.7)*
2.4
(0.2-26.2)
1.1
(0.4-2.8)
0.9
(0.3-3.0)
1.6
(0.7-3.5)
---
---
0.5
(0.3-1.9)
1.0
(0.4-2.5)
0.9
(0.4-1.7)
0.6
(0.1-3.4)
1.0
(0.4-2.3)
β
-0.9
SE
0.7
β
1.2
SE
0.3***
β
-1.6
SE
1.6
β
0.2
SE
0.7
0.6
0.2***
0.5
0.5
-0.3
0.3
Frequency of alcohol use
Frequency of marijuana use
-0.2
0.4
(≥ 30 times=0)
*p<0.1, **p<0.05; ***p<0.01
a Adjusted for gender, race/ethnicity and age
Summary
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High rates of HIV risk behaviors and frequent
marijuana use
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Few gender differences in risk behavior; females
more likely to use hard drugs and have abuse dx
Infrequent “hard drug” use, IDU, sex exchange,
MSM/same sex activity
About 50% of families were “Balanced”
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Other things in addition to family functioning
increase risk
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Peers, neighborhoods, mental health disorders
Conclusions
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Parents and family matter; different types of parenting
and family functioning have different outcomes
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Chaotically enmeshed family styles  frequent sexual and
unprotected sexual behavior, multiple partners
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Continuing style of relationships modeled by the family with
partners
Over-involvement of parents tends to drive youth away from
family toward influence of partners (and peers)
Youth in rigidly disengaged families  frequent use of
alcohol and marijuana
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Compensatory mechanism for managing difficult family
processes (self medication)
Conclusions
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Disengaged family styles  less unprotected sex.
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Perhaps resilience/self reliance on part of youth?
Target these families in specific ways in
interventions developed for both HIV and
substance use
Need to explore the processes through which
specific types of family functioning increase sex
risk and substance use behaviors
Need to examine other factors such as peers,
community characteristics that may also increase
risk
Limitations
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Limited demographic variation to examine
differences; sample non-representative
/consecutive admissions
Measure of sexual risk behavior limited in detail
and types of behaviors in last 3 months
Missing data
Do not examine parental report of family
functioning
Do not examine other factors related to both
family functioning and HIV risk (e.g. peers,
mental illness, parental substance use)
Treatment Implications
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Supports the APT model’s core hypothesis that
adolescent risk behavior is mediated strongly by family
functioning and the treatment objective of moving
families toward more a “balanced” profile
Supports some of the APT model’s assumptions about
parenting and adolescent development with our
population and helping parents to strategically “back
off ” (chaotically enmeshed) and/or re-engage (rigidly
disengaged) in the right dosage
These treatment strategies can be applied to
interventions that target both HIV sexual risk and
substance use behaviors
Acknowledgements
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Presentation supported in part by training grant
from the National Institute of Mental Health
(T32 MH19139; Behavioral Sciences Research in
HIV Infection; Principal Investigator, Anke A.
Ehrhardt, PhD) at the HIV Center for Clinical
and Behavioral Studies (P30 MH43250; Principal
Investigator, Anke A. Ehrhardt, PhD).
APT evaluation supported by a grant from the
Robert Wood Johnson Foundation (Principal
Investigator, Jim Parsons)