Transcript Document

Safer Sex for Youth in Mental Health
Treatment : What’s a mother to do?
Larry K. Brown, M.D.
Bradley/Hasbro Children’s Research Center
Professor of Psychiatry,
The Warren Alpert Medical School of Brown University
Providence, Rhode Island
Research Supported by NIMH Grants: 2R01 MH63008; R01 MH66641; T32 MH07878
and Lifespan/Tufts/Brown Center for AIDS Research (CFAR)
Is talking about sex and my teen’s bad
attitude worth the hassle?
Larry K. Brown, M.D.
Bradley/Hasbro Children’s Research Center
Professor of Psychiatry,
The Warren Alpert Medical School of Brown University
Providence, Rhode Island
Research Supported by NIMH Grants: 2R01 MH 63008; T32 MH 07878 and
Lifespan/Tufts/Brown Center for AIDS Research (CFAR)
HIV Prevention Team
Co-Investigators
Brown University: Celia Lescano, Wendy Hadley, David Pugatch
& Ronald Seifer
Emory University: Ralph DiClemente & Delia Lang
University of Illinois, Chicago: Geri Donenberg
University of Pennsylvania: Michael Hennessy
HIV Risk of Adolescents in Mental
Health Treatment
HIV-related risk behavior:
* Earlier onset of sex
* Less condom use
* More partners; STIs
* More frequent substance use
- IV drug use infrequent
HIV Risk of Adolescents in Mental
Health Treatment
Comparative Risk Profile
Mental Health Treatment (n=795) & National Sample (YRBS)
60
50
Percent
40
* Mental Health Care
30
* National Sample
20
10
0
Sexually Active
No Condom Use
Binge Drinking
STIs
HIV – Related Risk Behaviors
HIV Risk of Adolescents in Mental
Health Treatment
Cluster Analysis Among At-Risk Community Youth
Girls(n=645)
P
R
O
P
O
R
T
I
O
N
75
80
70
62
60
50
54
54
42
38
A
B
40
30
20
13
10
0
12
14
2
Unprotected Sex
Marijuana
Cocaine
Suicide Attempt
Arrest
(upper half)
( past 30 days)
(ever)
(ever)
(ever)
Houck, Lescano, Brown, et al, J. Ped. Psych, 2006
HIV Risk of Adolescents in Mental Health
Treatment
Self-Cutting and Sexual Risk (N= 196)
35% of sample were self-cutters; 40% > 3X
Variable
Adj OR*
p
Self-cutting
3.6
.04
HIV selfefficacy
Sexual abuse
3.6
.04
3.0
.05
*Gender, race, age entered in MLR
Brown, et al, Psych Services, 2005
HIV Risk of Adolescents in Mental
Health Treatment
Clinical Challenge
 15 year old girl with Affective Disorder and
prior suicide attempts, self-cutting
 Parents divorced-conflict
 Previous boyfriend-verbally abusive
 Current boyfriend
– “rough” during sex
– “my only real love, would die without him”
HIV Risk of Adolescents in Mental
Health Treatment
Factors associated with HIV risk behavior:
Social Personal Framework:
* Personal attributes
* Family context
* Peer & partner relations
* Environmental conditions
Brown, L. JAACAP, 1997
Donenberg & Pao, JAACAP, 2005
HIV Prevention for Adolescents
Programs have focused on:
* Condom use
- Clear behavioral message is best
“Use a condom” not “stay safe”
* Individual motivation and skills
* Substance use as a co-factor
Adolescent Study
Outcome Analysis
55.0
Intervention
50.0
45.0
40.0
35.0
Baseline
3-Month Followup
6-Month Followup
Outcome:
Condom Use
Last Time
Had Sex
HIV Prevention for Adolescents
Outcomes of programs:
* Short term increase of condom use
- (3 to 6 months)
* Less effective for those with psychiatric
disorders
* Families not involved
- Family programs are school based
- target younger, abstinent teens
Family Context & Adolescent HIV Risk
Sexual risk associated with:
* Family conflict a,b
* Negative affect a
* Less parental monitoring b
a
Black & Stanton, JR Adol, 1997
b McBride
& Paikoff, J C C Psych, 2003
Family Context & Adolescent HIV Risk
Family communication leads to:
• Increased condom use
2,4,5,7,8,9
• Decreased number of sexual partners 2,5
• Increased condom self-efficacy 1,3
• Increased communication with sexual partners 3,8
• Talking prior to debut is important 6
1Dittus
et al., 1999; 2Holtzman & Robinson, 1995; 3Hutchinson & Cooney, 1998; 4Lehr et
al., 2000; 5Leland & Barth, 1993; 6Miller, Levin et al., 1998; 7Romer et al., 1999;
8Whitaker
et al., 1999; 9Whitaker & Miller, 2000
Family Context & Adolescent HIV Risk
Parent-teen condom discussion
and condom use at last sex
70
Condom use (%)
60
50
Condom
discussion
No condom
discussion
40
30
20
10
0
Hadley, Brown, et al., AIDS & Behavior, in press
Family Context & Adolescent HIV Risk
Family Based Interventions:
• Mother – Child
• Parents targeted
(DiIorio, 2006; Jemmott, 2000)
(Krauss, 2000; Stanton, 2004)
• Parent / Community based
•
(CHAMP, McKay, 20000)
School programs with younger teens
 None with youth in mental health treatment
 None examined STIs or delay of sex
Design and Method


Multi-site 3-arm randomized controlled trial
 Providence
 Atlanta
 Chicago
721 parent-teen dyads
 Adolescents in mental health treatment
 Living with parent/caregiver
 Not pregnant
 HIV negative
Recruitment, Randomization,
Retention
 Scheduled for screen / consent
971
 Consented
893
 Randomized
721 (74%)
 No demo or risk differences between conditions
 Retention (no site differences)
 6 months
88%
 12 months
85% (still open)
Assessment
•
Sexual Behavior: lifetime; past 90 days; by partner;
STI by hx and urine screen
• Drug Use Behavior: frequency and quantity
• Psychopathology: CDISC (Adol. and Parent reports)
SCL-90-R (parent self-report)
• Family Processes: Video-taped interaction
Miller Sexual Communication
Parent / Adol. General Communication( Barnes & Olson)
Parenting Style Questionnaire (Oregon Social Learning Cntr, 1990)
Baseline Demographics
N=721 randomized

Age (mean)
14.8 years

Gender
57% female

Ethnicity
11% Latino

Race
56% African American
Baseline Demographics
N=721 randomized
Sexual Risk

Vaginal / anal sex, ever
53%

Unprotected sex acts *
(mean) in past 90 days
6.4
STD, ever *
12%

*among sexually active
Baseline Demographics
N=721 randomized
Substance Use

Cigarette in past 30 days
29%

Alcohol in past 30 days
22%

Binge drinking, past 30 days
26%

Marijuana in past 30 days
38%

Injected drugs, ever
0.8%
CDISC Diagnostic Data
70
60
MDD
GAD
PTSD
Mania
Hypomania
ODD
CD
ADHD
Percent
50
40
30
20
10
0
Diagnoses
Psychopathology and Sex Risk
Ever had vaginal
or anal sex
Adj OR*
95% CI
Major Depressive Disorder
2.4
1.4-4.1
Generalized Anxiety Disorder
2.0
1.2-3.3
Mania
2.1
1.2-3.5
Oppositional Defiant Disorder
2.2
1.4-3.5
More than one Disorder
2.1
1.4-3.3
*Compared to those with no Dx
Psychopathology and Sex Risk
No condom use
at last sex
Adj OR*
95% CI
Major Depressive Disorder
2.3
1.0-5.7
Generalized Anxiety Disorder
2.5
1.0-6.0
Mania
2.9
1.2-7.2
Oppositional Defiant Disorder
2.3
1.0-5.1
More than one Disorder
2.2
1.0-5.1
*Compared to those with no Dx
Psychopathology and Sex Risk
STD History
(sexually active)
Adj OR*
95% CI
Major Depressive Disorder
1.9
0.6-6.2
Generalized Anxiety Disorder
1.2
0.4-3.8
Mania
1.7
0.5-5.6
Oppositional Defiant Disorder
1.6
0.5-4.6
More than one Disorder
1.2
0.4-3.9
*Compared to those with no Dx
Parent Baseline Demographics
N=721 randomized

Bio parent
75%

Adoptive parent
9%

Grandparent
6%

Aunt or Uncle
4%

Foster parent
2%

Step parent
2%
Parent Baseline Demographics
N=721 randomized

Gender
89% Female

Household
35% Married with partner

Race
44% African American

Ethnicity
8% Latino
Parent Baseline Demographics
N=721 randomized

Family Income
63% less than $30,000

Education
20% Less than H.S.
59% H.S. or GED
20% College degree
Parent Baseline Demographics
N=721 randomized

Psychiatric Dx
Depressive Disorder
Anxiety Disorder
Bipolar Disorder
24%
19%
9%
7%

GSI clinical range
40%
Design and Method
 Interventions
 Family
 HIV prevention skills
 Parent-adolescent communication
 Adolescent-Only
 HIV prevention skills
 Health Promotion
Delivered in 1-day workshop, individual session, and ½
day booster
Family Intervention Goals
 Parental monitoring with respect
 Topics often peers, drug use, school or
house rules
 Personal risk plan for adolescents
 Normalize and teach communication about sex
 Mastery experience at communication with
reinforcement
Family – Based Intervention
Module 1
Adolescents
* General HIV Info
Parents
* General HIV Info
* Vulnerability to HIV
* Adolescent Development,
Psychiatric Disorders & HIV
* Assertive Communication
* Assertive Communication
Parent – Teen Communication, Part 1
“Get To Know You Game”
Reverse Role Plays
Family – Based Intervention
Module 2
Adolescents
* Talking with parents about sex
Parents
* Talking with teens about sex
* Assertiveness with peers, parents
* Assertive communication
* Risky situations and behaviors
* Parental Monitoring
* Affect management
*Affect management
Parent – Child Communication II
•Communication Styles
•Parent Challenge
*Observed Discussion
Family – Based Intervention Module 3
Adolescents
* Condom Use Skills
Parents
* Condom Use Skills
Parent – Child Communication Part III
Condom Skills Development
Values Discussion with Teen Feedback
Six Month Outcomes
(n=354)
90
80
70
60
50
Family
Control
40
30
20
10
0
Condom Discussion
w/Parent (p<.01)
Avoided Sexual
Situations
Six Month Outcomes
(RM ANOVA, n=354)
Outcomes (Past 90 Days)
Unprotected Sex Acts*
Self-Cut (# of times)
Mediators
Condom Discussion w/Parent
Comfort Condom Discussion
Positive Communication
*Sexually Active Only
Family Adol. only
(n=113) (n=123)
4.4 (5.3) 6.0 (5.8)
0.5
0.7
HP
(n=118)
6.5 (6.0)
1.3
82%
63%
64%
6.3 (1.9) 5.2 (1.8)
4.9 (1.7)
36.1 (7.8) 35.2 (8.8) 35.0 (7.3)
p
.04
.11
.00
.01
.09
Preliminary Outcomes
FAMILY
Intervention
Sexual
communication
ADOLESCENT-ONLY
Intervention
No increase
in sex
Preliminary Outcomes
X2 = 2.9, p = .4;
TLI = 1.003;
RMSEA = 0
FAMILY
Intervention
Sexual
communication
HIV Self-Efficacy
ADOLESCENT-ONLY
Intervention
Fewer unsafe
sex acts
Conclusions
Family-Based HIV Prevention Intervention
• Reduces unprotected sex for adolescents in
mental health treatment
• Impact appears mediated by change in
family communication
Next Steps
Family-Based HIV Prevention Intervention
• Long term (36 month follow-up)
• STI rates
• Onset of sex
•Videotaped observations
• Moderator (Dx) and mediator analyses
• Adaptation for Latino families
• Effectiveness and dissemination
DVD Intervention
Phase 1 SBIR with MEE Productions
• Focus groups and iterative feedback
• Target: Urban youth and parents
• Interactive DVD (parent, teen, conjoint)
Soap opera style
Instructional material
• Workbook – practice skills and handouts
DVD Intervention
Steps to Condom Use
1.



1. Always use a latex condom.
2. Check the expiration date; pinch the package
to make sure there is air inside.
3. Open the package carefully.
4. Put the condom on the penis once it is fully
hard before it enters the body.
5. Pinch the tip of the condom.
6. Unroll the condom all the way down to the base
of the penis slowly.
7. Keep the condom on the man’s penis until after
he ejaculates or cums.
8. AFTER EJACULATION: The man should pull
out before he gets soft.
9. Throw the condom away.
Six Month Outcomes
(RM ANOVA, n=354)
Drug Use Outcomes
Family Adol. only
(n=113) (n=123)
HP
p
(n=118)
Alcohol past 30 days
18%
24%
26%
Days used alcohol, past 30
3.8 (3.5)
5.3 (7.0)
3.4 (2.9) .08
Drugs with sex, past 90 *
22%
48%
53%
* Sexually active boys
.11
.04