Family Functioning, HIV Risk and Substance Use in Detained Adolescents

1. 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

2. Background and Context • 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 • 3-year program evaluation and the dataset we will discuss today

3. Adolescent Portable Therapy • 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

4. APT Treatment Model • 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 • 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 • Uniform training and supervision • Replicability

5. APT Office

6. APT Highlights • 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

7. Longitudinal Evaluation • Robert Wood Johnson Foundation funded a 3-year randomized, controlled program evaluation • 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

8. Introduction • 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)

9. Introduction cont’d • Interventions focused on individual level factors, while efficacious, do not sustain HIV risk behavior change over time for adolescents • 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 (DiClemente et al., 2007; Malow et al., 2007; Repetti et al., 2002)

10. Introduction cont’d • Much is known about the effect of family functioning (FamF) on substance use and abuse among detainees • Family therapy (i.e. APT) is the state-of-the-science for treatment of substance abuse in adolescents • 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 • 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)

11. Research Questions: • To understand the association between FamF and HIV sexual risk behaviors and frequency and type of substance use we asked the following: • What is the association between FamF and HIV sexual risk behaviors? • What is the association between FamF and type and frequency of substance use?

12. Methods • Procedures/recruitment • 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 • 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) • 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.

13. Family Functioning (N=232)

14. Definitions of FACES Family Functioning • Chaotically Disengaged: Erratic leadership; roles are unclear; little involvement among family members; poor support • Chaotically Enmeshed: Erratic leadership; decisions are impulsive; extreme amount of emotional closeness; individuals are very dependent on one another • Rigidly Enmeshed: One individual is in charge and is highly controlling; limited negotiations; roles are strictly defined; extreme amount of emotional closeness; no personal space • Rigidly Disengaged:One individual is in charge and is highly controlling; limited negotiations; great deal of personal separateness/independence; limited support from family members • Balanced: Some emotional separateness and time apart but 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

15. Sample Characteristics of Pre-adjudicated Juvenile Detainees (n=232)

16. Prevalence of HIV Sexual Risk Behaviors

17. Prevalence of Substance Use

18. What is the Association between Family Functioning and HIV Sexual Risk Behavior?

19. What is the Association between Family Functioning and Substance Use?

20. Summary • High rates of HIV risk behaviors and frequent marijuana use • 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” • Other things in addition to family functioning increase risk • Peers, neighborhoods, mental health disorders

21. Conclusions • Parents and family matter; different types of parenting and family functioning have different outcomes • Chaotically enmeshed family styles  frequent sexual and unprotected sexual behavior, multiple partners • 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 • Compensatory mechanism for managing difficult family processes (self medication)

22. Conclusions • Disengaged family styles  less unprotected sex. • 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

23. Limitations • 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)

24. Treatment Implications • 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

25. Acknowledgements • 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)