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Safer Sex for Youth in Mental Health Treatment : What’s a mother to do?

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.

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Safer Sex for Youth in Mental Health Treatment : What’s a mother to do?

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  1. 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 MH07878and Lifespan/Tufts/Brown Center for AIDS Research (CFAR)

  2. 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 07878and Lifespan/Tufts/Brown Center for AIDS Research (CFAR)

  3. 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

  4. 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

  5. HIV Risk of Adolescents in Mental Health Treatment Comparative Risk Profile Mental Health Treatment (n=795) & National Sample (YRBS) Percent *Mental Health Care *National Sample HIV – Related Risk Behaviors

  6. HIV Risk of Adolescents in Mental Health Treatment Cluster Analysis Among At-Risk Community Youth Girls(n=645) 75 PROPORTION 62 54 54 42 38 13 14 12 2 Unprotected Sex (upper half) Marijuana ( past 30 days) Cocaine (ever) Suicide Attempt (ever) Arrest (ever) Houck, Lescano, Brown, et al, J. Ped. Psych, 2006

  7. HIV Risk of Adolescents in Mental Health Treatment Self-Cutting and Sexual Risk (N= 196) 35% of sample were self-cutters; 40% > 3X *Gender, race, age entered in MLR Brown, et al, Psych Services, 2005

  8. 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”

  9. 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

  10. 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

  11. Adolescent Study Outcome Analysis Outcome: Condom Use Last Time Had Sex

  12. 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

  13. 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

  14. 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

  15. Family Context & Adolescent HIV Risk Parent-teen condom discussion and condom use at last sex Hadley, Brown, et al., AIDS & Behavior, in press

  16. Family Context & Adolescent HIV Risk Family Based Interventions: • Mother – Child (DiIorio, 2006; Jemmott, 2000) • Parents targeted (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

  17. 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

  18. 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)

  19. 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)

  20. Baseline DemographicsN=721 randomized • Age (mean) 14.8 years • Gender 57% female • Ethnicity 11% Latino • Race 56% African American

  21. Baseline DemographicsN=721 randomized Sexual Risk • Vaginal / anal sex, ever 53% • Unprotected sex acts * 6.4 (mean) in past 90 days • STD, ever * 12% *among sexually active

  22. Baseline DemographicsN=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%

  23. CDISC Diagnostic Data

  24. 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

  25. 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

  26. 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

  27. Parent Baseline DemographicsN=721 randomized • Bio parent 75% • Adoptive parent 9% • Grandparent 6% • Aunt or Uncle 4% • Foster parent 2% • Step parent 2%

  28. Parent Baseline DemographicsN=721 randomized • Gender 89% Female • Household 35% Married with partner • Race 44% African American • Ethnicity 8% Latino

  29. Parent Baseline DemographicsN=721 randomized • Family Income 63% less than $30,000 • Education 20% Less than H.S. 59% H.S. or GED 20% College degree

  30. Parent Baseline DemographicsN=721 randomized • Psychiatric Dx 24% Depressive Disorder 19% Anxiety Disorder 9% Bipolar Disorder 7% • GSI clinical range 40%

  31. 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

  32. 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

  33. Family – Based Intervention Module 1 AdolescentsParents * General HIV Info * 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

  34. Family – Based Intervention Module 2 AdolescentsParents * Talking with parents about sex * 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

  35. Family – Based Intervention Module 3 AdolescentsParents * Condom Use Skills * Condom Use Skills Parent – Child Communication Part III Condom Skills Development Values Discussion with Teen Feedback

  36. Six Month Outcomes (n=354)

  37. Six Month Outcomes (RM ANOVA, n=354) Family Adol. only HP p Outcomes (Past 90 Days) (n=113) (n=123) (n=118) Unprotected Sex Acts*4.4 (5.3) 6.0 (5.8) 6.5 (6.0) .04 Self-Cut (# of times) 0.5 0.7 1.3 .11 Mediators Condom Discussion w/Parent 82% 63% 64% .00 Comfort Condom Discussion 6.3 (1.9) 5.2 (1.8) 4.9 (1.7) .01 Positive Communication 36.1 (7.8) 35.2 (8.8) 35.0 (7.3) .09 *Sexually Active Only

  38. Preliminary Outcomes FAMILY Intervention No increase in sex Sexual communication ADOLESCENT-ONLY Intervention

  39. 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

  40. Conclusions • Family-Based HIV Prevention Intervention • Reduces unprotected sex for adolescents in mental health treatment • Impact appears mediated by change in family communication

  41. 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

  42. 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

  43. DVD Intervention

  44. 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.

  45. Six Month Outcomes (RM ANOVA, n=354) Family Adol. only HP p Drug Use Outcomes (n=113) (n=123) (n=118) Alcohol past 30 days 18% 24% 26% .11 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% .04 * Sexually active boys

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