Evidence-informed Interventions for Addressing Adolescent Relationship Abuse (ARA) in SBHC’s

1. Evidence-informed Interventions for Addressing Adolescent Relationship Abuse (ARA) in SBHC’s Sandi Goldstein, MPH California Adolescent Health Collaborative Lisa James, MA Futures Without Violence

2. Objectives At the end of this session, participants will be better able to: • demonstrate a greater understanding of the prevalence and impact of ARA. • implement new strategies for integrating ARA into clinical encounters. • formulate a multidisciplinary approach.

3. Definitions: Why Language Matters Reframing the conversation from Teen Dating Violence to Adolescent Relationship Abuse: “Are you hanging out with anyone?” “Are you seeing anyone right now?”

4. What is adolescent relationship abuse? • ARA refers to an escalating pattern of repeated acts that physically, sexually, or emotionally abuse a member of a heterosexual or homosexual couple in in the context of a dating or similarly defined relationship which one or both partners is a minor. • Range of controlling behaviors: monitoring cell phone usage, telling a partner what s/he can wear, controlling where s/he goes, and manipulating contraceptive use. • The defining characteristic is a repetitive pattern of behaviors aiming to maintain power and control in a relationship.

5. ARA AND Technology One in four teens in a relationship report being called names, harassed, or put down by their partner via cell phone/texting One in five teen girls have electronically sent or posted nude/semi-nude photos or videos of themselves (12% of these girls say they felt ‘pressured’ to do so)

6. Health Consequences of ARA

7. (CDC Morbidity and Mortality Weekly Report. February 2008. ;Silverman et al, 2001) 1 in 5 (20%) U.S. teen girls report ever experiencing physical and/or sexual violence in an intimate relationship.

8. ARA and Teen Pregnancy (Roberts et al, 2005) • Adolescent girls in physically abusive relationships were 3.5 times more likely to become pregnant than non-abused girls • Pregnant adolescents 2-3 times more likely to have experienced violence during and after pregnancy than older pregnant women

9. ARA and Sexual Risk for Adolescents Partner violence among teen girls linked with: • Early sexual intercourse (before age 15) • Condom inconsistent use or non-use at last sex • Multiple partnering (3+) in past 3 months • Use alcohol or drugs before sex • Have a past or current sexually transmitted infection • Have a partner with known HIV risk factors (Silverman,et al. 2004;Kim-Goodwin et al, 2009; Wu et al, 2003)

10. ARA and Mental Health Over 50% of youth reporting both physical and sexual violence in their relationship also reported attempting suicide. (Bossarte et al, 2008; Ackard & Neumark-Sztainer , 2002)

11. ARA and Mental Health Young women who have experienced partner abuse have higher rates of: • Depression and anxiety • Disordered eating • Substance abuse • more likely to report sadness, hopelessness or suicide ideation (Kim-Godwin YS, et al 2009;Howard DE, et al ,2008;Brossard RM, et al, 2008)

12. What happens at school for these teens? • (Champion et al, 2008; Goldstein et al, 2009; Banyard & Cross, 2008; Coyne-Beasley et al, 2003) Victims and perpetrators are more likely to carry weapons as well as engage in physical fighting and other high risk behaviors. Physical and sexual victimization is associated with anincreased risk for school dropout, lower grades, and less connectedness to school. A third (32%) of female homicides among adolescents between the ages of 11 and 18 are committed by an intimate partner.

13. New Strategies

14. ARA Projects Involving Healthcare Providers • Project Connect • HEART (Healthcare Education, Assessment & Response Tool for Teen Relationships) • SHARP (School Health Center Healthy Adolescent Relationship Program)

15. Project Connect • National Initiative to improve collaboration between public health and domestic violence programs • Worked in 8 states and 2 tribes in phase one and now working in 6 new states and 5 new tribes beginning 2013 • Trained over 6,000 providers from over 150 clinical sites • Changed health policy at the state level • Integrated violence prevention into teen pregnancy prevention • New statewide requirements for all school based health settings to screen and respond to ARA

16. SHARP Model • Provider training • Provider Assessment at every encounter • Distribute Safety Card at every encounter • Peer activities

17. Promoting Healthy Relationships Every adolescent clinical encounter is an opportunity to: • convey prevention education messages about healthy relationships • share with youth that your clinical space is safe and confidential • identify and support youth who may be experiencing controlling and abusive behaviors in their relationships

18. Goals for Universal Education about Healthy Relationships • Distinguish between healthy and unhealthy relationship behavior • Encourage safe and respectful relationships • How to help a friend in an unhealthy relationship • Educate sexually active adolescents about sexual coercion and the importance of consent • Create an environment where youth will see the clinic or provider’s office as a safe place to seek related advice and assistance for relationship abuse

19. Getting Started First things first: Always review the limits of confidentiality-- even if you are not asking DIRECT questions about abuse--in case there is disclosure and you need to report For more information, please refer to Future’s Mandatory Reporting: Using a Trauma-informed Approach module

20. Providing Universal Education on Healthy Relationships The way you start the conversation sets the tone: “I talk about this with all my patients because it’s so common…”

21. Making Healthy RelationshipConversationsSimple

22. “We’ve started talking to all the teens in our clinic about what they deserve in relationships and giving them this card, it talks about health and unhealthy relationships.”

23. “Everyone deserves to be treated with respect- but defining what that looks like can be confusing.” “This panel of the card breaks it down a little more...”

24. Video: Olivia The following video clip demonstrates providing universal education on healthy relationships during an adolescent health visit.

25. Olivia Debrief “So Olivia is anything like this happening to you?” Universal education and focusing on friends opens the door for direct assessment.

26. Talk about healthy relationships with girls and boys: “We find a lot of the teen that come to the clinic have situations like this come up with people they are seeing...”

27. Adolescents report disclosing abusive relationship experiences to friends far more than to health professionals, suggesting that education within clinic settings about “how to tell a friend” may resonate with youth.

28. Voices from the field "I learned long ago not to make assumptions about our patients and that by screening every patient for domestic violence and reproductive coercion, you uncover unlikely stories of abuse. The study helped reinforce the practice of normalizing my screening questions.” -Nurse Practitioner at New Generation Health Center, San Francisco

29. SHARP Peer activities • Each team led by an adult ally • Each team received training from Kat Gutierrez, CSHC • Peers organized one school wide project • Peers organized a bathroom campaign

30. Examples of Activities • Lunchtime session on Valentine’s Day called "Hearts or Bombs" during which students describe healthy and unhealthy relationship qualities. • Theater production on healthy relationships. Production is an interactive piece that will engage audience members in acting out relationship trauma that they or a loved one might have experienced.

32. Examples of Activities • Mock dating game with three contestants, each representing healthy, unhealthy, and abusive relationship tendencies. • Two cupids passing out wallet cards with candy.

33. Evaluation Data

34. HEART Evaluation Results • Tech abuse victimization in the past 3 months decreased in both sites: 65% to 22% (school health center) and from 26% to 7% (teen/young adult health center) • In the teen/young adult health center site, past 3 month reproductive coercion decreased from 13% to 2%. -no significant difference in the school health center site (baseline reproductive coercion was low).

35. HEART Evaluation Results: Client Exit Surveys Clients were overwhelmingly positive about receiving this information from their provider: • 70% of the time clients reported talking to their provider about healthy and unhealthy relationships during the clinical encounter • 57% reported receiving this information helped them know how to help someone in an unhealthy relationship • 77% agree that it is helpful for health care providers to talk about healthy and unhealthy relationships • 84% state they would bring a friend to the health center if they were experiencing an unhealthy relationship

36. HEART Evaluation Results: Providers Since being trained: • 26% reported an increased number of disclosures about ARA by youth • 26% reported having more contact with domestic violence and sexual assault advocates since the training • 66% reported increased counseling about harm reduction strategies with their clients (strategies to stay safer, reduce risk for unintended pregnancy)

37. SHARP Preliminary Results Prevalence of ARA • Approximately 27% (n=197) of students experienced ARA • 63% experienced technology-based abuse • 10% of females experienced reproductive coercion.

38. SHARP Preliminary Results • A majority of students (87%, n=688) identified their SBHC as an ARA resource at baseline. • Post-visit, intervention SBHC students were significantly more likely to have discussed ARA with their provider compared to control students. • Among those who had experienced ARA, intervention SBHC students were more likely to disclose this history of abuse to a provider compared to controls, but this did not persist in adjusted analysis.

39. Building a Multi-disciplinary team • Develop protocol • Develop a collaborative model of care • Have a private place to talk with patients • Use safety care intervention and response • Resources and displaying educational materials

40. Resources For more information about how to do direct assessment for adolescent relationship abuse and pregnancy prevention for adolescents, please see Futures eLearning: Reproductive Coercion Module

41. Contact Information Sandi Goldstein, Director (510)285-5711 sandig@californiateenhealth.org www.californiateenhealth.org Lisa James, Director of Health Futures Without Violence (415)678-5500 ljames@futureswithoutviolence.org