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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,

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Presentation on theme: "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,"— Presentation transcript:

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 MH07878 and 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 and Lifespan/Tufts/Brown Center for AIDS Research (CFAR)

3 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 Prevention Team

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

6 Cluster Analysis Among At-Risk Community Youth Girls(n=645) 62 Unprotected Sex (upper half) Marijuana ( past 30 days) Cocaine (ever) Suicide Attempt (ever) Arrest (ever) Houck, Lescano, Brown, et al, J. Ped. Psych, 2006 PROPORTIONPROPORTIONPROPORTIONPROPORTION

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

8 HIV Risk of Adolescents in Mental Health Treatment Clinical Challenge 15 year old girl with Affective Disorder and prior suicide attempts, self-cutting 15 year old girl with Affective Disorder and prior suicide attempts, self-cutting Parents divorced-conflict Parents divorced-conflict Previous boyfriend-verbally abusive Previous boyfriend-verbally abusive Current boyfriend 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

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11 HIV Prevention for Adolescents Programs have focused on: * Condom use - Clear behavioral message is best - Clear behavioral message is best “Use a condom” not “stay safe” * Individual motivation and skills * Substance use as a co-factor

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13 Adolescent Study Outcome Analysis Outcome: Condom Use Last Time Had Sex

14 HIV Prevention for Adolescents Outcomes of programs: * Short term increase of condom use - (3 to 6 months) - (3 to 6 months) * Less effective for those with psychiatric disorders * Families not involved - Family programs are school based - target younger, abstinent teens

15 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

16 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 Decreased number of sexual partners 2,5 Increased condom self-efficacy 1,3 Increased condom self-efficacy 1,3 Increased communication with sexual partners 3,8 Increased communication with sexual partners 3,8 Talking prior to debut is important 6 Talking prior to debut is important 6 1 Dittus et al., 1999; 2 Holtzman & Robinson, 1995; 3 Hutchinson & Cooney, 1998; 4 Lehr et al., 2000; 5 Leland & Barth, 1993; 6 Miller, Levin et al., 1998; 7 Romer et al., 1999; 8 Whitaker et al., 1999; 9 Whitaker & Miller, 2000

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

18 Family Context & Adolescent HIV Risk Family Based Interventions: Mother – Child (DiIorio, 2006; Jemmott, 2000) Parents targeted (Krauss, 2000; Stanton, 2004) Parents targeted (Krauss, 2000; Stanton, 2004) Parent / Community based (CHAMP, McKay, 20000) Parent / Community based (CHAMP, McKay, 20000) School programs with younger teens School programs with younger teens  None with youth in mental health treatment  None examined STIs or delay of sex

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20 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

21  Scheduled for screen / consent 971  Consented 893  Randomized 721 (74%)  No demo or risk differences between conditions  Retention (no site differences)  6 months88%  12 months85% (still open) Recruitment, Randomization, Retention

22 Assessment Sexual Behavior: lifetime; past 90 days; by partner; STI by hx and urine screen Drug Use Behavior: frequency and quantity Drug Use Behavior: frequency and quantity Psychopathology: CDISC (Adol. and Parent reports) Psychopathology: CDISC (Adol. and Parent reports) SCL-90-R (parent self-report) Family Processes: Video-taped interaction Family Processes: Video-taped interaction Miller Sexual Communication Parent / Adol. General Communication( Barnes & Olson) Parenting Style Questionnaire (Oregon Social Learning Cntr, 1990)

23 Baseline Demographics N=721 randomized Age (mean) 14.8 years Age (mean) 14.8 years Gender 57% female Gender 57% female Ethnicity11% Latino Ethnicity11% Latino Race56% African American Race56% African American

24 Baseline Demographics N=721 randomized Sexual Risk Vaginal / anal sex, ever53% Vaginal / anal sex, ever53% Unprotected sex acts * 6.4 Unprotected sex acts * 6.4 (mean) in past 90 days STD, ever *12% STD, ever *12% *among sexually active

25 Baseline Demographics N=721 randomized Substance Use Cigarette in past 30 days29% Cigarette in past 30 days29% Alcohol in past 30 days 22% Alcohol in past 30 days 22% Binge drinking, past 30 days26% Binge drinking, past 30 days26% Marijuana in past 30 days38% Marijuana in past 30 days38% Injected drugs, ever0.8% Injected drugs, ever0.8%

26 CDISC Diagnostic Data

27 Psychopathology and Sex Risk Ever had vaginal or anal sex or anal sex Adj OR*95% CI Adj OR*95% CI Major Depressive Disorder Generalized Anxiety Disorder Mania Oppositional Defiant Disorder More than one Disorder *Compared to those with no Dx

28 Psychopathology and Sex Risk No condom use at last sex at last sex Adj OR*95% CI Adj OR*95% CI Major Depressive Disorder Generalized Anxiety Disorder Mania Oppositional Defiant Disorder More than one Disorder *Compared to those with no Dx *Compared to those with no Dx

29 Psychopathology and Sex Risk STD History STD History (sexually active) Adj OR*95% CI Adj OR*95% CI Major Depressive Disorder Generalized Anxiety Disorder Mania Oppositional Defiant Disorder More than one Disorder *Compared to those with no Dx *Compared to those with no Dx

30 Parent Baseline Demographics N=721 randomized Bio parent 75% Bio parent 75% Adoptive parent9% Adoptive parent9% Grandparent6% Grandparent6% Aunt or Uncle4% Aunt or Uncle4% Foster parent2% Foster parent2% Step parent2% Step parent2%

31 Parent Baseline Demographics N=721 randomized Gender 89% Female Gender 89% Female Household35% Married with partner Household35% Married with partner Race44% African American Race44% African American Ethnicity8% Latino Ethnicity8% Latino

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

33 Parent Baseline Demographics N=721 randomized Psychiatric Dx 24% Psychiatric Dx 24% Depressive Disorder19% AnxietyDisorder 9% Bipolar Disorder 7% Bipolar Disorder 7% GSI clinical range40% GSI clinical range40%

34  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 Design and Method

35  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 Intervention Goals

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37 Family – Based Intervention Module 1 AdolescentsParents * General HIV Info* General HIV Info * Vulnerability to HIV* Adolescent Development, Psychiatric Disorders & HIV Assertive Communication * Assertive Communication * Assertive Communication * Assertive Communication Parent – Teen Communication, Part 1 Parent – Teen Communication, Part 1 “Get To Know You Game” Reverse Role Plays

38 Family – Based Intervention Module 2 Adolescents Parents * 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 StylesCommunication Styles Parent ChallengeParent Challenge *Observed Discussion

39 Family – Based Intervention Module 3 Adolescents Parents * Condom Use Skills * Condom Use Skills Parent – Child Communication Part III Condom Skills Development Values Discussion with Teen Feedback

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41 Six Month Outcomes (n=354)

42 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) 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 Communication36.1 (7.8) 35.2 (8.8) 35.0 (7.3).09 *Sexually Active Only

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

44 Preliminary Outcomes FAMILY Intervention ADOLESCENT-ONLY Intervention Sexual communication HIV Self-Efficacy Fewer unsafe sex acts X 2 = 2.9, p =.4; TLI = 1.003; RMSEA = 0

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

46 Next Steps Family-Based HIV Prevention Intervention Long term (36 month follow-up) Long term (36 month follow-up) STI rates STI rates Onset of sex Onset of sex Videotaped observationsVideotaped observations Moderator (Dx) and mediator analyses Moderator (Dx) and mediator analyses Adaptation for Latino families Adaptation for Latino families Effectiveness and dissemination Effectiveness and dissemination

47 DVD Intervention Phase 1 SBIR with MEE Productions Focus groups and iterative feedback Focus groups and iterative feedback Target: Urban youth and parents Target: Urban youth and parents Interactive DVD (parent, teen, conjoint) Interactive DVD (parent, teen, conjoint) Soap opera style Instructional material Workbook – practice skills and handouts Workbook – practice skills and handouts

48 DVD Intervention

49 Steps to Condom Use 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.

50 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 (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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