1. The Healthcare Education, Assessment & Response Tool for Teen Relationships (HEART) Primer and Training Project Robin Kirkpatrick, LCSW, MPH Elizabeth Miller, MD, PhD

2. Disclosure We have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in the CE activity We do not intend to discuss an unapproved/investigative use of a commercial produce/device in my presentation

3. Objectives At the end of this session, participants will be better able to: Articulate a greater understanding of the prevalence and range of adolescent relationship abuse (ARA) including uses of social media and the impact of ARA on adolescent health. Identify provider barriers to assessment of relationship violence, such as concerns about mandated reporting and confidentiality, and demonstrate increased skills in assessment and intervention using the resource. Integrate ARA discussions into routine adolescent care, including promotion of healthy relationships.

4. HEART is a collaborative project of three organizations California Adolescent Health Collaborative (CAHC),a project of the Public Health Institute Dr. Elizabeth Miller, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center Futures Without Violence

5. From Teen Dating Violence to Adolescent Relationship Abuse Adolescence spans a LONG time (ages 10 – 24) – i.e., not just teenagers Interventions need to be developmentally appropriate Opportunity for youth and young adults to define diverse relationships Inclusive of range of abusive behaviors (not only violence)

6. Adolescent Developmental Framework Developmental trajectories and transitions –Biological –Psychological –Social –Cognitive How might this impact their experiences of adolescent relationship abuse?

7. Adolescent Developmental Framework for Adolescent Relationship Abuse Sexual drive, bodies maturing faster than brains Intensity of need for social acceptance Constant connections through social media = greater vulnerability to abuse New independence, more reticent to disclose to adults Expectation for violence as norm in the context of trying out new relationships

8. Adolescent Relationship Abuse is Prevalent Approximately one in three adolescent girls in the United States is a victim of physical, emotional or verbal abuse from a dating partner Nationwide, nearly one in ten high-school students has been hit, slapped or physically hurt on purpose by a boyfriend or girlfriend.

9. Adolescent Relationship Abuse is Prevalent 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)

10. Adolescent Health Programs: Opportunity for Prevention AND Intervention The Healthcare Education, Assessment & Response Tool for Teen Relationships (H.E.A.R.T.) Primer and Training Project: 1)Linking education about relationship abuse and adolescent health concerns (universal anticipatory guidance and assessment) 2)Discuss harm reduction behaviors 3)Raise awareness of victim advocacy services relevant for youth Funding: Office of Juvenile Justice and Delinquency Prevention Programs

11. HEART Primer Content –Current research on ARA –Policy and procedure recommendations on system changes in healthcare settings –Assessments and protocols for screening in different healthcare settings, –Legal issues in minor consent and mandated reporting –Educational materials for teens and parents

12. Program Goals: To decrease the incidence of adolescent relationship abuse (ARA) among California youth through improved case identification and clinic based interventions. To increase teen health and safety by promoting healthy relationships. To improve healthcare systems capacity to prevent ARA.

13. Program Activities Provide Primer and Train 100 providers across California to identify and respond to ARA among their patients in every clinical encounter. Evaluation to follow up with healthcare providers as well as youth receiving clinical services at two sites with trained providers.

14. Evaluation: Increase screening and self-efficacy to respond to ARA by 50% in the 100 clinicians who receive HEART Primer Training. Increase by 20% dating safety knowledge, including awareness of violence-related resources among 500 teen male and female patients of HEART Primer trained providers.

15. Adolescent Relationship Abuse is a Public Health Problem Sexual and reproductive health Mental health and substance use Overall health status?

16. Intimate Partner Violence (IPV) and Pregnancy Pregnant adolescents 2-3 times more likely to have experienced violence during and after pregnancy than older pregnant women

17. ARA and Sexual Risk for Adolescents Partner violence linked with poor reproductive and sexual health outcomes: –unplanned pregnancies, rapid repeat pregnancies –STI/HIV Girls reporting physical/sexual violence more likely to report early age of sexual activity, greater condom nonuse, more sexual partners

18. Why Adolescent Clinical Settings?

19. Adolescent Health Programs are KEY sites for ARA education, assessment and intervention 5 confidential teen clinics in low-income neighborhoods Greater Boston area ACASI Anonymous cross-sectional survey Female teen clinic users ages 14-20 (N=448) 76% response rate

20. Adolescent Health Programs are KEY sites for ARA education, assessment and intervention Adolescent Females Utilizing Teen Clinics N=448 Sexual violence in intimate relationship (insisted, threatened, physical force to have sex) 21.2% Physical violence in intimate relationship (includes hit, choked, used knife or gun against) 31.9% Physical and/or sexual violence ever in relationship 40.0%

21. Adolescent Health Programs are KEY sites for ARA education, assessment and intervention So where do we begin?

22. Video Vignettes: Confidentialty

23. Group Think: Reporting What went wrong? Additional Thoughts…

24. Minor Consent and Confidentiality Confidentiality statutes and minor consent laws vary state by state Limits of confidentiality (or conditional confidentiality) should be stated up front (part of education about seeking care) Integrate discussions about minor consent and confidentiality with adult caregivers (when present)

25. Recognizing ARA Youth may not recognize particular behaviors as being coercive or violent

26. Lack of Control Around Sex with Abusive Male Partner I'm not gonna say he raped me... he didn't use force, but I would be like, "No," and then, next thing, he pushes me to the bedroom, and I'm like, "I don't want to do anything, " and then, we ended up doin' it, and I was cryin' like a baby, and he still did it. And then, after that... he got up, took his shower, and I just stayed there like shock...

27. Perpetrator Condom Refusal Leading to STD I told him to put a condom on, he didn't...I went to a clinic, and they were like, "Oh, he gave you Chlamydia." [H]e said it was me messin' around with some other guy, and that's not true, 'cause I was like, "You were the only guy I was with." And he's like, "Oh, that's you, you're messin' around," he's like, fuck you, I thought you loved me."

28. Perpetrator Condom Refusal Leading to Pregnancy He [used condoms] when we first started, and then he would fight with me over it, and he would just stop [using condoms] completely, and didn't care. He got me pregnant on purpose, and then he wanted me to get an abortion….

29. Survey Findings on Forced Condom Nonuse Forced Condom non-use and IPV OR Adj = 4.67 (95% CI 2.55, 8.57)

30. Survey Findings on Pregnancy Experience Lifetime Pregnancy History and IPV OR Adj = 1.88 (95% CI 1.12, 3.16)

31. Birth Control Sabotage Leading to Pregnancy I was on the birth control, and I was still taking it, and he ended up getting mad and flushing it down the toilet, so I ended up getting pregnant. I found out that [before this] he talked to my friends and he told them that we were starting a family. I didn't know that. I didn't want to start a family. I wanted to finish school. Miller E, Decker MR, Reed E, Raj A, Hathaway J, Silverman JG. Male Partner Pregnancy Promoting Behaviors and Adolescent Partner Violence: Findings From a Qualitative Study With Adolescent Females. Ambulatory Pediatrics 2007;7:360-66.

32. Survey Findings on Pressure to Become Pregnant Lifetime Pregnancy Pressure and IPV OR Adj = 7.79 (95% CI 2.60, 23.73)

33. Adolescent Relationship Abuse and Mental Health Depression and anxiety Disordered eating Suicidality Substance abuse

34. Exploring Chronologies of ARA and Mental Health Suicide attempt in context of ARA: It got so bad, I tried to kill myself. I tried jumping off the bridge, and stuff like that; cause I just couldn't deal with it anymore. I couldn't deal with it. I stopped talking to all my friends. I had a ton of friends from [my hometown], and I wasn't allowed to talk to any of them.

35. Exploring Chronologies IPV and Mental Health Suicide attempt in context of family violence; persistent suicidal ideation: And like my mom use to hit me a lot. Me and my brother. Like me and my brother have the same father, and then she has 2 other kids like from my stepfather, and like I would get so mad because she only hits me and him, and it was just, so I decided to like run away with my boyfriend and stuff, so I went to live with him. (cont.)

36. Exploring Chronologies of IPV and Mental Health Suicide attempt in context of family violence; persistent suicidal ideation in context of ARA: I mean like we were always fighting and stuff. Like the first time he hit me, oh my God, I went like, I wanted to kill myself so badly, I just, I mean it was the same thing. Like I didnt even know what to think, because it was the same thing from moving to one hell to another. So it didnt change anything. I dont know, it didnt change anything, and like so many times Id like, like when I was pregnant, I wanted to kill myself so bad. Like I always thought about it.

37. Felt Depressed (past year) Depression and IPV: OR Adj = 2.35 (95% CI 1.56-3.53)

38. Attempted Suicide (past year) Suicide Attempt and IPV: OR Adj = 3.51 (95% CI 1.57-7.83)

39. Summary of Research on Adolescent Partner Violence Adolescent IPV: is COMMON is associated with multiple risk behaviors and poor health indicators has SIGNIFICANT CONSEQUENCES for health is highly prevalent in clinical and school-based settings

40. Adolescent Health Programs: Opportunity for Prevention AND Intervention Points of contact?

41. Adolescent Health Programs: Opportunity for Prevention AND Intervention Points of contact: Teen clinics, school health centers, primary care, health education, other prevention programs (after-school programs), sports teams, juvenile hall, group homes, pregnant/parenting teen programs, etc. etc.

42. Assessment or Education? Few adolescents report experiences of violence to adults, and adolescents make up a small proportion of clients utilizing domestic violence services. (Foshee et. al, 2000) Goal may be education about ARA and that the adolescent health program is a safe place to discuss these issues

43. Universal Anticipatory Guidance One of the things that I talk to all my patients about is how you deserve to be treated by the people you go out with. You have the right to: Be treated with kindness Be with your friends when you want to be Wear what you want to wear Feel safe and have your boundaries be respected. Go only as far as you want to go as far as touching, kissing, or anything sexual Speak up about any controlling behavior, including textual harassment such as receiving too many texts, phone calls or embarrassing posts about you on Facebook or other sites.

44. Review Adolescent Card: A tool for talking with all adolescents about healthy relationships

45. Clinical Example of Anticipatory Guidance: Video Vignette -- Sam

46. Practical Application Scenario Janice is a 17 year-old young woman. Today you are telling her that she has a Chlamydia infection. Providers goal: Assess for safety, introduce and hand her the card Observer, what did the provider do to make the client comfortable? Did they normalize the card and the conversation… 7 minutes to assess, introduce and give card; Debrief session: 3 minutes

47. 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

48. For More Information California Adolescent Health Collaborative 555 12 th Street, 10 th Floor Oakland, California 94607 510.285.5712 robink@californiateenhealth.org www.californiateenhealth.org

49. THANK YOU!