Family Functioning, HIV Risk and Substance Use in Detained Adolescents
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Transcript of Family Functioning, HIV Risk and Substance Use in Detained Adolescents
Family Functioning, Family Functioning, HIV Risk and HIV Risk and
Substance Use in Substance Use in Detained AdolescentsDetained Adolescents
Evan Elkin, MAEvan Elkin, MADirector, Adolescent Portable TherapyDirector, Adolescent Portable Therapy
Vera Institute of JusticeVera Institute of Justice
Katherine Elkington, PhDKatherine Elkington, PhDPostdoctoral Research Fellow Postdoctoral Research Fellow
HIV Center for Clinical and Behavioral HIV Center for Clinical and Behavioral SciencesSciences
Columbia University and NYSPIColumbia University and NYSPI
Background and ContextBackground and Context
Vera Institute of JusticeVera Institute of Justice The Adolescent Portable Therapy The Adolescent Portable Therapy
(APT) treatment model (APT) treatment model Mission and impetus behind the Mission and impetus behind the
programprogram Overview of the program and the Overview of the program and the
treatment modeltreatment model 3-year program evaluation and the 3-year program evaluation and the
dataset we will discuss todaydataset we will discuss today
Adolescent Portable Adolescent Portable TherapyTherapy
APT emerged from conversations with Juvenile APT emerged from conversations with Juvenile justice system stakeholders in 1999justice system stakeholders in 1999
The push for evidence-supported, manualized The push for evidence-supported, manualized interventions interventions
The challenge of maintaining continuity of care for The challenge of maintaining continuity of care for system-involved youthsystem-involved youth
Lack of interventions tailored for adolescentsLack of interventions tailored for adolescents The challenge of addressing treatment need in The challenge of addressing treatment need in
settings where intervention philosophies are settings where intervention philosophies are punitivepunitive
Designed as an alternative to institutional Designed as an alternative to institutional intervention for youth who contact multiple systems intervention for youth who contact multiple systems but don’t typically get treatmentbut don’t typically get treatment
APT Treatment ModelAPT Treatment Model Portability across systemsPortability across systems At its core, a family therapy interventionAt its core, a family therapy intervention Blends CBT with family therapyBlends CBT with family therapy Short term, intensive, delivered in-home and in the Short term, intensive, delivered in-home and in the
fieldfield 4-months4-months 2x/weekly in home contact2x/weekly in home contact Blends individual and family sessionsBlends individual and family sessions Between session contact and contact with other Between session contact and contact with other
“system” players“system” players Captured in manual form Captured in manual form
Uniform training and supervisionUniform training and supervision ReplicabilityReplicability
APT OfficeAPT Office
APT HighlightsAPT Highlights A finalist for the 2005 Innovations in American A finalist for the 2005 Innovations in American
Government Award from Harvard’s Ash Government Award from Harvard’s Ash InstituteInstitute
OJJDP and Drug Strategies listed Model OJJDP and Drug Strategies listed Model ProgramProgram
The only program in New York State licensed The only program in New York State licensed by OASAS to provide home based substance by OASAS to provide home based substance abuse treatment for adolescentsabuse treatment for adolescents
Publication of APT treatment manual: available Publication of APT treatment manual: available at Chestnut.org or at Chestnut.org or www.vera.org/aptmanualwww.vera.org/aptmanual
Replications underway: NH, Buffalo, WinnipegReplications underway: NH, Buffalo, Winnipeg
Longitudinal EvaluationLongitudinal Evaluation Robert Wood Johnson Foundation funded a 3-Robert Wood Johnson Foundation funded a 3-
year randomized, controlled program year randomized, controlled program evaluationevaluation Roughly 500 youth and families assessed at baseline, Roughly 500 youth and families assessed at baseline,
3, 9 and 15 months3, 9 and 15 months Youth recruited for heavy substance useYouth recruited for heavy substance use More than 80% had significant co-occurring mental More than 80% had significant co-occurring mental
health symptomshealth symptoms More than 50% were first time, misdemeanor More than 50% were first time, misdemeanor
offendersoffenders More than 80% had no prior history of drug More than 80% had no prior history of drug
treatmenttreatment More than 60% had no prior history of MH treatmentMore than 60% had no prior history of MH treatment
IntroductionIntroduction Juvenile detainees are at high risk HIVJuvenile detainees are at high risk HIV
Higher rates of HIV risk behaviors and Higher rates of HIV risk behaviors and earlier sexual debutearlier sexual debut ~66% engaged in 10+ HIV risk behaviors in ~66% engaged in 10+ HIV risk behaviors in
past 3 monthspast 3 months
Higher rates of STIs Higher rates of STIs
Higher rates of substance use and Higher rates of substance use and disorderdisorder Alcohol and drug use associated with Alcohol and drug use associated with
numerous sexual risk behaviors among numerous sexual risk behaviors among adolescentsadolescents
(Teplin et al., 2002; Teplin et al., 2003; Malow et al., 2006; Bachanas et al., 2002; Lowry et al., 1994; Shrer et al., 1997)
Interventions focused on individual level Interventions focused on individual level factors, while efficacious, do not sustain factors, while efficacious, do not sustain HIV risk behavior change over time for HIV risk behavior change over time for adolescentsadolescents
Greater attention is now being paid to the Greater attention is now being paid to the important role of the family in either important role of the family in either promoting or reducing HIV risk behaviorpromoting or reducing HIV risk behavior ProtectiveProtective: family cohesion and : family cohesion and
connectedness; positive parent-child connectedness; positive parent-child relationships; parental monitoring of behaviorrelationships; parental monitoring of behavior
RiskyRisky: Overt family conflict; impoverished : Overt family conflict; impoverished nurturing; lack of structure; hostile, nurturing; lack of structure; hostile, unsupportive and neglectful family unsupportive and neglectful family relationshipsrelationships
Introduction cont’dIntroduction cont’d
(DiClemente et al., 2007; Malow et al., 2007; Repetti et al., 2002)
Much is known about the effect of family Much is known about the effect of family functioning (FamF) on substance use and functioning (FamF) on substance use and abuse among detaineesabuse among detainees Family therapy (i.e. APT) is the state-of-the-science Family therapy (i.e. APT) is the state-of-the-science
for treatment of substance abuse in adolescentsfor treatment of substance abuse in adolescents Little is known about FamF on HIV risk Little is known about FamF on HIV risk
behaviors among juvenile detainees behaviors among juvenile detainees Hard to reach population, once in treatment Hard to reach population, once in treatment
for substance abuse, opportune time to for substance abuse, opportune time to intervene to reduce HIV risk behaviors intervene to reduce HIV risk behaviors Are the same FamF characteristics associated with Are the same FamF characteristics associated with
both HIV and substance abuse?both HIV and substance abuse? Understanding the role FamF plays in HIV Understanding the role FamF plays in HIV
sex risk behaviors and substance use/abuse is sex risk behaviors and substance use/abuse is important in informing the development of important in informing the development of interventions that can target interventions that can target bothboth problems in problems in these high-risk youth.these high-risk youth.
Introduction cont’dIntroduction cont’d
(Liddle, 2004; Donenberg et al. 2006)
Research Questions:Research Questions: To understand the association To understand the association
between FamF and HIV sexual risk between FamF and HIV sexual risk behaviors and frequency and type behaviors and frequency and type of substance use we asked the of substance use we asked the following: following:
1)1) What is the association between FamF What is the association between FamF and HIV sexual risk behaviors?and HIV sexual risk behaviors?
2)2) What is the association between FamF What is the association between FamF and type and frequency of substance and type and frequency of substance use?use?
MethodsMethods Procedures/recruitmentProcedures/recruitment
N= 477 youth screened and recruited on intakeN= 477 youth screened and recruited on intake Inclusion CriteriaInclusion Criteria:: age 12-16; use of any age 12-16; use of any
substance at least 30 times in past 30 days; or substance at least 30 times in past 30 days; or meet criteria for SUDmeet criteria for SUD
Exclusion CriteriaExclusion Criteria:: Unwilling family Unwilling family involvement; acute psychosis or suicidality; involvement; acute psychosis or suicidality; requiring psychiatric medicationrequiring psychiatric medication
Assent/consent obtained and baseline interview Assent/consent obtained and baseline interview occurred within 24hrs of intakeoccurred within 24hrs of intake
MeasuresMeasures Global Appraisal of Individual NeedsGlobal Appraisal of Individual Needs (GAIN-I): (GAIN-I):
Substance use and disorder; HIV sexual risk Substance use and disorder; HIV sexual risk behaviorsbehaviors
Family Adaptability and Cohesion Scales Family Adaptability and Cohesion Scales (FACES II)(FACES II): Family Functioning (n=232): Family Functioning (n=232)
CohesionCohesion: Emotional bonding that family members have : Emotional bonding that family members have towards one another towards one another
AdaptabilityAdaptability: Amount of change in leadership/control, roles : Amount of change in leadership/control, roles and relationship rules, how systems balance versus change.and relationship rules, how systems balance versus change.
Family Functioning Family Functioning (N=232)(N=232)
Chaotic
Flexible
Structured
Rigid
Disengaged Separated Connected Enmeshed
Adaptability
Cohesion
Balanced (n=108; 47%)
Chaotically disengaged (n=24; 10%)
Rigidly disengaged (n=62; 27%)
Rigidly enmeshed (n=7; 3%)
Chaotically enmeshed (n=31; 13%)
Definitions of FACES Definitions of FACES Family FunctioningFamily Functioning
Chaotically Disengaged:Chaotically Disengaged: Erratic leadership; roles are Erratic leadership; roles are unclear; little involvement among family members; poor unclear; little involvement among family members; poor supportsupport
Chaotically Enmeshed:Chaotically Enmeshed: Erratic leadership; decisions Erratic leadership; decisions are impulsive; extreme amount of emotional closeness; are impulsive; extreme amount of emotional closeness; individuals are very dependent on one another individuals are very dependent on one another
Rigidly Enmeshed: Rigidly Enmeshed: One individual is in charge and is One individual is in charge and is highly controlling; limited negotiations; roles are strictly highly controlling; limited negotiations; roles are strictly defined; extreme amount of emotional closeness; no defined; extreme amount of emotional closeness; no personal spacepersonal space
Rigidly Disengaged:Rigidly Disengaged: One individual is in charge and is One individual is in charge and is highly controlling; limited negotiations; great deal of highly controlling; limited negotiations; great deal of personal separateness/independence; limited support personal separateness/independence; limited support from family membersfrom family members
Balanced: Balanced: Some emotional separateness and time Some emotional separateness and time apart but there is emphasis on togetherness and apart but there is emphasis on togetherness and support; egalitarian leadership; joint decision-making support; egalitarian leadership; joint decision-making and open negotiations; rules maybe changed but are and open negotiations; rules maybe changed but are enforced; roles are relatively stableenforced; roles are relatively stable
Sample Characteristics of Pre-Sample Characteristics of Pre-adjudicated Juvenile Detainees (n=232)adjudicated Juvenile Detainees (n=232)
N %
Male 182 78Female 50 22
Mean (sd) 14.8 (0.8)Median 15
African American 109 47Latino 74 32Other 33 14
8th grade or less 160 69Grade 9-12 72 31
Parents living together 20 9Parents separated 2 1Single parent 157 68Other family members 38 16County/State 4 2Other 11 5
Bi-sexual 2 1
Lesbian 4 2Gay 0 0Celibate 3 1
Youth used at home 42 18Youth used with a family member 70 30Family members ever trouble w/alcohol 78 34Family members ever trouble w/drugs 84 36Family members get drunk weekly 39 17Family members used drugs weekly 56 24Family members ever been in treatment 31 13
*% may not total 100% due to missing data
Characteristic
Substance use related variables
Age
Race/ethnicity*
Gender
Education
Self identified Orientation
Primary Caregiver
Table 1. Sample Characteristics of Pre-adjudicated Juvenile
Detainees (n=232)a
Prevalence of HIV Sexual Prevalence of HIV Sexual Risk BehaviorsRisk Behaviors
Male (n=182)
Female (n=50)
N % % % pInjected drugs 2 1 1 2 nsSexually active 207 90 90 90 ns
114 50 50 51 nsSex with IDU 1 0 1 0 nsAnal sex 28 12 15 4 0.05Sex with MSM 4 2 1 4 nsSex exchange for drugs, money etc 4 2 0 8 ns
0 0 0 0 ns2+ sex partners 153 67 69 61 nsSex without a condom 100 44 43 49 ns
24 11 12 4 nsPast three months (n=186)Sexually active 186 95 95 95 nsSex with a condom 56 41 40 44 nsSex without a condom 148 79 78 81 ns
TotalSexual risk behavior in past 12 months
Table 2. Prevalence of HIV sexual risk behaviors among detained youth by gender (n=232)
Sex while you or partner was drunk or high
Use alchol or drugs to make sex last longer
Exchanged drugs, money, etc for sex
Prevalence of Substance Prevalence of Substance UseUse
Total Male Female% % % p
Any alcohol use 76 76 75 nsAny marijuana use 85 84 88 nsAny hard drug use 10 8 20 0.03Both alcohol and marijuana use 67 67 69 ns≥ 30 times use of alcohol 4 4 4 ns≥ 30 times use of marijuana 54 55 49 ns≥ 30 times use of marijuana and any alcohol 56 56 58 nsSubstance dependence (past 6 months) 19 20 15 nsSubstance abuse (past 6 months) 59 55 71 0.053
Table 3. Prevalence of drug and alcohol use in past 30 days among detained youth, by gender (n=232)
Substance use in past 30 days
What is the Association between What is the Association between Family Functioning and HIV Family Functioning and HIV
Sexual Risk Behavior?Sexual Risk Behavior?
AORa (95%CI) AORa (95%CI) AORa (95%CI) AORa (95%CI)
Sexually active 1.1 (0.2-5.3) 1.3 (0.4-4.6) --- --- 2.8 (0.3-23.0)Sex while high 0.5 (0.2-1.4) 1.1 (0.6-2.2) --- --- 1.1 (0.5-2.7)Anal sex 0.7 (0.1-3.3) 0.9 (0.3-2.7) --- --- 0.8 (0.2-3.1)2+ sex partners 0.8 (0.3-2.2) 1.6 (0.8-3.3) 1.3 (0.2-7.5) 5.2 (1.5-18.6)**Unprotected sex 0.5 (0.2-1.3) 0.8 (0.4-1.5) 0.2 (0.0-1.7) 1.0 (0.4-2.3)Use drugs to make sex last 2.0 (0.6-7.3) 0.6 (0.1-2.1) --- --- 0.3 (0.0-2.4)
Unprotected sex 0.2 (0.1-0.6)*** 0.3 (0.1-0.8)** 0.5 (0.1-6.1) 0.6 (0.2-2.0)Condom use 1.9 (0.7-5.6) 1.7 (0.8-3.8) 0.9 (0.1-9.5) 1.8 (0.7-4.7)
β SE β SE β SE β SEFrequency of sex occasions -0.3 0.4 0.2 0.2 -1.3 1.1 0.5 0.2*Frequency of unprotected sex -1.1 0.6 0.1 0.2 -1.3 1.2 0.2 0.3**
a Adjusted for gender, race/ethnicity and age*p<0.1, **p<0.05; ***p<0.01
Table 4. Sexual risk behaviors by family functioning - Balanced family functioning is the comparison group
Sexual risk behavior
Chaotically enmeshed
(Past 12 mos)
(Past 3 mos n=186)
Chaotically disengaged
Rigidly disengaged
Rigidly enmeshed
What is the Association between What is the Association between Family Functioning and Substance Family Functioning and Substance
Use?Use?
AORa (95%CI) AORa (95%CI) AORa (95%CI) AORa (95%CI)
Any alcohol use 0.8 (0.3-2.4) 1.6 (0.7-3.9) 1.8 (0.2-16.3) 0.7 (0.3-1.7)≥ 30 times use of marijuana 1.8 (0.7-4.6) 2.5 (1.2-5.0)** 2.4 (0.4-14.2) 1.4 (0.6-3.4)≥ 30 times use of marijuana and alcohol
0.9 (0.3-2.9) 2.1 (0.9-4.7)* 2.4 (0.2-26.2) 1.1 (0.4-2.8)
Substance dependence (past 6 months)
0.9 (0.3-3.0) 1.6 (0.7-3.5) --- --- 0.5 (0.3-1.9)
Substance abuse (past 6 months)
1.0 (0.4-2.5) 0.9 (0.4-1.7) 0.6 (0.1-3.4) 1.0 (0.4-2.3)
β SE β SE β SE β SE
Frequency of alcohol use -0.9 0.7 1.2 0.3*** -1.6 1.6 0.2 0.7Frequency of marijuana use (≥ 30 times=0)
-0.2 0.4 0.6 0.2*** 0.5 0.5 -0.3 0.3
a Adjusted for gender, race/ethnicity and age*p<0.1, **p<0.05; ***p<0.01
Table 5. Substance use by family functioning; Balanced family functioning is the comparison group
Substance use in past 30 days
Chaotically enmeshed
Chaotically disengaged
Rigidly disengaged
Rigidly enmeshed
SummarySummary High rates of HIV risk behaviors and High rates of HIV risk behaviors and
frequent marijuana usefrequent marijuana use Few gender differences in risk behavior; Few gender differences in risk behavior;
females more likely to use hard drugs and females more likely to use hard drugs and have abuse dxhave abuse dx
Infrequent “hard drug” use, IDU, sex Infrequent “hard drug” use, IDU, sex exchange, MSM/same sex activityexchange, MSM/same sex activity
About 50% of families were “Balanced” About 50% of families were “Balanced” Other things in addition to family Other things in addition to family
functioning increase riskfunctioning increase risk Peers, neighborhoods, mental health disordersPeers, neighborhoods, mental health disorders
ConclusionsConclusions Parents and family matter; different types of Parents and family matter; different types of
parenting and family functioning have parenting and family functioning have different outcomesdifferent outcomes
Chaotically enmeshedChaotically enmeshed family styles family styles frequent sexual and unprotected sexual frequent sexual and unprotected sexual behavior, multiple partnersbehavior, multiple partners Continuing style of relationships modeled by the Continuing style of relationships modeled by the
family with partners family with partners Over-involvement of parents tends to drive youth Over-involvement of parents tends to drive youth
away from family toward influence of partners (and away from family toward influence of partners (and peers)peers)
Youth in Youth in rigidly disengaged rigidly disengaged families families frequent use of alcohol and marijuanafrequent use of alcohol and marijuana Compensatory mechanism for managing difficult Compensatory mechanism for managing difficult
family processes (self medication)family processes (self medication)
ConclusionsConclusions Disengaged Disengaged family styles family styles less less
unprotected sex.unprotected sex. Perhaps resilience/self reliance on part of Perhaps resilience/self reliance on part of
youth?youth? Target these families in specific ways in Target these families in specific ways in
interventions developed for both HIV and interventions developed for both HIV and substance usesubstance use
Need to explore the processes through Need to explore the processes through which specific types of family functioning which specific types of family functioning increase sex risk increase sex risk andand substance use substance use behaviorsbehaviors
Need to examine other factors such as Need to examine other factors such as peers, community characteristics that peers, community characteristics that may also increase riskmay also increase risk
LimitationsLimitations Limited demographic variation to examine Limited demographic variation to examine
differences; sample non-representative differences; sample non-representative /consecutive admissions/consecutive admissions
Measure of sexual risk behavior limited in Measure of sexual risk behavior limited in detail and types of behaviors in last 3 detail and types of behaviors in last 3 monthsmonths
Missing dataMissing data Do not examine parental report of family Do not examine parental report of family
functioningfunctioning Do not examine other factors related to Do not examine other factors related to
both family functioning and HIV risk (e.g. both family functioning and HIV risk (e.g. peers, mental illness, parental substance peers, mental illness, parental substance use)use)
Treatment ImplicationsTreatment Implications Supports the APT model’s core hypothesis that Supports the APT model’s core hypothesis that
adolescent risk behavior is mediated strongly by adolescent risk behavior is mediated strongly by family functioning and the treatment objective of family functioning and the treatment objective of moving families toward more a “balanced” profilemoving families toward more a “balanced” profile
Supports some of the APT model’s assumptions Supports some of the APT model’s assumptions about parenting and adolescent development with about parenting and adolescent development with our population and helping parents to strategically our population and helping parents to strategically “back off” (chaotically enmeshed) and/or re-“back off” (chaotically enmeshed) and/or re-engage (rigidly disengaged) in the right dosageengage (rigidly disengaged) in the right dosage
These treatment strategies can be applied to These treatment strategies can be applied to interventions that target both HIV sexual risk and interventions that target both HIV sexual risk and substance use behaviorssubstance use behaviors
AcknowledgementsAcknowledgements
Presentation supported in part by training Presentation supported in part by training grant from the National Institute of Mental grant from the National Institute of Mental Health (T32 MH19139; Behavioral Health (T32 MH19139; Behavioral Sciences Research in HIV Infection; Sciences Research in HIV Infection; Principal Investigator, Anke A. Ehrhardt, Principal Investigator, Anke A. Ehrhardt, PhD) at the HIV Center for Clinical and PhD) at the HIV Center for Clinical and Behavioral Studies (P30 MH43250; Behavioral Studies (P30 MH43250; Principal Investigator, Anke A. Ehrhardt, Principal Investigator, Anke A. Ehrhardt, PhD).PhD).
APT evaluation supported by a grant from APT evaluation supported by a grant from the Robert Wood Johnson Foundation the Robert Wood Johnson Foundation (Principal Investigator, Jim Parsons)(Principal Investigator, Jim Parsons)