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Brown 1 20 10


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Larry K. Brown, M.D., Professor, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, Rhode Island - presenting on the topic of Adolescent Sexual Behavior: What Does Reserch Say and What Can Clinicians Do? -- at the Sheppard Pratt Health System Wednesday Grand Rounds Series for Mental Health Professionals (in Towson, MD). Presentation delivered on January 20, 2010. Contact for more information on CME presentations at Sheppard Pratt.

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Brown 1 20 10

  1. 1. ADOLESCENT SEXUAL RISK BEHAVIOR: WHAT DOES RESEARCH SAY AND WHAT CAN CLINICIANS 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: R01 MH 63008; R01 MH 66641; U01 MH 66785; T32 MH 07878 and Lifespan/Tufts/Brown Center for AIDS Research (CFAR)
  2. 2. Disclosure Statements <ul><li>Larry K. Brown, M.D., reports having no relevant financial relationships with commercial interests. He will not be discussing the use of commercial products or services, nor will he be discussing off-label use of any pharmaceuticals. </li></ul><ul><li>Event Planner Disclosure : The following event planners are reported as having no financial interest, arrangement or affiliation with commercial interests or pharmaceutical companies, over the past 12 months with pharmaceutical companies whose products may have relevance to the content of this presentation: Steven Sharfstein, M.D., Robert Roca, M.D., Meena Vimalananda, M.D., Ben Borja, M.D., Marty Spence, RN,BSN, LCSW-C , Leonard Derogatis, Ph.D., Marlene Shapiro LCSW-C, Talya Nack , LCPC, Jennifer Tornabene and Bonnie Katz. </li></ul>
  3. 3. Objectives <ul><li>Identify risk factors for sexual risk behavior in adolescents. </li></ul><ul><li>Apply emotion regulation principles and affect management skills to improving safer sexual behavior </li></ul><ul><li>Describe strategies for better communication and monitoring of sexual behavior with families of youth in mental health treatment </li></ul>
  4. 4. Rhode Island Hospital Investigators Celia Lescano, Wendy Hadley, Christopher Houck, Marina Tolou-Shams, Christie Rizzo, Nancy Beausoleil & Laura Whiteley Co-Investigators Brown University : Christy Esposito, Ronald Seifer & Caron Zlotnick Emory University: Ralph DiClemente Syracuse University , Michael Carey University of Illinois, Chicago: Geri Donenberg University of Pennsylvania : Daniel Romer HIV Prevention Team
  5. 8. AIDS Risk Groups in the 1980s H emophiliacs H omosexuals H eroin Addicts H aitians
  6. 9. Adolescents in the U.S. are at Risk <ul><li>HIV growing particularly among minority adolescents </li></ul><ul><ul><li>2 new infections per hour </li></ul></ul><ul><li>Rates of unprotected sex and multiple partners higher in adolescents and young adults than other ages </li></ul><ul><li>One half of all STIs are in those under 24 </li></ul><ul><li>Rate of STIs and pregnancy rates higher in the U.S. than any European country </li></ul><ul><ul><li>1/3 will have a STI by age 24 </li></ul></ul>
  7. 10. Lessons Learned <ul><li>Adolescent interventions can be effective </li></ul><ul><li>School interventions impact knowledge, attitudes (Brown, Health Ed Q , 1991) </li></ul><ul><li>Skills-based interventions result in behavior change for 6 to 12 months </li></ul><ul><li>(Assertive, Decision, Communication, Condom Use) </li></ul>
  8. 11. Adolescent Study Outcome Analysis <ul><li>Outcome: Condom Use Last Time Had Sex </li></ul>
  9. 12. HIV – Related Risk Behaviors Percent Comparative Risk Profile Mental Health Treatments (n=795) & National Sample (YRBS) HIV Risk Behaviors
  10. 13. Adolescent HIV Prevention 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) 38 13 42 2 75 12 54 14 54 Houck, Lescano, Brown, et al, J. Ped. Psych , 2006 PROPORTION
  11. 14. Adolescent HIV Prevention <ul><li>Clinical Challenge </li></ul><ul><li>15 year old girl with Affective Disorder and prior suicide attempts, self-cutting </li></ul><ul><li>Parents divorced-conflict </li></ul><ul><li>Previous boyfriend-verbally abusive </li></ul><ul><li>Current boyfriend </li></ul><ul><ul><li>“ rough” during sex </li></ul></ul><ul><ul><li>“ my only real love, would die without him” </li></ul></ul>
  12. 15. Safe Sexual Behavior Information Motivation Behavioral Skills Sexual Behavior IMB Model-Fisher & Fisher
  13. 16. Environmental Conditions Personal Attributes HIV Risk Family Context Peer & Partner Relations Donenberg & Pao, JAACAP , 2005. Social Personal Framework HIV risk among adolescents with psychiatric disorders is increased because of difficulties in the following areas (Brown, JAACAP , 1997)
  14. 17. <ul><li>Environmental Condition </li></ul><ul><li>Poverty </li></ul><ul><li>Community Norms </li></ul><ul><li>Stigma </li></ul><ul><li>Media </li></ul>Personal Attributes Substance use/abuse Trauma history Psychopathology Condom Attitudes Prevention Skills Family Context Family Dysfunction Communication/Monitoring Parental Attitudes Previous Risk Behaviors <ul><li>Peer and Partner Relations </li></ul><ul><li>Attitudes </li></ul><ul><li>Norms </li></ul><ul><li>Behavior </li></ul><ul><ul><li>- partner violence, drug use </li></ul></ul><ul><li>Relationship Meaning </li></ul>
  15. 18. Adolescent Sexual Behavior <ul><li>Complex but with multiple intervention opportunities </li></ul>
  16. 19. Personal Attributes that Influence HIV Risk Behavior <ul><li>Sexual behaviors-oral/vaginal/anal sex </li></ul><ul><li>Substance use/abuse </li></ul><ul><li>Perceived vulnerability/susceptibility </li></ul><ul><li>Trauma/abuse history </li></ul><ul><li>Emotional reactivity </li></ul><ul><li>Condom use and discussion skills </li></ul>
  17. 20. Assessment: Personal Attributes that Influence HIV Risk Behavior <ul><li>Sexual behavior assessment is therapeutic </li></ul><ul><ul><li>Conveys: </li></ul></ul><ul><ul><ul><li>Importance of sexual behavior to therapy </li></ul></ul></ul><ul><ul><ul><li>Concern about behavior and teen </li></ul></ul></ul><ul><ul><ul><li>Relevance of behavior to adolescent </li></ul></ul></ul><ul><ul><ul><li>Control that patient has over sex </li></ul></ul></ul>
  18. 21. Clinical Practice: Personal Attributes that Influence HIV Risk Behavior <ul><li>Tell me about your sexual behavior. </li></ul><ul><li>How likely are you to get an STD or pregnant? </li></ul><ul><li>How do you stay safe? </li></ul><ul><li>[What is awareness of risk and motivation] </li></ul>
  19. 22. Adolescent Study Outcome Analysis <ul><li>Outcome: Proportion Condom Use </li></ul>
  20. 23. <ul><li>Have you ever had sexual intercourse? </li></ul><ul><li>55% have not </li></ul><ul><li>Did you have sexual intercourse in the past 90 days? 2/3 have not </li></ul><ul><li>Did you have 5 or more drinks in a row at some point? 75% of teens your age have not </li></ul><ul><li>Did you use alcohol or drugs before the last time you had </li></ul><ul><li>sexual intercourse? </li></ul><ul><li>75% did not </li></ul>Personalize Risk
  21. 24. Crack/Cocaine Use Among Adolescents with Psychiatric Disorders (N=282) <ul><li>Crack/cocaine use by 13% of adolescents (mean age 14.8) </li></ul><ul><li>Predicators of Inconsistent Condom Use </li></ul>Variable O.R. P Crack/Cocaine Use 3.0 .04 Gender (Female) 3.3 .01 Age (>14) 2.4 .08 Race (White) 1.6 .42 Sexual Abuse Hx 2.0 .13 Low Self Restraint 1.2 .68 Alcohol (weekly or daily) 1.6 .40 Marijuana (weekly or daily) 1.7 .36
  22. 25. HIV Behavior: Differences by Sexual Abuse Brown, American Journal of Psychiatry 2000 ; 157 : 1713-5
  23. 26. 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 *Gender, race, age entered in MLR Variable Adj OR* p Self-cutting 3.6 .04 HIV self-efficacy 3.6 .04 Sexual abuse 3.0 .05
  24. 27. Clinical Practice: Personal Factors that Influence HIV Risk Behavior <ul><li>Substance use and abuse - Assess and treat </li></ul><ul><li>Trauma and sexual abuse - Assess and treat </li></ul><ul><li>Self injurious behavior - Assess and treat </li></ul><ul><ul><li>These patients are emotionally reactive </li></ul></ul>
  25. 28. Condom Use Self-Efficacy During Distress and Risk Behaviors (n=133) Affective Arousal: High Self Efficacy Low Self Efficacy Lescano, C.M. & Brown, L.K., Journal of Prevention Intervention in the Community , 2007. PROPORTION
  26. 29. Triggers Feelings You Take Charge! Feelings Take Charge!
  27. 30. TAKING CHARGE OF FEELINGS Get Out Get away or get your mind off of Triggers. Let It Out Do something to keep your feelings from getting bottled up. Think It Out Look for other ways to think about Triggers.
  28. 31. Emotion Regulation (DBT, Linehan) <ul><li>Sexuality Specific </li></ul><ul><ul><li>Affect Regulation -- Anxiety </li></ul></ul><ul><ul><li>Distress Prompts -- Partner Refuses to Use a Condom </li></ul></ul><ul><ul><li>Cognition – “If I don’t have sex he will leave.” </li></ul></ul><ul><ul><li>Management Skills – 3 Rs (Remove, Release, Return) </li></ul></ul><ul><ul><li> (Lescano & Brown, J HIV Ed, 2004). </li></ul></ul>
  29. 32. D istract yourself R emember a plan B reathe deeply and relax A pply positive thinking L eave the situation A llow the feeling to pass N ame people who care about you C onsider other options E xpress yourself positively UNSAFE SAFE
  30. 34. Clinical Practice: Personal Attributes that Influence HIV Risk Behavior <ul><li>Can you be in charge of your sexual behavior? </li></ul><ul><li>Condom Use </li></ul><ul><ul><ul><li>Techniques of use </li></ul></ul></ul><ul><ul><ul><li>Fit and comfort </li></ul></ul></ul><ul><li>Outercourse options </li></ul>
  31. 36. Steps to Condom Use <ul><li>Always use a latex condom   </li></ul><ul><li>Check the expiration date; pinch the package to make sure there is air inside </li></ul><ul><li>Open the package carefully   </li></ul><ul><li>Put the condom on the penis once it is fully hard before it enters the body   </li></ul><ul><li>Pinch the tip of the condom </li></ul><ul><li>Unroll the condom all the way down to the base of the penis slowly </li></ul><ul><li>Keep the condom on the man’s penis until after he ejaculates </li></ul><ul><li>AFTER EJACULATION: The man should pull out before he gets soft </li></ul><ul><li>Throw the condom away </li></ul>
  32. 37. Peer and Partner Influences on HIV Risk Behavior <ul><li>Teens associate with similar values and behaviors </li></ul><ul><li>Behavior is reinforced by associations with others </li></ul><ul><li>Meaning of relationship determines impact on behavior </li></ul>
  33. 38. Peer and Partner Influences on HIV Risk Behavior <ul><li>Main vs. Casual Partners (past 3 months) </li></ul><ul><ul><li>Love matters </li></ul></ul>Lescano, Vazquez, Brown, et al., J Adol Health, 2006. Main Partner (N=861) Casual Partner (N=460) p Male 34% 61% .000 # of Partners 1.2 2.3 .001 % Condom Use 37% 47% .001 Unprotected sex acts 18.9 21.5 .65
  34. 39. HIV Prevention: Peers are important <ul><li>In a skills based intervention for adolescents/young adults safer sexual behavior associated with: </li></ul><ul><ul><ul><li>Improved peer norms </li></ul></ul></ul><ul><ul><ul><li>Attendance at peer intervention </li></ul></ul></ul><ul><ul><ul><li>Less emotional distress </li></ul></ul></ul><ul><li>No pretest differences between groups </li></ul><ul><li>L. Brown, Pediatrics , 2000. </li></ul>
  35. 40. Clinical Practice: Peer/Partner Influence <ul><li>What risks do your friends take? </li></ul><ul><li>Are you sure your partner would not use a condom (or have “outercourse”)? </li></ul><ul><ul><ul><li>Leave condoms or STD brochure out </li></ul></ul></ul><ul><ul><ul><li>Make “outercourse” sexy </li></ul></ul></ul>
  36. 41. Adolescents With Psychiatric Disorders Family Context & HIV Risk <ul><li>Sexual Risk Associated With: </li></ul><ul><li>Family Conflict a,b </li></ul><ul><li>Negative Affect a </li></ul><ul><li>Less Parental Monitoring b </li></ul><ul><li>a Black & Stanton, JR Adol , 1997 </li></ul><ul><li>b McBride & Paikoff, J C C Psych , 2003 </li></ul>
  37. 42. Adolescents With Psychiatric Disorders Family Context & HIV Risk: Family Communication Leads to: <ul><li>Increased condom use 2,4,5,7,8,9 </li></ul><ul><li>Decreased number of sexual partners 2,5 </li></ul><ul><li>Increased condom self-efficacy 1,3 </li></ul><ul><li>Increased communication with sexual partners 3,8 </li></ul><ul><li>Talking prior to debut is important 6 </li></ul><ul><li>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 </li></ul>
  38. 44. Family Context & Adolescent HIV Risk Parent-teen condom discussion and condom use at last sex Hadley, Brown, et al., AIDS & Behavior , 2009.
  39. 45. <ul><li>Parents overestimate the frequency of discussions </li></ul><ul><li>Barriers to talking are embarrassment, acceptance of adolescent’s sexuality </li></ul><ul><li>Mothers talk more and mainly with daughters </li></ul>Talking with Teens About Sex
  40. 46. <ul><li>RCT at three sites (RI, Atlanta, Chicago) </li></ul><ul><li>Randomize 750 adolescents in mental health treatment </li></ul><ul><li>Three conditions </li></ul><ul><ul><li>Family based HIV prevention </li></ul></ul><ul><ul><li>Adolescent only HIV skills </li></ul></ul><ul><ul><li>General health promotion </li></ul></ul>
  41. 47. <ul><li>Project Aims </li></ul><ul><li>Normalize and teach communication about sex </li></ul><ul><li>Parental monitoring with respect </li></ul><ul><li>Personal risk plan for adolescents </li></ul><ul><li>Mastery experience at communication with reinforcement </li></ul>
  42. 49. Six Month Outcomes (n=354) PROPORTION
  43. 50. <ul><li>Six Month Outcomes </li></ul><ul><li>(RM ANOVA, n=354) </li></ul>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
  44. 52. Community/Media Influences on HIV Risk Behavior <ul><li>Society is ambivalent about sex </li></ul><ul><ul><li>Sex sells </li></ul></ul><ul><ul><li>Abstinence-only programs in schools </li></ul></ul><ul><li>Prevention programs influenced by </li></ul><ul><ul><li>Public health realism </li></ul></ul><ul><ul><li>Moralism </li></ul></ul>
  45. 53. Attempted Calls to the CDC National AIDS Hotline January 1991-January 1992 Thousands Month
  46. 54. Community/Media Influences on HIV Risk Behavior <ul><li>Media campaigns have proven impact </li></ul><ul><ul><li>Portland, OR, increased condom use with casual partners (Polan, 1995) </li></ul></ul><ul><ul><li>Sacramento, CA, CDC multilevel campaign increased condom use (Kennedy, 2000) </li></ul></ul><ul><ul><li>Seattle, WA, increased condom use and peer norms (Prausnitz, 1998) </li></ul></ul><ul><ul><li>Many examples outside of U.S. </li></ul></ul>
  47. 55. <ul><li>Targets 14-17 y.o. AA youth </li></ul><ul><li>Small group interventions </li></ul><ul><li>Media campaign in 2 of 4 cities </li></ul><ul><li>Assess impact of media and/or interventions </li></ul><ul><li>Self-report of behavior and STI rates </li></ul>
  48. 56. <ul><li>Themes from focus groups with 125 African American Youth: </li></ul><ul><li>Social pressure for sex </li></ul><ul><ul><li>Seen as “adult”; sign of commitment </li></ul></ul><ul><li>HIV not relevant </li></ul><ul><ul><li>Pregnancy is the worry; withdrawal works </li></ul></ul><ul><li>Condoms not pleasurable </li></ul><ul><ul><li>Heard from peers and partners </li></ul></ul><ul><ul><ul><li>Horner, et al, J Health Com , 2009. </li></ul></ul></ul>
  49. 57. <ul><li>Media Messages to Counter Themes </li></ul><ul><li>(MEE Films, Philadelphia) </li></ul><ul><li>Safer sex = respect </li></ul><ul><ul><li>Respect for women, reduces worry </li></ul></ul><ul><li>Risk of HIV/STIs </li></ul><ul><ul><li>Anyone can have STI; withdrawal not protective </li></ul></ul><ul><li>Protection feels great </li></ul>
  50. 59. <ul><li>Media Outcomes at 12 months </li></ul><ul><li>Media impact greater than group intervention </li></ul><ul><li>More positive condom attitudes </li></ul><ul><ul><li>Less hassle </li></ul></ul><ul><ul><li>More safety (STI - ) </li></ul></ul><ul><li>Condoms with all partners (STI+) </li></ul><ul><li>Less unprotected sex (STI+ females) </li></ul><ul><li>Romer, et. Al. AJPH, in press </li></ul>
  51. 60. Clinical Practice-Community/Media Factors <ul><li>What do you watch? </li></ul><ul><ul><li>If watch X-rated videos, 5x less likely to use condom ( DiClemente, 2005) </li></ul></ul><ul><li>What do you listen to? </li></ul><ul><li>Attended HIV programs in school, church, or organization? </li></ul>
  52. 61. Cultural Influence on HIV Risk Behaviors <ul><li>Latino Families </li></ul><ul><li>Heterogenity </li></ul><ul><ul><li>Country and Cultures </li></ul></ul><ul><ul><li>Acculturation Levels and Experiences </li></ul></ul><ul><li>Dominant Cultural Themes </li></ul><ul><ul><li>Religiosity </li></ul></ul><ul><ul><li>Sexual Socialization (Machismo, Marianisma) </li></ul></ul><ul><ul><li>Familismo (Monitoring) </li></ul></ul><ul><li>Dichotomy of Cultural Values </li></ul><ul><ul><li>Risk and Protective Factors </li></ul></ul>
  53. 62. Conclusions <ul><li>Adolescents with psychiatric disorders are at considerable risk for HIV/STIs </li></ul><ul><li>Factors associated with risk: personal attributes, peer & partner, family, and environmental </li></ul><ul><li>Intervention </li></ul><ul><ul><li>Assessment </li></ul></ul><ul><ul><li>Motivation </li></ul></ul><ul><ul><li>Skills for condom use, affect management </li></ul></ul><ul><ul><li>Family communication and monitoring </li></ul></ul><ul><li>Many options and techniques for prevention </li></ul>
  54. 63. CDISC Diagnostic Data
  55. 64. Psychopathology and Sexual Risk (N=840) Unprotected Ever had Sex Last Sex 1 STIs 1 1 Among sexually active only 2 OR adjusted for age, gender, race, alcohol use, and psychiatric hospitalization. Diagnostic Category (#of participants) % Adj OR 2 % Adj OR 2 % Adj OR 2 Mania (153) 62 1.9 39 1.7 21 5.1 Internalizing (48) 44 1.0 30 1.2 6 0.7 Externalizing (282) 53 2.3 23 1.9 12 2.1 Comorbid (252) 56 1.8 32 2.4 10 2.0 None (105) 43 1.0 12 1.0 9 1.0