Project STYLE: A Multisite RCT for HIV Prevention Among Youths in Mental Health Treatment
Abstract
Objective
The study examined the efficacy of family-based and adolescent-only HIV prevention programs in decreasing HIV risk and improving parental monitoring and sexual communication among youths in mental health treatment.
Methods
A randomized controlled trial (RCT) with 721 adolescents (ages 13–18 years) and their caregivers from mental health settings in three U.S. cities were randomly assigned to one of three theory-based, structured group interventions: family-based HIV prevention, adolescent-only HIV prevention, and adolescent-only health promotion. Interventions were delivered during an all-day workshop. Assessments were completed at baseline and three months postintervention.
Results
Compared with those in the health intervention, adolescents in the HIV prevention interventions reported fewer unsafe sex acts (adjusted rate ratio=.49, p=.01), greater condom use (adjusted relative change=59%, p=.01), and greater likelihood of avoiding sex (adjusted odds ratio=1.44, p=.05). They also showed improved HIV knowledge (p<.01) and self-efficacy (p<.05). The family-based intervention, compared with the other interventions, produced significant improvements in parent-teen sexual communication (p<.01), parental monitoring (p<.01), and parental permissiveness (p=.05).
Conclusions
This RCT found that the HIV prevention interventions reduced sexual risk behavior over three months in a large, diverse sample of youths in mental health treatment and that the family-based intervention improved parental monitoring and communication with teens about sex. These interventions show promise.
Compared with peers without mental illness, adolescents with psychiatric disorders engage more frequently in behavior that increases HIV risk (1,2). For example, prior research has found that 40%−50% of youths with a mental disorder reported having sex before age 13 (3,4) compared with only 6% of a nationally representative sample (5). Likewise, youths with psychiatric disorders are less likely to use condoms (55%) and more likely to use substances during sex (49%) compared with youths in the general population (40% and 22%, respectively) (5,6). Given the increased risk of HIV infection among these youths, HIV prevention programs targeted toward this population are important.
Although adolescents with mental health problems may engage in behavior that elevates HIV risk, only three studies have targeted this population (7–9) and only one study demonstrated a significant behavioral impact (7). These previous evaluations had a number of significant limitations, including a lack of the following: a comprehensive assessment of risk behavior (8,9), a time- and attention-matched comparison condition (7–9), random group assignment of participants (7–9), and participants with racial, ethnic, and geographic diversity (7,8). These interventions all addressed individual-level factors, such as knowledge, personal motivation, and safer sex skills, but did not target broader social factors related to HIV risk. Parents can affect teen risk behavior through their parenting practices, such as monitoring, permissiveness, and parent-adolescent communication about sex (10). A number of studies have demonstrated improvements in communication and parental monitoring, although the impact on adolescent sexual risk behavior has been variable (11–16). Given the influence of parenting behaviors and family dynamics on youths in mental health treatment, improving these factors may reduce HIV risk (17). Because no previous study had developed or tested a family-based HIV prevention intervention for youths in mental health treatment, Project STYLE (Strengthening Today’s Youth Life Experiences) developed one (18).
This study examined the impact, after three months, of a family-based HIV intervention and an adolescent-only HIV intervention (7), compared with an adolescent-only general health condition, in reducing HIV risk behaviors and improving parental monitoring and sexual communication among adolescents in mental health treatment. The choice of analyzing the three-month postintervention data from the trial is consistent with the Centers for Disease Control’s criteria for identifying efficacious programs. The HIV prevention interventions (either family-based or adolescent-only intervention) shared several similar targets, so we hypothesized that they would be significantly more efficacious than the general health condition at three months in decreasing risky behavior among youths and in enhancing adolescent HIV-related knowledge and self-efficacy. Intervention targets specific to the family-based intervention (parental HIV knowledge, sexual communication, and monitoring) were hypothesized to improve more in the family-based relative to the adolescent-only interventions.
Methods
Participants
Participants (adolescents ages 13 to 18) were recruited from inpatient and outpatient mental health settings between 2003 and 2008 (19). The study was conducted at Rhode Island Hospital in Providence, Emory University in Atlanta, and the University of Illinois at Chicago. Project recruiters worked closely with clinicians, discharge coordinators, and office staff (including administrative support staff and intake coordinators) to identify all eligible adolescents, thus reducing bias due to “preselection” by site personnel. Referrals from clinicians and discharge coordinators accounted for 97% of the sample. Passive recruitment via project posters and flyers accounted for the remainder.
Eligible youths were in mental health treatment and living with a primary caregiver for the past three months. Both the participating parent and the teen spoke English. Adolescents who self-reported HIV infection, pregnancy, or sexual aggression were excluded because the intervention was not designed to address important issues relevant for those youths (such as disclosure of HIV, support during pregnancy, and legal charges). If more than one caregiver was present in the home, the family selected the primary caregiver to participate in the study with the adolescent. Of those referred, 74% were able to be contacted, and 36% were ineligible or refused participation. [A CONSORT diagram showing the flow of participants in the study is available online as a data supplement to this article.] Of the remaining eligible families, 80% were enrolled, for a final analytic sample of 721 adolescents. Reasons for nonenrollment included lack of interest in a research program, not having enough time, and a current crisis due to recent adolescent hospitalization (19). Study protocols were reviewed and approved by sites’ institutional review boards, and all participants completed written informed consent or assent. Randomization was conducted at each site on the morning of the intervention.
Interventions
The interventions, matched by time and attention (group size), were delivered during an eight-hour workshop at each site in groups of four to eight participants and led by trained facilitators (master’s- or doctoral-level clinician and research assistant). All three interventions served as a supplement to the ongoing mental health treatment of adolescents enrolled in the program. Interventions included engaging didactics, interactive exercises, videos, and in-depth discussions. Each intervention focused on knowledge, attitudes, and self-efficacy in regard to the intervention’s health targets and addressed the interaction between psychiatric disorders and health behaviors.
The family-based intervention (N=227 adolescents) included content to improve parental communication with teens, as well as monitoring and supervision of them, and content to improve the adolescent skills found in the adolescent-only HIV intervention. The family-based intervention was based on the Social-Personal Framework (17), which proposes that adolescent HIV risk taking is a function of the interplay of adolescent psychopathology (including substance use) and parenting styles (monitoring and communication), as well as personal, peer, and community factors. In this intervention, both parents and teens attended group sessions separately and then came together to practice skills learned in their respective groups, including improved parent-adolescent general and sexual communication. The family-based intervention was developed through an iterative process of qualitative work, feasibility and acceptability testing, and pilot trials in all three cities over one year (18,19).
The adolescent-only HIV intervention (N=259) emphasized sexual decision making, refusal of sex, abstinence, and condom use and was based on a previously developed efficacious group intervention for adolescents in mental health treatment (7). The adolescent-only general health intervention was based on school health programs, and it targeted exercise, nutrition, sleep, smoking, and information about HIV. In the adolescent-only HIV (N=259) and general health (N=235) interventions, only the adolescents attended the group sessions. All participants completed a risk reduction plan and received practice assignments to review in an individual session with a facilitator two weeks later.
Training and quality assurance
Centralized training of the intervention protocol was conducted annually for all facilitators. Training consisted of presentation of factual information regarding HIV, adolescent psychosexual development, group dynamics, and behavior management. Facilitators practiced all material under supervision. In all three conditions, adherence to a training manual and competence of delivery were rated as having been done “well” to “very well” more than 90% of the time (ratings given at more than 20% of sessions).
Data collection
Parents and adolescents completed audio computer-assisted structured interview (ACASI) assessments before randomization (baseline) and three months postintervention. Assessments lasted approximately 90 minutes, and parents and adolescents were each compensated $50. Demographic data collected included age, gender, ethnicity, race, household income, and parent education.
Psychiatric measures
The Columbia Impairment Scale (CIS) (20), a 13-item scale administered to both parent (α=.83) and adolescent (α=.78), provides a global measure of adolescent impairment. It assesses interpersonal relations, broad psychopathological domains, functioning in job or schoolwork, and use of leisure time, with higher scores indicating greater impairment (range 0–52). The Diagnostic Interview Schedule for Children (C-DISC) (21) is a structured computer-assisted diagnostic interview that generates DSM diagnoses (22,23). The following disorders were assessed: major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, mania, hypomania, oppositional defiant disorder, conduct disorder, and attention-deficit hyperactivity disorder. Disorders were counted if the screening threshold was exceeded by either parent or adolescent reports on the C-DISC, consistent with other studies (24,25).
Measures of risk behavior
The primary outcome measure was adolescent self-reported unprotected episodes of vaginal sex, anal sex, or both during the past 90 days. Youths completed the AIDS Risk Behavior Assessment (6,26,27), a structured interview designed specifically for use with adolescents to assess sexual and other HIV risk behaviors, such as alcohol and marijuana use. The measure assessed history of sexual behavior and condom use during each sexual event in the past 90 days. Both the number of unprotected sexual episodes and the proportion of times that condoms were used in the past 90 days were calculated. Secondary outcomes were the proportion of youths reporting any sex, avoidance of sex, number of partners in the past 90 days, and use of alcohol or marijuana in the past 30 days.
Measures of knowledge, attitudes, and parental behaviors
For all measures used, higher scale scores indicate greater knowledge, self-efficacy, open communication, monitoring, or permissiveness.
The HIV Knowledge Scale (28) surveys participants’ knowledge of routes of HIV transmission and general information, with 27 true-false items for adolescents (α=.97) and parents (α=.99) summed to create a total knowledge index. The Self-Efficacy for HIV Prevention Scale (29) was administered to adolescents and assesses perceived ability to engage in specific HIV-preventive behaviors, such as discussion of safe-sex measures with partners (α=.89; range 12–48). The Parent-Adolescent Sexual Communication Scale (30) assesses the openness of sexual communication (range 6–42); youths (α=.79) and parents (α=.61) completed separate versions. The Parenting Style Questionnaire (31) measures the degree of parental monitoring (α=.69; range 1–20) and permissiveness (α=.75; range 1–20) as perceived by the adolescent.
Data analyses
Across the three arms of the trial, retention at three months was 91% (N=654), and there were no differences in attrition between treatment arms (χ2=2.52, df=2, p=.28). In order to address potential bias introduced by attrition, multiple imputations by chained equations were used to address missing data and account for differences in distributional assumptions (32).
Study hypotheses were tested with generalized linear models. Negative binomial distributions were used for behavioral counts. All models controlled for the baseline assessment of the respective measure. Adolescent sexual risk, substance use, knowledge, and self-efficacy were compared between both HIV interventions (family-based and adolescent-only) and the adolescent-only health intervention. Parental measures were compared between family-based and the adolescent-only HIV and health interventions.
At both assessments, most of the individuals in the sample reported no unprotected sex acts and were recorded as having contributed a zero for the variable “unprotected sex acts in the past 90 days,” which resulted in a zero-inflated distribution. Those who contributed a zero were in one of three categories: those who had never had sex, those who had not had sex in the past 90 days, or those who had not had any unprotected sex in the past 90 days. To address the zero inflation and help distinguish between the three categories, we first compared among the trial arms the number of participants who had ever had sex. Then, for those who reported by the three-month assessment ever having had sex, we evaluated differences among arms in the number of youths engaged in any sexual activity during the past 90 days. Finally, for participants who reported sexual activity during the past 90 days, we used a negative binomial model to evaluate the number of unprotected acts. Imputations were generated with the use of IVEware (33). Analyses were run on each of ten imputed data sets with SAS Proc Genmod, and results were concatenated across imputations with SAS Proc MIanalyze (34).
Results
Sample characteristics and comparisons between conditions
The mean±SD age of adolescent participants was 14.85±1.59 years, and 57% (N=410) were female. Racially, 60% (N=429) were African American, 33% (N=238) were Caucasian, 7% (N=54) were other races. Ethnically, 11% (N=78) were Latino. Mean income was $31,947. All youths were in mental health treatment at the time of enrollment, 51% (N=368) had received psychotropic medications in the past three months, and 43% (N=310) had been psychiatrically hospitalized in the past 90 days, with a stay of 15.49±13.32 days. Nearly half (42%, N=303) of youths met C-DISC threshold screening criteria for at least one mental disorder by either their own or their parent’s report, and 22% (N=159) met criteria for more than one disorder. Participants met criteria for the following: oppositional defiant disorder (23%, N=166), conduct disorder (20%, N=144), major depressive disorder (11%, N=79), generalized anxiety disorder (8%, N=57), posttraumatic stress disorder (5%, N=36), hypomania (5%, N=36), attention-deficit hyperactivity disorder (4%, N=29), and mania (3%, N=22). Parental reports on the CIS revealed significant functional impairment for 62% (N=447) of the teens. There were no significant baseline differences across intervention conditions on demographic characteristics, impairment, or risk behaviors.
Risk outcomes
Sexual risk.
Consistent with hypotheses, youths in the family-based and adolescent-only interventions, compared with youths in the general health intervention, reported a significantly greater increase in condom use 100% of the time and more avoidance of sexual encounters during the past 90 days (Table 1). Likewise, youths in the HIV interventions reported a significant decrease in unprotected sexual acts and an increase in the proportion of protected sexual acts (Table 2).
| Baseline (N=721) | 3 months postintervention (N=654) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| HIV prevention (N= 486) | Control (N=235) | HIV prevention (N=446) | Control (N=208) | HIV prevention versus control | |||||||
| Behavior | N | % | N | % | N | % | N | % | ORb | 95% CI | p |
| Ever had vaginal or anal sex | 257 | 53 | 130 | 56 | 303 | 65 | 140 | 63 | 1.88 | .91–3.92 | .09 |
| Avoid sex past 90 days | 164 | 35 | 72 | 33 | 154 | 36 | 50 | 26 | 1.44 | 1.00–2.08 | .05 |
| Vaginal or anal sex, past 90 daysc | 157 | 53 | 71 | 52 | 160 | 61 | 73 | 60 | 1.06 | .68–1.66 | .79 |
| 100% condom use, past 90 daysd | 66 | 46 | 36 | 54 | 78 | 53 | 29 | 45 | 2.37 | 1.05–5.38 | .04 |
| Alcohol use, past 30 days | 104 | 22 | 45 | 19 | 98 | 23 | 43 | 21 | 1.07 | .68–1.69 | .77 |
| Marijuana use, past 30 days | 116 | 24 | 49 | 21 | 108 | 25 | 42 | 20 | 1.22 | .78–1.93 | .38 |
a
HIV prevention included an intervention for adolescents only or for parent and teen; the control condition was a general health intervention for adolescents only. Percentages are based on the number of valid cases for each measure.
b
Adjusted for baseline measurements
c
Reported for adolescents who were sexually active by the 3-month assessment
d
Reported for adolescents who reported sexual activity during the past 90 days
| Baseline | 3 months postintervention | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| HIV prevention (N=157) | Control (N=71) | HIV prevention (N=160) | Control (N=73) | HIV prevention versus control | |||||||
| Behaviorb | M | SD | M | SD | M | SD | M | SD | RRc | 95% CI | p |
| Partners past 90 days | 2.11 | 1.79 | 2.04 | 1.83 | 2.69 | 4.01 | 2.26 | 2.53 | 1.32 | .91–1.90 | .14 |
| Unprotected sex acts | 5.58 | 13.54 | 5.88 | 13.60 | 3.53 | 7.10 | 9.32 | 19.80 | .49 | .28–.86 | .01 |
| Percentage of protected sex acts | 63.51 | 41.51 | 65.85 | 42.22 | 72.02 | 37.23 | 63.02 | 41.03 | 59.04 | 16.50–82.23 | .01 |
a
HIV prevention included an intervention for adolescents only or for parent and teen; the control condition was a general health intervention for adolescents only.
b
Sexual risk outcomes were reported for those who reported sexual activity during the past 90 days.
c
Rate ratio, adjusted for baseline measurements
Substance use.
There were no significant differences in alcohol or marijuana use among participants in the general health intervention and the two HIV interventions (Table 1).
Knowledge, attitude, and parenting behaviors
Compared with youths in the general health intervention, those in the family-based and adolescent-only HIV interventions reported significantly more HIV prevention self-efficacy (adjusted relative change=3.75%; 95% confidence interval [CI]=.16−6.86, p=.04) and more HIV knowledge (adjusted relative change=18.85%; CI=8.89–27.21, p<.01) at three months. As expected, youths in the family-based intervention, compared with those in adolescent-only HIV and general health interventions, reported significantly more sexual communication with parents, more parental monitoring, and less parental permissiveness (Table 3). Parents in the family-based HIV prevention intervention also had a significantly greater increase in HIV knowledge.
| Baseline (N=721) | 3 months postintervention (N=654) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Family (N=227) | Other (N=494) | Family (N=206) | Other (N=448) | HIV prevention versus control | |||||||
| Measure | M | SD | M | SD | M | SD | M | SD | Relative change (%)a | 95% CI | p |
| Adolescent report | |||||||||||
| Communicationb | 27.15 | 9.48 | 26.32 | 9.82 | 28.14 | 8.40 | 25.02 | 9.28 | 17.98 | 7.62 to 30.70 | <.01 |
| Monitoringc | 15.21 | 3.89 | 15.44 | 3.83 | 15.75 | 3.89 | 14.86 | 4.39 | 11.41 | 3.60 to 21.62 | <.01 |
| Permissivenessc | 10.22 | 4.00 | 9.99 | 3.89 | 10.44 | 4.00 | 10.90 | 4.21 | –12.15 | –21.86 to .05 | .05 |
| Parent report | |||||||||||
| Communicationb | 34.34 | 6.52 | 33.63 | 6.02 | 34.76 | 5.99 | 34.28 | 5.91 | .24 | –6.42 to 5.38 | .94 |
| Parent HIV knowledged | 67.31 | 15.74 | 65.75 | 15.90 | 74.90 | 15.40 | 67.90 | 16.87 | 24.19 | 11.59 to 44.05 | <.01 |
a
(Adjusted mean difference/adjusted comparison condition mean) × 100%. Relative change scores were adjusted for baseline measurements.
b
Possible scores range from 6 to 42, with higher scores indicating greater communication.
c
Possible scores range from 1 to 20, with higher scores indicating greater perceived parental monitoring or permissiveness.
d
Possible scores range from 1 to 27, with higher scores indicating greater perceived knowledge about HIV.
Discussion
This study revealed promising short-term efficacy of Project STYLE, an HIV prevention program for families and youths with mental health problems. Findings indicated that youths who received the HIV prevention programs reported significantly fewer unsafe sex acts, a greater proportion of consistent condom use, and greater likelihood of avoiding sex three months after the interventions than youths in the attention- and time-matched general health intervention. The magnitude of the impact is similar to other effective prevention programs (11,14–16). For youths in the HIV prevention programs, unsafe sex acts decreased by nearly half, whereas they increased over time by nearly half among adolescents in the general health intervention. Similarly, the proportion of youths consistently using condoms increased by 15% in the HIV interventions and decreased by 17% among those in general health condition.
These results are significant in several ways. First, youths in mental health treatment are at increased vulnerability for HIV and other sexually transmitted infections relative to their peers, and this study yielded positive changes in this high-risk population. Second, the study extends previous HIV prevention trials by revealing change in behavioral outcomes (that is, sexual behavior), including a time- and attention-matched comparison condition, random assignment of individuals, and enrollment of a diverse population (by race, ethnicity, and location). Third, the methodological strengths of this study provide greater confidence that HIV prevention, either for adolescents or for adolescents and their parents, can have a short-term impact on safer sexual behavior. An important finding was that the interventions did not result in increased sexual activity or substance use, despite parental concerns that explicit discussion will increase teen risky behavior. In fact, youths in the HIV prevention interventions reported greater likelihood of avoiding sexual encounters.
The study found improvements in most factors hypothesized to account for the interventions’ impact. The HIV interventions were associated with increased adolescent HIV knowledge and self-efficacy for HIV prevention skills. Similarly, the family intervention, which targeted parenting behaviors, produced significant improvement in parental HIV knowledge and, by adolescent report, increased parent-teen communication about sex, more parental monitoring, and less parental permissiveness. It is possible that these improvements, which change the family dynamics, will manifest themselves in safer adolescent behavior over a longer follow-up period (16).
Most HIV prevention programs for adolescents have been lengthy multisession interventions, but these data suggest that a single-day workshop can produce change, even for troubled families. The extent of mental health treatment received by the sample (43% had been hospitalized in the past three months, and 51% had received psychiatric medications) suggests that the adolescents and families faced numerous psychosocial stresses. Despite the diverse, urgent symptoms that brought the adolescent to treatment (such as suicidal behavior or aggression), families participated in a full-day workshop, were retained at follow-up, and demonstrated significant positive impact from a one-day workshop. For such distressed families, multisession interventions are unlikely to be feasible, and thus, by fitting STYLE to the needs of families (a one-day workshop), the intervention was ecologically valid and effective.
This randomized controlled trial (RCT) had several strengths, including a diverse multisite sample of youths whose HIV risk behavior has been infrequently studied (those in mental health treatment), manualized interventions based on accepted theoretical constructs, rigorous attention to fidelity and monitoring of the intervention, excellent retention, and both adolescent and parent assessments. Nevertheless, there were limitations. The sample comprised families agreeable to participation in a trial, and so the results may not generalize to all families in mental health treatment. The outcome assessments were by self-report, so social desirability bias is possible. However, evidence suggests that ACASI methods increase validity when sensitive behaviors are being reported (26).
Conclusions
This multisite RCT found that theory-based HIV prevention interventions tailored for youths in mental health treatment reduced sexual risk behavior. The family intervention targeted sexual communication and parental monitoring—topics relevant to general functioning—as well as adolescent sexual risk. It is possible that techniques used to improve family communication and parental monitoring of children could be adapted for use with teens’ other problematic behaviors. The one-day HIV interventions with one brief follow-up visit had a behavioral impact and were effectively delivered in either groups with only adolescents or with parents and adolescents together. This feasibility and efficacy suggest that STYLE may be worthy of future dissemination. Not all approached families were able to commit to a full-day weekend workshop. Treatment centers might be able to provide more options in offering the interventions and thus extend their reach. It will be important to replicate and extend these findings. If replicated, effective approaches for implementing these interventions in mental health care settings can be determined.
Acknowledgments and disclosures
This research was supported by National Institute of Mental Health grant R01MH 63008 to Rhode Island Hospital and grant P30 AI042853 to the Lifespan/Tufts/Brown Center for AIDS Research. The trial is registered as NCT00496691 on clinicaltrials.gov.
The authors report no competing interests.
Supplementary Material
Supplementary Material (338_ds001.pdf)
- View/Download
- 31.96 KB
References
1.
Brown LK, Hadley W, Stewart A, et al.: Psychiatric disorders and sexual risk among adolescents in mental health treatment. Journal of Consulting and Clinical Psychology 78:590–597, 2010
2.
Costello EJ, Egger H, Angold A: 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: I. methods and public health burden. Journal of the American Academy of Child and Adolescent Psychiatry 44:972–986, 2005
3.
DiClemente RJ, Ponton LE: HIV-related risk behaviors among psychiatrically hospitalized adolescents and school-based adolescents. American Journal of Psychiatry 150:324–325, 1993
4.
Valois R, Bryant E, Rivard J, et al.: Sexual risk-taking behaviors among adolescents with severe emotional disturbance. Journal of Childhood Studies 21:789–803, 1997
5.
CDC: Trends in the Prevalance of Sexual Behaviors and HIV Testing National YRBS: 1991–2011. Atlanta, Centers for Disease Control and Prevention, 2012
6.
Donenberg GR, Emerson E, Bryant FB, et al.: Understanding AIDS-risk behavior among adolescents in psychiatric care: links to psychopathology and peer relationships. Journal of the American Academy of Child and Adolescent Psychiatry 40:642–653, 2001
7.
Brown LK, Nugent NR, Houck CD, et al.: Safe Thinking and Affect Regulation (STAR): human immunodeficiency virus prevention in alternative/therapeutic schools. Journal of the American Academy of Child and Adolescent Psychiatry 50:1065–1074, 2011
8.
Brown LK, Kessel SM, Lourie KJ, et al.: Influence of sexual abuse on HIV-related attitudes and behaviors in adolescent psychiatric inpatients. Journal of the American Academy of Child and Adolescent Psychiatry 36:316–322, 1997
9.
Thurstone C, Riggs PD, Klein C, et al.: A one-session human immunodeficiency virus risk-reduction intervention in adolescents with psychiatric and substance use disorders. Journal of the American Academy of Child and Adolescent Psychiatry 46:1179–1186, 2007
10.
Miller KS, Forehand R, Wiegand R, et al.: Making HIV prevention programming count: identifying predictors of success in a parent-based HIV prevention program for youth. AIDS Education and Prevention 23:38–53, 2011
11.
Dilorio C, Resnicow K, McCarty F, et al.: Keepin’ it REAL! Results of a mother-adolescent HIV prevention program. Nursing Research 55:43–51, 2006
12.
Johnson BT, Scott-Sheldon LA, Huedo-Medina TB, et al.: Interventions to reduce sexual risk for human immunodeficiency virus in adolescents: a meta-analysis of trials, 1985–2008. Archives of Pediatrics and Adolescent Medicine 165:77–84, 2011
13.
McKay M, Chasse K, Paikoff R, et al.: Family-level impact of the CHAMP program: a community collaborative effort to support urban families and reduce youth HIV risk exposure. Process 43:79–93, 2004
14.
O’Donnell L, Stueve A, Agronick G, et al.: Saving Sex for Later: an evaluation of a parent education intervention. Perspectives on Sexual and Reproductive Health 37:166–173, 2005
15.
Prado G, Pantin H, Briones E, et al.: A randomized controlled trial of a parent-centered intervention in preventing substance use and HIV risk behaviors in Hispanic adolescents. Journal of Consulting and Clinical Psychology 75:914–926, 2007
16.
Stanton B, Cole M, Galbraith J, et al.: Randomized trial of a parent intervention: parents can make a difference in long-term adolescent risk behaviors, perceptions, and knowledge. Archives of Pediatrics and Adolescent Medicine 158:947–955, 2004
17.
Donenberg GR, Pao M: Youths and HIV/AIDS: psychiatry’s role in a changing epidemic. Journal of the American Academy of Child and Adolescent Psychiatry 44:728–747, 2005
18.
Donenberg G, Brown L, Hadley W, et al.: A multi-site–based HIV-prevention program for adolescents with psychiatric disorders; in Families and HIV/AIDS: Cultural and Contextual Issues in Prevention and Treatment. Edited by, Pequegnant W, Bell C. New York, Springer, 2011
19.
Kapungu C, Nappi C, Thakral C, et al.: Recruiting and retaining high-risk adolescents into family-based HIV prevention intervention research. Journal of Childhood Studies 21:578–588, 2012
20.
Bird H, Shaffer D, Fisher P, et al.: The Columbia Impairment Scale (CIS): pilot findings on a measure of global impairment for children and adolescents. International Journal of Methods in Psychiatric Research 3:167–176, 1993
21.
Schwab-Stone ME, Shaffer D, Dulcan MK, et al.: Criterion validity of the NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3). Journal of the Academy of Child and Adolescent Psychiatry 35:878–888, 1996
22.
Shafer MA, Boyer CB: Psychosocial and behavioral factors associated with risk of sexually transmitted diseases, including human immunodeficiency virus infection, among urban high school students. Journal of Pediatrics 119:826–833, 1991
23.
Shaffer D: Diagnostic Interview Schedule for Children (DISC 2.3), Parent Version 2.3. New York, Columbia University, 1991
24.
Garland AF, Hough RL, McCabe KM, et al.: Prevalence of psychiatric disorders in youths across five sectors of care. Journal of the American Academy of Child and Adolescent Psychiatry 40:409–418, 2001
25.
Hadley W, Barker D, Lescano C, et al.: Prevalence of sexual risk behavior among teens in mental health treatment and the influence of psychiatric impairment. Journal of HIV/AIDS and Social Services, in press
26.
Dowling-Guyer S, Johnson M, Fisher D: Reliability of drug users’ self-reported HIV risk behaviors and validity of self-reported recent drug use. Assessment 1:383–392, 1994
27.
Needle R, Fisher D, Weatherby N, et al.: Reliability of self-reported HIV risk behaviors of drug users. Psychology of Addictive Behaviors 9:242–250, 1995
28.
Brown LK, DiClemente RJ, Beausoleil NI: Comparison of human immunodeficiency virus related knowledge, attitudes, intentions, and behaviors among sexually active and abstinent young adolescents. Journal of Adolescent Health 13:140–145, 1992
29.
Lawrance L, Levy SR, Rubinson L: Self-efficacy and AIDS prevention for pregnant teens. Journal of School Health 60:19–24, 1990
30.
Dutra R, Miller K, Forehand R: The process and content of sexual communication with adolescents in two-parent families: associations with sexual risk-taking behavior. AIDS and Behavior 3:59–66, 1999
31.
Oregon Social Learning Center Parental Monitoring and Supervision Constructs. Eugene, Oregon Social Learning Center, 1990
32.
Raghunathan T, Lepkowski J, Van Hoewyk J, et al.: A multivariate technique for multiply imputing missing values using a sequence of regression models. Survey Methodology 27:85–95, 2001
33.
IVEware: Imputation and Variance Estimation Version 0.2 Users Guide. Ann Arbor, University of Michigan, Survey Research Center, Institute for Social Research, 2011
34.
SAS/STAT 9.2 User’s Guide. Cary, NC, SAS Institute, 2008
Information & Authors
Information
Published In
Cover: Young Girl Playing, by Jessie Willcox Smith, 1902. Watercolor and charcoal on board. © Copyright 2014 National Museum of American Illustration™, Newport, Rhode Island. Photo courtesy of Archives of the American Illustrators Gallery™, New York.
History
Published in print: March 2014
Published online: 15 October 2014
Authors
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).