EVIDENCE-INFORMED

INTERVENTIONS FOR

ADDRESSING ADOLESCENT

RELATIONSHIP ABUSE

(ARA) IN SBHC’S

Sandi Goldstein, MPHCalifornia Adolescent Health Collaborative

Lisa James, MAFutures Without Violence

At the end of this session, participants will be better able to:

demonstrate a greater understanding of the prevalence and impact of ARA.

implement new strategies for integrating ARA into clinical encounters.

formulate a multidisciplinary approach.

OBJECTIVES

DEFINITIONS: WHY LANGUAGE MATTERS

Reframing the conversation fromTeen Dating Violence to Adolescent Relationship Abuse:

“Are you hanging out with anyone?”

“Are you seeing anyone right now?”

WHAT IS ADOLESCENT RELATIONSHIP ABUSE?

ARA refers to an escalating pattern of repeated acts that physically, sexually, or emotionally abuse a member of a heterosexual or homosexual couple in in the context of a dating or similarly defined relationship which one or both partners is a minor.

Range of controlling behaviors: monitoring cell phone usage, telling a partner what s/he can wear, controlling where s/he goes, and manipulating contraceptive use.

The defining characteristic is a repetitive pattern of behaviors aiming to maintain power and control in a relationship.

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)

ARA AND TECHNOLOGY

One in four teens in a relationship report being called names, harassed, or put down by their partner via cell phone/texting

HEALTH CONSEQUENCES

OF ARA

1 in 5 (20%) U.S. teen

girls report ever experiencing

physical and/or sexual violence in

an intimate relationship.

(CDC Morbidity and Mortality Weekly Report. February 2008. ;Silverman et al, 2001)

ARA AND TEEN PREGNANCY

Adolescent girls in physically abusive relationships were 3.5 times more likely to become pregnant than non-abused girls

Pregnant adolescents 2-3 times more likely to have experienced violence during and after pregnancy than older pregnant women

(Roberts et al, 2005)

Partner violence among teen girls linked with:

Early sexual intercourse (before age 15)

Condom inconsistent use or non-use at last sex

Multiple partnering (3+) in past 3 months

Use alcohol or drugs before sex

Have a past or current sexually transmitted infection

Have a partner with known HIV risk factors

ARA AND SEXUAL RISK FOR ADOLESCENTS

(Silverman,et al. 2004; Kim-Goodwin et al, 2009; Wu et al, 2003)

Over 50% of youth reporting both physical and sexual violence in their relationship also reported attempting suicide.(Bossarte et a l , 2008; Ackard & Neumark-

Szta iner , 2002)

ARA AND MENTAL HEALTH

Young women who have experienced partner abuse have higher rates of:

Depression and anxiety

Disordered eating

Substance abuse

more likely to report sadness, hopelessness or suicide ideation

ARA AND MENTAL HEALTH

(Kim-Godwin YS, et al 2009;Howard DE, et al ,2008;Brossard RM, et al, 2008)

WHAT HAPPENS AT SCHOOL FOR THESE TEENS?

Victims and perpetrators are more likely to carry weapons as well as engage in physical fi ghting and other high risk behaviors.

Physical and sexual victimization is associated with an increased risk for school dropout, lower grades, and less connectedness to school.

A third (32%) of female homicides among adolescents between the ages of 11 and 18 are committed by an intimate partner.

(Champion et al, 2008; Goldstein et al, 2009; Banyard & Cross, 2008; Coyne-Beasley et al, 2003)

NEW STRATEGIES

Project Connect

HEART (Healthcare Education, Assessment & Response Tool for Teen Relationships)

SHARP (School Health Center Healthy Adolescent Relationship Program)

ARA PROJECTS INVOLVING HEALTHCARE PROVIDERS

National Initiative to improve collaboration between public health and domestic violence programs

Worked in 8 states and 2 tribes in phase one and now working in 6 new states and 5 new tribes beginning 2013

Trained over 6,000 providers from over 150 clinical sites

Changed health policy at the state level Integrated violence prevention into teen pregnancy prevention

New statewide requirements for all school based health settings to screen and respond to ARA

PROJECT CONNECT

ModelProvider training

Provider Assessment at every encounter

Distribute Safety Card at every encounter

Peer activities

SHARP

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

PROMOTING HEALTHY RELATIONSHIPS

Distinguish between healthy and unhealthy relationship behavior

Encourage safe and respectful relationships

How to help a friend in an unhealthy relationship

Educate sexually active adolescents about sexual coercion and the importance of consent

Create an environment where youth will see the clinic or provider’s offi ce as a safe place to seek related advice and assistance for relationship abuse

GOALS FOR UNIVERSAL EDUCATION ABOUT HEALTHY RELATIONSHIPS

First things first: Always review the limits of confidentiality-- even if you are not asking DIRECT questions about abuse--in case there is disclosure and you need to report

GETTING STARTED

For more information, please refer to Future’s Mandatory Reporting: Using a Trauma-informed Approach module

The way you start the conversation sets the tone:

PROVIDING UNIVERSAL EDUCATION ON HEALTHY RELATIONSHIPS

“I talk about this with all my patients because it’s so common…”

MAKING HEALTHY RELATIONSHIPCONVERSATIONS

SIMPLE

“We’ve started

talking to all the

teens in our

clinic about

what they

deserve in

relationships

and giving them

this card, it talks

about health

and unhealthy

relationships.”

“Everyone deserves to be treated with respect- but defining what that looks like can be confusing.”

“This panel of the card breaks it down a little more...”

The following video clip

demonstrates providing

universal education on

healthy relationships

during an adolescent

health visit.

Video: Olivia

OLIVIA DEBRIEF

Universal education and focusing on friends opens the door for direct assessment.

“So Olivia is anything like this happening to you?”

Talk about healthy relationships with girls and boys:

“We find a lot of the teen that come to the clinic have situations like this come up with people they are seeing...”

Adolescents report disclosing abusive relationship experiences to friends far more than to health professionals, suggesting that education within clinic settings about “how to tell a friend” may resonate with youth.

"I learned long ago not to make assumptions about our patients and that by screening every patient for domestic violence and reproductive coercion, you uncover unlikely stories of abuse. The study helped reinforce the practice of normalizing my screening questions.”

-Nurse Practitioner at New Generation Health Center, San Francisco

VOICES FROM THE FIELD

Each team led by an adult ally

Each team received training from Kat Gutierrez, CSHC

Peers organized one school wide project

Peers organized a bathroom campaign

SHARP PEER ACTIVITIES

Lunchtime session on Valentine’s Day called "Hearts or Bombs" during which students describe healthy and unhealthy relationship qualities.

Theater production on healthy relationships. Production is an interactive piece that will engage audience members in acting out relationship trauma that they or a loved one might have experienced.

EXAMPLES OF ACTIVITIES

Click icon to add picture

Mock dating game with three contestants, each representing healthy, unhealthy, and abusive relationship tendencies.

Two cupids passing out wallet cards with candy.

EXAMPLES OF ACTIVITIES

EVALUATION DATA

Tech abuse victimization in the past 3 months decreased in both sites: 65% to 22% (school health center) and from 26% to 7% (teen/young adult health center)

In the teen/young adult health center site, past 3 month reproductive coercion decreased from 13% to 2%.

-no significant difference in the school health center site (baseline reproductive coercion was low).

HEART EVALUATION RESULTS

Clients were overwhelmingly positive about receiving this information from their provider:

70% of the time clients reported talking to their provider about healthy and unhealthy relationships during the clinical encounter

57% reported receiving this information helped them know how to help someone in an unhealthy relationship

77% agree that it is helpful for health care providers to talk about healthy and unhealthy relationships

84% state they would bring a friend to the health center if they were experiencing an unhealthy relationship

HEART EVALUATION RESULTS: CLIENT EXIT SURVEYS

Since being trained: 26% reported an increased number of disclosures

about ARA by youth 26% reported having more contact with domestic

violence and sexual assault advocates since the training

 66% reported increased counseling about harm

reduction strategies with their clients (strategies to stay safer, reduce risk for unintended pregnancy)

HEART EVALUATION RESULTS: PROVIDERS

Prevalence of ARA

Approximately 27% (n=197) of students experienced ARA

63% experienced technology-based abuse

10% of females experienced reproductive coercion.

SHARP PRELIMINARY RESULTS

A majority of students (87%, n=688) identified their SBHC as an ARA resource at baseline.

Post-visit, intervention SBHC students were significantly more likely to have discussed ARA with their provider compared to control students.

Among those who had experienced ARA, intervention SBHC students were more likely to disclose this history of abuse to a provider compared to controls, but this did not persist in adjusted analysis.

SHARP PRELIMINARY RESULTS

Develop protocol Develop a collaborative model of

care Have a private place to talk with

patients Use safety care intervention and

response Resources and displaying educational

materials

BUILDING A MULTI-DISCIPLINARY TEAM

RESOURCES

For more information about how to do direct assessment for adolescent relationship abuse and pregnancy prevention for adolescents, please see Futures eLearning: Reproductive Coercion Module

Sandi Goldstein, Director(510)285-5711sandig@cal i forniateenhealth.orgwww.cal i forniateenhealth.org

Lisa James, Director of HealthFutures Without Violence(415)678-5500l james@futureswithoutviolence.org

CONTACT INFORMATION