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)