HIV-Risk Reduction with Juvenile Offenders on Probation

Analyses of the TCU Drug Screen 5: Using an Item Response Theory Model with a Sample of Juvenile Justice Youth

It is important to identify substance use disorders among youth who enter the juvenile justice system using a validated screener, such as the Texas Christian University Drug Screen 5 (TCU DS 5), so that necessary services can be provided to youth in need of treatment. While the TCU DS 5 is a valid, evidence-based screener, the use of an Item Response Theory model may better differentiate between mild, moderate, and severe forms of substance use disorders. The current study analyzed the feasibility and incremental value gained in using an Item Response Theory model to compute drug use severity scores as compared to its current scoring methodology. Results showed that while Item Response Theory may not be worthwhile as the standard method of scoring, item level analyses revealed there are benefits to using Item Response Theory to determine which items on a screener are most suggestive of severe substance use problems.

A Technology-Based Training Tool for a Health Promotion and Sex Education Program for Justice-Involved Youth: Development and Usability Study

Background

Justice-involved youth are especially vulnerable to mental health distress, substance misuse, and risky sexual activity, amplifying the need for evidence-based programs (EBPs). Yet, uptake of EBPs in the justice system is challenging because staff training is costly in time and effort. Hence, justice-involved youth experience increasing health disparities despite the availability of EBPs.

Objective

To counter these challenges, this study develops and pilot-tests a prototype of a technology-based training tool that teaches juvenile justice staff to deliver a uniquely tailored EBP for justice-involved youth—PHAT (Preventing HIV/AIDS Among Teens) Life. PHAT Life is a comprehensive sex education, mental health, and substance use EBP collaboratively designed and tested with guidance from key stakeholders and community members. The training tool addresses implementation barriers that impede uptake and sustainment of EBPs, including staff training and support and implementation costs.

Methods

Staff (n=11) from two juvenile justice settings pilot-tested the technology-based training tool, which included five modules. Participants completed measures of HIV and sexually transmitted infection (STI) knowledge, sex education confidence, and implementation outcomes such as training satisfaction, adoption, implementation, acceptability, appropriateness, and sustainability. PHAT Life trainers assessed fidelity through two activity role plays participants submitted upon completing the training modules.

Results

Participants demonstrated increases in HIV and STI knowledge (t₁₀=3.07; P=.01), and were very satisfied (mean 4.42, SD 0.36) with the training tool and the PHAT Life curriculum. They believed that the training tool and curriculum could be adopted, implemented, and sustained within their settings as an appropriate and acceptable intervention and training.

Conclusions

Overall, the results from this pilot test demonstrate feasibility and support continuing efforts toward completing the training tool and evaluating it within a fully powered randomized controlled trial. Ultimately, this study will provide a scalable option for disseminating an EBP and offers a more cost-effective and sustainable way to train staff in an EBP.

Intervening for HIV prevention and mental health: a review of global literature

INTRODUCTION

Numerous effective HIV prevention options exist, including behaviour change interventions, condom promotion and biomedical interventions, like voluntary medical male circumcision and pre-exposure prophylaxis. However, populations at risk of HIV also face overlapping vulnerabilities to common mental disorders and severe mental illness. Mental health status can affect engagement in HIV risk behaviours and HIV prevention programmes. We conducted a narrative review of the literature on HIV prevention among key populations and other groups vulnerable to HIV infection to understand the relationship between mental health conditions and HIV prevention outcomes and summarize existing evidence on integrated approaches to HIV prevention and mental healthcare.

METHODS

We searched five databases for studies published from January 2015 to August 2020, focused on HIV prevention and mental health conditions among key populations and individuals with serious mental illness. Studies were included if they evaluated an HIV prevention intervention or assessed correlates of HIV risk reduction and included assessment of mental health conditions or a mental health intervention.

RESULTS AND DISCUSSION

We identified 50 studies meeting our inclusion criteria, of which 26 were randomized controlled trials or other experimental designs of an HIV prevention intervention with or without a mental health component. Behaviour change interventions were the most common HIV prevention approach. A majority of studies recruited men who have sex with men and adolescents. Two studies provided distinct approaches to integrated HIV prevention and mental health service delivery. Overall, a majority of included studies showed that symptoms of mental disorder or distress are associated with HIV prevention outcomes (e.g. increased risky sexual behaviour, poor engagement in HIV prevention behaviours). In addition, several studies conducted among groups at high risk of poor mental health found that integrating a mental health component into a behaviour change intervention or linking mental health services to combination prevention activities significantly reduced risk behaviour and mental distress and improved access to mental healthcare.

CONCLUSIONS

Evidence suggests that mental health conditions are associated with poorer HIV prevention outcomes, and tailored integrated approaches are urgently needed to address overlapping vulnerabilities among key populations and other individuals at risk.

Brief Report: HIV Testing and Risk Among Justice-Involved Youth

Justice-involved youth have a number of risk factors for HIV infection, including high rates of substance use, psychiatric comorbidities, and risky sexual behaviors. Although detained youth are likely to receive health care-which may include HIV testing-court-involved, non-incarcerated (CINI) youth may be unlikely to receive HIV testing services either before or during their justice involvement. However, the relationship between risk factors and HIV testing among CINI youth is largely unknown. We explored the association between HIV testing and factors commonly associated with both HIV testing and HIV risk among 173 CINI youth with identified behaviors that put them at risk for HIV acquisition. Only 15.6% of participants reported a lifetime history of HIV testing, despite high rates of sexual and substance use risk behaviors. Age (older), gender (female), sexual orientation (non-heterosexual), recent marijuana use, lifetime use of other drugs, history of a sexually transmitted infection, pap smear in the past year and history of mental health/substance use treatment were all significantly associated with lifetime HIV testing. The extremely low testing rates in this sample emphasize that the juvenile justice system outside of detention is not adequately addressing youths' needs related to HIV testing or ensuring access to testing services for youth at risk of contracting HIV. Results suggest that additional efforts are needed to connect justice-involved youth to healthcare more broadly and HIV testing in particular.

Juvenile justice staff endorsement of HIV/STI prevention, testing, and treatment linkage

BACKGROUND

While involvement in the legal system offers an opportunity to educate, screen, and treat high-risk youth, research shows that staff attitudes toward these practices can serve as barriers to implementation. The current study investigates the degree to which JJ staff endorse HIV prevention, testing, and treatment linkage practices with youth under community supervision and examines differences between individuals who supervise youth (e.g., juvenile probation officer) and those working in non-supervisory roles (e.g., case manager, assessment specialist).

METHODS

Juvenile justice staff consenting to participation in JJ-TRIALS completed an initial staff survey (N = 501). Survey items measured perceived importance of HIV/STI prevention (4 items); perceived importance of HIV/STI testing (7 items); and perceived importance of HIV/STI treatment linkage (8 items).

RESULTS

Confirmatory Factor Analysis (CFA) was computed (SAS CALIS procedure) for each of the three domains. Findings suggest that while staff recognize that youth are at risk for HIV/STIs and require provision of HIV/STI prevention and treatment linkage, attitudes concerning the importance of procuring or providing testing services for youth is substantially lower. Furthermore, analytic models comparing staff with and without supervision responsibilities (computed using SAS PROC MIXED) indicated that attitudes differed by site and staff responsible for supervision rated HIV treatment linkage practices as less important compared to non-supervising staff.

CONCLUSIONS

Establishing partnerships with health agencies equipped with resources and skillsets to provide HIV/STI testing and related services may be an effective model to promote greater awareness and use of best practices among JJ staff and more effectively address the unmet needs of this high-risk population of youth.

Juvenile justice systems of care: results of a national survey of community supervision agencies and behavioral health providers on services provision and cross-system interactions

BACKGROUND

Youth involved in the juvenile justice (JJ) system have high needs for behavioral health services, especially related to substance use and mental disorders. This study aimed to understand the extent to which elements in the cascade model of behavioral health services for JJ-involved youth are provided to youth by Community Supervision (CS) and/or Behavioral Health (BH) providers. In order to understand interactions across CS and BH systems, this study used a multistage probabilistic survey design to sample CS agencies and their primary BH service providers of substance use and mental health treatment in the United States. Parallel surveys were administered to both CS and BH providers regarding: characteristics of youth served, BH services available, whether services were provided directly and/or by referral, use of evidence-based practices (EBPs), and methods of collaboration, referral, and information exchange across CS and BH providers.

RESULTS

The findings from weighted national estimates demonstrate that youth referred from CS to the BH programs represent a more severe sub-group of youth under CS supervision. There are established cross-system relationships for assessment and referral for substance use and mental health treatment, but less so for prevention services. Most CS programs refer youth to BH providers for these services, which typically utilize more highly trained staff to provide EBPs to a majority of the youth served. More intensive substance use and mental health treatment, aftercare, and recovery support services were limited in availability.

CONCLUSIONS

The findings suggest that although many elements in a cascade model of BH services for JJ-involved youth have been implemented within local systems of care through collaboration between CS and BH providers, there are several underdeveloped areas and potential for attrition across the service cascade. Greater attention to providing services to youth with higher levels of severity, aftercare services, and recovery support is warranted within a multi-systemic framework.

Sexual risk among African American girls seeking psychiatric care: A social-personal framework

OBJECTIVE

This study examined individual and social factors associated with sexual risk behavior among African American girls seeking outpatient mental health services across 2 years and key developmental transitions.

METHOD

African American females 12-16 years old (M = 14.5; SD = 1.15; n = 266) were recruited from eight outpatient mental health clinics and completed interviewer-administered and computer-assisted measures at baseline, 12, and 24 months. Analyses tested individual attributes (externalizing and internalizing problems) and family context (maternal acceptance-rejection, mother-daughter communication about sex) at baseline, peer influences (peer support of substance use, girlfriend dating behavior) and partner relationship characteristics (rejection sensitivity, partner risk communication frequency and openness) at 12 months, and girls' sexual behavior at 24 months.

RESULTS

At baseline, 32% of girls reported having had vaginal/anal sex compared with 60% at 24 months. Data analyses revealed robust associations between externalizing problems and maternal acceptance-rejection and mother-daughter risk communication during early adolescence, peer support of substance use and girlfriend dating behavior 1 year later, and girls' sexual risk taking 2 years later.

CONCLUSION

Findings support a social-personal framework (SPF) of sexual risk for African American girls seeking mental health care, underscoring the potential benefits of early intervention to reduce externalizing problems while strengthening mother-daughter communication and relationships to prevent subsequent sexual risk and associated negative outcomes. (PsycINFO Database Record

Substance Use and HIV Among Justice-Involved Youth: Intersecting Risks

PURPOSE OF REVIEW

This review discusses recent advances in research on the intersection of HIV prevention and substance use among youth involved with the justice system. We discuss current themes of recent findings and provide guidance for researchers, policymakers, and clinicians on the next steps in advancing work in this nascent area.

RECENT FINDINGS

Of the 46 studies that measured HIV risk and substance use among justice-involved youth, 56% were cross-sectional designs, 22% were intervention trials, and 22% were longitudinal designs. Cross-sectional studies suggested that substance use is highly associated with HIV risk behaviors. Longitudinal analyses underscored the importance of understanding contextual risk factors, such as trauma and violence. Intervention trials demonstrated improved scientific rigor of behavioral approaches. Despite recent advances, research in this field remains limited. Future directions include longer follow-up periods, consideration of biomedical HIV-prevention interventions, and a focus on dissemination and implementation science of efficacious interventions.

Screening for HIV and linkage to care in adolescents: insights from a systematic review of recent interventions in high- versus low- and middle-income settings

Introduction

Compared to adults, adolescents and young adults have a higher incidence of HIV infection, yet lower rates of HIV testing. Few evidence-based interventions effectively diagnose new HIV infections among adolescents while successfully providing linkage to care.

Methods

We conducted a systematic review of recent interventions to increase HIV testing among adolescents and young adults using data retrieved from PubMed and Google Scholar, and using abstracts presented at the International AIDS Society conferences and Conference on Retroviruses and Opportunistic Infections published between January 1, 2015, and April 28, 2018.

Results

We identified 36 interventions (N=14 in high- income countries and N=22 in low- and middle-income countries) that were published in the literature (N=28) or presented at conferences (N=8). Interventions were categorized as behavioral/educational, alternate venue/self-testing, youth-friendly services, technology/mobile health, incentives, or peer-based/community-based interventions. The studies consisted of randomized controlled trials (RCTs), prospective and retrospective observational studies, and quasi-experimental/pre-post evaluations with variable sample sizes. Study designs, populations, and settings varied. All categories showed some degree of acceptability, yet not all interventions were effective in increasing HIV testing. Effectiveness was seen in more than one RCT involving technology/mobile health (2/3 RCTs) and alternative venue/self-testing (3/3 RCTs) interventions, and only in one RCT each for behavioral interventions, community interventions, and incentives. There were no effective RCTs for adolescent-friendly services. Data were limited on the number of new infections identified and on the methods to increase linkage to care after diagnosis.

Conclusion

Future studies should include combinations of proven methods for engaging adolescents in HIV testing, while ensuring effective methods of linkage to care.

Effect of Including Alcohol and Cannabis Content in a Sexual Risk-Reduction Intervention on the Incidence of Sexually Transmitted Infections in Adolescents: A Cluster Randomized Clinical Trial

Importance

Adolescents in the juvenile justice system are at high risk for sexually transmitted infections (STIs). Concurrent use of alcohol and cannabis increase this risk.

Objective

To determine whether a theory-based sexual risk-reduction intervention that included alcohol- and cannabis-focused content resulted in greater reductions in STIs than an intervention that included alcohol-related content only and an intervention that did not include substance use content.

Design, Setting, and Participants

Cluster randomized clinical trial with 3 conditions. Between July 1, 2010, and December 10, 2014, adolescents living at a juvenile detention facility in the southwestern United States were tested and treated for STI before randomization and again 12 months after the intervention. Data analyses were conducted in July and August 2017. Eligibility criteria included (1) being aged 14 to 18 years, (2) able to speak English, (3) having a remaining detention term of less than 1 month, and (4) signing a release granting access to STI results if tested at intake. Six hundred ninety-three adolescents were assessed for eligibility. Of these, 460 completed baseline assessments and were randomized to 1 of 3 intervention conditions. Data analysis was by intent-to-treat.

Interventions

There were 3 intervention conditions: sexual risk reduction intervention (SRRI); SRRI plus alcohol content (SRRI + ETOH); and SRRI + ETOH plus cannabis content (SRRI + ETOH + THC). Interventions were conducted in same-sex groups by trained clinicians and included video presentations with discussion, group activities, and active feedback by participants, consistent with the principles of motivational enhancement therapy.

Main Outcomes and Measures

Although not the outcome on which the study was originally powered, the main outcome variable presented herein is STI incidence (Chlamydia trachomatis and/or Neisseria gonorrhoeae) 12 months after the intervention.

Results

Of the 460 participants randomized, mean (SD) age was 15.8 (1.1) years, 347 participants (75.4%) were male, and 57.0% were of Hispanic ethnicity. Among the participants, 143 were randomized to SSRI, 155 to SRRI + ETOH, and 162 to SRRI + ETOH + THC. Attrition at 12-month follow-up was 99 (21.5%) for the STI outcome variable. Participants in the SRRI + ETOH + THC intervention had lower incidence of STI at follow-up (3.9%) than those in either the SRRI (12.4%; odds ratio, 0.29; 95% CI, 0.10-0.84) or the SRRI + ETOH (10.2%; odds ratio, 0.36; 95% CI, 0.12-1.05) interventions.

Conclusions and Relevance

An intervention delivered in a motivational enhancement therapy format that includes theory-based sexual risk reduction combined with alcohol- and cannabis-focused elements is effective at reducing STI incidence among justice-involved adolescents. This 1-session manualized intervention can be delivered in the context of short-term detention and is easily disseminated to juvenile justice agencies.

Trial Registration

clinicaltrials.gov Identifier: NCT01170260.

HIV-risk reduction intervention for juvenile offenders on probation: The PHAT Life group randomized controlled trial

OBJECTIVE

Juvenile offenders report high rates of sexual risk taking, increasing the possibility of HIV. This 2-arm group randomized controlled trial tested the efficacy of PHAT Life, a sexual risk reduction program, compared with a time-matched health promotion program for youth on probation.

METHOD

Male and female 13- to 17-year-olds (M = 16.08; SD = 1.09) recently arrested and placed on probation at an Evening Reporting Center were eligible for the study. Youth were 66% male, and 90% African American. Teens self-reported their sexual behavior (condom use, number of sexual partners) at baseline and 6 months. Retention was 85%.

RESULTS

Youth were randomized to PHAT Life (n = 163) or a health promotion program (n = 147). Among youth reporting the highest risk at baseline (a composite measure of multiple partners and inconsistent condom use), those who received PHAT Life were over 4 times more likely than the control group to report a lower level of risk (i.e., no sex or one partner plus consistent condom use) by 6 months, OR = 4.28 with 95% CI [1.37, 13.38], SE = 0.58, p = .01. Among sexually active teens who reported sexual debut before 12-years-old, those who received PHAT Life reported significantly fewer sexual partners at 6-months than controls, partial eta squared = .32, p = .002.

CONCLUSIONS

Findings support PHAT Life's efficacy to reduce sexual risk for juvenile offenders on probation. Future research should examine how best to disseminate PHAT Life to ensure that it is self-sustaining within the juvenile justice system. (PsycINFO Database Record

A Two-Week Psychosocial Intervention Reduces Future Aggression and Incarceration in Clinically Aggressive Juvenile Offenders

OBJECTIVE

There is a largely unmet need for evidence-based interventions that reduce future aggression and incarceration in clinically aggressive juvenile offenders serving probation. We addressed this gap using a group randomized controlled trial. Offenders both with and without clinical aggression were included, enabling comparison of intervention effects.

METHOD

Juveniles 13 to 17 years old (N = 310, mean = 16 years, 90% African-American, 66% male) on probation were assigned to a 2-week intervention targeting psychosocial factors implicated in risky behavior (e.g., learning strategies to manage "hot" emotions that prompt risk taking) or to an equally intensive health promotion control. Participants completed aggression measures at baseline, 6-, and 12-month follow-up and reported on incarceration at 12 months. Spline regression tested symptom change.

RESULTS

Among clinically aggressive offenders (n = 71), the intervention arm showed significantly greater reductions in aggression over the first 6 months compared with controls. Juveniles from the intervention no longer met clinical criteria, on average, but clinically significant symptoms persisted in the control group. By 12 months, participants from the intervention appeared to maintain treatment gains, but their symptom levels no longer differed significantly from those in the control. However, the intervention group was nearly 4 times less likely than controls to report incarceration. Intervention effects were significantly stronger for offenders with clinical than with nonclinical (n = 239) baseline aggression.

CONCLUSION

A 2-week intervention expedited improvements in aggression and reduced incarceration in clinically aggressive juvenile offenders. The findings underscore the importance of directing intervention resources to the most aggressive youth. Clinical trial registration information-PHAT Life: Preventing HIV/AIDS Among Teens in Juvenile Justice (PHAT Life); http://clinicaltrials.gov/; NCT02647710.

Judges' Perceptions of Screening, Assessment, Prevention, and Treatment for Substance Use, Mental Health, and HIV among Juveniles on Community Supervision: Results of a National Survey

Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) National Survey was funded in part to describe the current status of screening, assessment, prevention and treatment for substance use, mental health, and HIV for youth on community supervision within the US juvenile justice system. Surveys were administered to community supervision agencies and their primary behavioral healthcare providers, as well as the juvenile or family court judge with the largest caseload of youth on community supervision. This article presents the findings from the judges' survey. Survey results indicated juvenile and family court judges were open to innovations for improving the court's performance, rated their relationships with collaborators highly, and appreciated the impact of screening, assessment, prevention, and treatment on judicial practices.

Does Parental Monitoring Moderate the Impact of Community Violence Exposure on Probation Youth's Substance Use and Sexual Risk Behavior?

The present study examined whether parental monitoring buffers the negative effects of communtity violence exposure on probation youth's substance use and sexual risk behaviors. Among a sample of 347 Chicago youth on probation, ages 13-17 years, parental monitoring did not moderate the relationship between community violence exposure and probation youth's sexual risk and substance use. However, parental monitoring was independently associated with less engagement in sexual risk and substance use, and community violence exposure was independently associated with more risk behavior among probation youth. The present study contributes to the growing literature on the impact of community violence exposure and parenting on adjudicated youth risk.

Outcomes of a family-based HIV prevention intervention for substance using juvenile offenders

Approximately 80% of all arrested youth are diverted from detention and supervised in the community through probation, specialty courts and other community-based diversion efforts. Justice-involved youth have greater psychiatric impairment, substance use and sexual risk behaviors than their non-justice-involved peers. Family-based interventions to address mental health, substance use and recidivism have been successful in improving these youth outcomes; but the lack of integration of HIV/STI prevention is notable given the co-occurrence of substance use, delinquency and sexual risk-taking behaviors among justice-involved youth. Moreover, emotion dysregulation may be an important and understudied underlying construct of these co-occurring risk behaviors for justice-involved youth. Study participants were 47 caregiver-youth dyads enrolled in a juvenile drug court program. As part of a pilot efficacy trial, dyads were randomized to a 5-session family-based integrated substance use and HIV/STI prevention intervention that relied on affect management strategies for risk reduction or an adolescent-only psychoeducation condition matched for time and attention. Data collected at baseline and 3months post-intervention suggest that a family-based integrated affect management substance use and HIV prevention pilot intervention may lead to justice-involved youths' enhanced motivation to change their marijuana use, decreased marijuana use and decreased risky sexual behavior over time. Future research is required to replicate these pilot trial findings and should also examine family-level mediators and moderators of treatment response, particularly with respect to HIV prevention efforts for these youth.

Barriers to Independently Accessing Care Among Detention Youth

Youth in juvenile detention suffer from various health disparities that warrant access to health and mental health care. Although adjudicated youth receive health care while detained, many are disconnected from youth-serving institutions that may facilitate access to care when in the community. Examining the unique challenges impacting detention youth’s independent access to health services has the potential to improve health care services for this high-risk population. Qualitative interviews were conducted with 13 detention youth, and five health professionals serving justice-involved youth to identify barriers preventing detention youth from independently accessing care. Individual-level and structural barriers were identified. Individual-level barriers included youth’s lack of knowledge in a variety of areas, including fear, disinterest, and instability. Structural barriers included clinic restrictions on when patients can access services, challenging scheduling processes, and difficult interactions with clinic staff and providers. Several barriers limiting detention youth’s ability to independently access care were identified. Based on study findings, programs fostering health care utilization among detention youth should address both individual-level factors and structural factors.