The Research Process

Research Article

CHOICES-TEEN: Reducing Substance- Exposed Pregnancy and HIV Among Juvenile Justice Adolescent Females

Danielle E. Parrish1, Kirk von Sternberg2, Laura J. Benjamins3, Jacquelynn Duron4, and Mary Velasquez2

Abstract Objective: The feasibility and acceptability of CHOICES-TEEN—a three-session intervention to reduce overlapping risks of alcohol-exposed pregnancy (AEP), tobacco-exposed pregnancy (TEP), and HIV—was assessed among females in the juvenile justice system. Method: Females aged 14–17 years on community probation in Houston, TX, were eligible if presenting with aforementioned health risks. Outcome measures—obtained at 1- and 3-months postbaseline—included the Timeline Followback, Client Satisfaction Questionnaire-8, session completion/checklists, Working Alliance Inventory–Short, and open-ended ques- tions. Twenty-two participants enrolled (82% Hispanic/Latina; mean age ¼ 16). Results: The results suggest strong acceptability and feasibility with high client satisfaction and client/therapist ratings, 91% session completion, and positive open-ended responses. All youth were at risk at baseline, with the following proportions at reduced risk at follow-up: AEP (90% at 1 month, 71.4% at 3 months), TEP (77% of smokers [n ¼ 17] at reduced risk at 1 month, 50% at 3 months), and HIV (52.4% at 1 month, 28.6% at 3 months).

Keywords adolescent, HIV infections, alcohol, juvenile justice, substance-exposed pregnancy

Adolescent females detained or on probation in juvenile justice

settings often engage in multiple health behaviors that place

them at risk of HIV and substance-exposed pregnancies

(Lawrence, Snodgrass, Robertson, & Baird-Thomas, 2008;

Rosengard et al., 2006). Specifically, they engage in frequent

sexual behaviors that put them at risk of unplanned pregnancy,

sexually transmitted infections (STIs; Belenko et al., 2008),

and HIV (Committee on Pedatric AIDS, 2006) while also

smoking (Helstrom, Bryan, Hutchison, Riggs, & Blechman,

2004) and engaging in alcohol use (Lawrence et al., 2008),

which further place them at risk of both tobacco-exposed preg-

nancy (TEP) and alcohol-exposed pregnancy (AEP; Delpisheh,

Attia, Drammond, & Brabin, 2006; Helstrom et al., 2004).

There are well-documented health consequences of smoking

and drinking during pregnancy for both female youth and the

fetus (Delpisheh et al., 2006; Kulig, 2005; Wiemann &

Berenson, 1998). While many cease alcohol or cigarette use

after discovering they are pregnant (Forray, Merry, Lin, Ruger,

& Yonkers, 2015), nearly half of the U.S. pregnancies are

unplanned (Finer & Zolna, 2016) with females unaware of their

pregnancy continuing to drink or smoke during the early and

critical weeks of gestation. Compared with adult women, ado-

lescents are more likely to have an unplanned pregnancy, take

longer to recognize they are pregnant (De Genna, Larkby, &

Cornelius, 2007), and are less likely to reduce alcohol or

tobacco consumption once they find out they are pregnant

(Cornelius et al., 1994), putting them at higher risk of TEP or

AEP. These pregnancies are also at risk for mother-to-child

HIV or STI, as many of these youth may not seek early or

regular prenatal care (CDC, 2018a).

The association between substance use and STI/HIV sexual

risk behavior among youth is well-documented, with younger,

female, and racially/ethnic minority populations at highest risk

of HIV infection through heterosexual contact (CDC, 2018b;

Howard & Wang, 2004). Co-occurring substance use and sex-

ual risk behaviors are more pronounced among juvenile justice

populations, with females in these settings presenting with a

unique, multirisk profile (Rosengard et al., 2006; Teplin,

Mericle, McClelland, & Abram, 2003). While nationally rep-

resentative samples are generally lacking for this population,

1 Baylor University, Houston, TX, USA 2 University of Texas at Austin, Austin, TX, USA 3 University of Texas Mc Govern Medical School, Houston, TX, USA 4 Rutgers University, The State University of New Jersey, New Brunswick, NJ,

USA

Corresponding Author:

Danielle E. Parrish, Baylor University, 4100 Main St., Houston, TX 77002, USA.

Email: [email protected]

Research on Social Work Practice 2019, Vol. 29(6) 618-627 ª The Author(s) 2018 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1049731518779717 journals.sagepub.com/home/rsw

several trends have been identified in the literature. Alcohol use

and smoking are more prevalent and comorbid among females

in criminal justice settings (Helstrom et al., 2004; Parrish et al.,

2011), with delinquent adolescent females reporting more fre-

quent smoking than males and nearly a third meeting clinical

criteria for a substance use disorder (Cropsey, Linker, & Waite,

2008; Domalanta, Risser, Roberts, & Risser, 2003; Helstrom

et al., 2004; Lederman, Dakof, Larrea, & Li, 2004). In addition,

most (90%) are sexually active and less than half use condoms or contraception (Crosby et al., 2004; Kingree, Braithwaite, &

Woodring, 2000; Lawrence et al., 2008; Teplin et al., 2003).

Approximately a third of female youth in these settings have

previously been pregnant one or more times (Lawrence et al.,

2008; Lederman et al., 2004; Schmiege, Broaddaus, Levin, &

Bryan, 2009). Compared with community female youth sam-

ples, this population engages in earlier and more frequent

sexual risk behavior with multiple partners (Lederman

et al., 2004).

Females in juvenile justice settings are also consistently at

high risk of STIs and sexually transmitted HIV compared to

their noninvolved peers and at an even higher risk than their

male involved counterparts (Belenko et al., 2008), reporting

less frequent condom use (Belzer et al., 2001; Broaddus &

Bryan, 2008; Committee on Pedatric AIDS, 2006; Kelly,

Lesser, & Paper, 2008; Robertson, Stein, & Baird-Thomas,

2006) and more frequent acquisition of STIs placing them at

further risk of HIV infection (CDC, 2018a).

Despite this population’s unique, multirisk health profile

and the critical opportunity to intervene while youth are on

community probation, there is a paucity of gender-specific

prevention programming to reduce these risks (DiClemente

et al., 2014; Lawrence et al., 2008). This presents a challenge

for prevention and highlights an urgent need to develop effica-

cious, gender-specific, multirisk “bundled” (targeting more

than one behavior) prevention approaches for this vulnerable

population (Belenko et al., 2008; Committee on Pediatric

AIDS, 2006; Ickovics, 2008). Bundling efficiently aggregates

services to promote synergistic gain when intervening with

high-risk populations that do not routinely seek services

(Ickovics, 2008) and is increasingly being used in medical or

other opportunistic settings. While not yet tested with adoles-

cents, a bundling (Ickovics, 2008; Parrish et al., 2011) or

multiple-behavior approach (Geller, Lippke, & Nigg, 2017;

Nigg, Allegrante, & Ory, 2002) has shown promise in more

efficiently reducing health risk behavior (Werch, 2007). There

is a need, however, to conduct research to better understand

which and how many behaviors can be bundled and for which

target populations (Werch, 2007).

The CHOICES Line of Research and CHOICES-TEEN

One possibility to meet these overlapping needs among the

female juvenile justice population is to adapt an existing

empirically supported prevention intervention for adult women

called the CHOICES preconception intervention. This

intervention utilizes the transtheoretical model of behavior

change, motivational interviewing (MI), and content aimed to

increase participants’ motivation to change risky alcohol use,

smoking, and contraception use, along with a referral for con-

traception education and services (Velasquez, von Sternberg, &

Parrish, 2013). The need for the CHOICES intervention and its

efficacy has been demonstrated through a line of epidemiolo-

gical and intervention research funded by the Centers for Dis-

ease Control and Prevention (CDC; Floyd et al., 2007; Project

CHOICES Intervention Research Group, 2003; Velasquez

et al., 2017). In the first multisite randomized controlled trial

testing the efficacy of a four-session version of CHOICES

among high-risk women of childbearing age (18–44), the

CHOICES intervention group, relative to a brief advice group,

significantly reduced their risk of AEP (69.1% vs. 54.3%) and had 2-fold greater odds of being at reduced risk of AEP at

9 months (Floyd et al., 2007). This intervention has been

broadly disseminated to the public, with the original manual

and related training materials available on the CDC website

(https://www.cdc.gov/ncbddd/fasd/choices-implementing-choi

ces.html). This first aforementioned efficacy study highlighted

the need (and opportunity) to also prevent nicotine-exposed

pregnancies, as more than 70% of those at risk of AEP were also smoking (Floyd et al., 2007). Analysis of study data also

indicated that women receiving two sessions were as likely to

reduce their risk of AEP as those receiving four. Consequently,

a second efficacy trial was funded by the CDC to test a two-

session version of CHOICES, called CHOICES Plus, that

would also focus on reducing the overlapping risk of TEP

within a large, public medical setting (Velasquez et al.,

2017). This study also supported the efficacy of CHOICES Plus

in significantly reducing the risk of both AEP and TEP among

women aged 18–44 years compared to a brief advice group

(Velasquez et al., 2017).

CHOICES-TEEN was adapted from the original CHOICES

and CHOICES Plus preconception interventions to be devel-

opmentally appropriate for adolescent females and reduced

HIV/STI risk in addition to reducing risks of AEP and TEP

(Floyd et al., 2007; Project CHOICES Intervention Research

Group, 2003; Velasquez et al., 2010; Velasquez et al., 2017).

CHOICES-TEEN builds upon the CHOICES line of research

by expanding the reach of this intervention to high-risk adoles-

cent females who are—compared to adult women—more

likely to have an unplanned pregnancy, take longer to realize

they are pregnant, and less likely to stop using substances once

they realize they are pregnant (Cornelius et al., 1994; Cnattin-

gius, 2004; De Genna et al., 2007). This intervention, which

will be described in more detail in the Methods section, con-

sists of two sessions with a master’s level counselor, a session

with an adolescent medicine specialist to discuss HIV/STI and

pregnancy prevention, possible referral for HIV/STI testing

and contraceptive services, and a referral to a phone-based

smoking cessation program called the Texas Quitline. The

intervention was delivered to female youth on intensive juve-

nile community probation.

Parrish et al. 619

The aims of this one-arm pilot study were to further under-

stand the feasibility of targeting multiple bundled health risks

in high-risk adolescents as well as to evaluate the feasibility

and potential promise of an adapted gender-specific prevention

intervention—CHOICES-TEEN—in reducing the risks of

HIV/STI, TEP, and AEP among adolescent females on com-

munity probation.

Materials and Method

Following Stage 1a/1b intervention development guidelines

(Rounsaville, Carroll, & Onken, 2001), a one-arm design was

used to assess the reductions of risk (among an all-risk sample

at baseline) following the CHOICES-TEEN intervention at 1-

and 3-month follow-up. Supplemental data were collected to

assess client adherence, retention, acceptability, and the feasi-

bility and quality of treatment delivery. Data were collected by

research assistants trained in the study protocol. This study was

approved by the Harris County Juvenile Justice, University of

Houston and University of Texas Health Science Center at

Houston Institutional Review Boards.

Female adolescents aged 14–17 years were recruited from

three community probation programs in Houston, TX. Youth

assent and the parent/guardian permission were obtained in

person or by phone to conduct eligibility screenings. To be

eligible, participants were at risk of HIV/STI, AEP, and TEP

and had all of the following behaviors in the prior 3 months:

(1) sexual intercourse with a male, (2) inconsistent/ineffec-

tive condom use, (3) inconsistent/ineffective contraception

use, (4) drinking at risky levels (>3 drinks in 1 day or >7

drinks in a week), and (5) current smoking. Given that this

was a feasibility study, and the initial recruitment numbers

were lower than expected, the smoking inclusion criterion

was relaxed after 6 months to ensure an adequate sample.

Of the 150 females screened, 31 (21%) were at risk of both AEP and TEP and 37 (25%) at risk of AEP. If eligible, the voluntary nature and details of the study were described to

the youth and guardian using IRB-approved assent and per-

mission documents, questions were elicited and answered,

and written informed consent was obtained from youth and

parent/guardians prior to study participation. As shown in

Figure 1, three (8.1%) declined participation and six (16.2%) did not return to the site for various reasons (e.g., additional criminal charges and noncompliance with the pro-

gram). Of the 28 who returned for assent/parental permission

and baseline assessment, 2 were identified as ineligible, leav-

ing a pool of 26 from which 4 did not return for similar

aforementioned reasons. Of the 22 participants who started

the intervention, 20 completed all three sessions (91%) and 2 completed one session. One- and 3-month follow-up assess-

ments were obtained for all 21 of the 22 (95%) youth who received the intervention. While two youth initiated the

smoking Quitline fax referral, none of them completed this

component of the program.

CHOICES-TEEN Intervention

CHOICES-TEEN was adapted from the original CHOICES

and CHOICES Plus preconception interventions to be devel-

opmentally appropriate for adolescent females and reduced

HIV risk (Floyd et al., 2007; Project CHOICES Intervention

Research Group, 2003; Velasquez et al., 2010, 2017). The effi-

cacy of the CHOICES and CHOICES Plus bundled preconcep-

tion interventions in reducing the risks of AEP and TEP among

adult women in high-risk settings has been established through

a series of CDC-funded studies (Floyd et al., 2007; Project

CHOICES Intervention Research Group, 2003; Velasquez

et al., 2017). CHOICES-TEEN builds upon this work by

expanding the reach of this intervention to high-risk adolescent

females. As shown in Table 1, CHOICES-TEEN includes two

motivational counseling sessions with a master’s level counse-

lor, one session with an adolescent medicine physician, and a

referral to the Texas Tobacco Quitline. The Quitline accepts

fax referrals from physicians of youth who are ready to quit

smoking. A Quitline counselor then assesses the youth for one

or more of the following referrals: telephone counseling,

community-based cessation services, and youth friendly smok-

ing cessation materials.

Master’s level counselors, previously trained for prior

CHOICES intervention studies, provided the counseling ses-

sions and were supervised by experts in MI and the CHOICES-

TEEN intervention. The majority of sessions (68.2%) were provided by one of the three master’s level counselors, and

outcome did not differ by counselor at 3-month outcome. All

sessions were audio-recorded, and 15% were reviewed for quality and fidelity using the Motivational Interviewing Integ-

rity Scale 3.1.1 and CHOICES-TEEN protocol checklist. All

counselors were deemed as proficient in the intervention by a

CHOICES expert who is also a member of the Motivational

Interviewing Network of Trainers. The adolescent medicine

physicians, who provided the second session focused on HIV

and pregnancy risk reduction education and the development of

a healthy behavior plan, received a 3-hr training on the use of

MI in a medical context and the CHOICES-TEEN protocol.

Measures

Demographic and background health variables. Demographic and background health variables, including sexual activity/risk

behaviors and substance use history/frequency, were collected

using an audio computer-assisted self-administered interview

(ACASI). The AUDIT, a 10-item questionnaire used to mea-

sure alcohol use and problems, was also used to describe the

sample with regard to harmful drinking (Babor, de la Fuente,

Saunders, & Grant, 1992).

Timeline followback interview (TLFB). The TLFB interview, which collected detailed self-report behavior data using a calendar

recall method, was administered by a trained interviewer at

baseline (i.e., 90 days prior), 1-month postbaseline follow-up,

and 3-month postbaseline follow-up (Floyd et al., 2007; Sobell,

620 Research on Social Work Practice 29(6)

Brown, Leo, & Sobell, 1996; Velasquez et al., 2017). Data

collected included number of daily alcohol drinks, sexual activ-

ity, condom use, effective contraception, and smoking. These

data were divided into 30-day increments to calculate the fol-

lowing: (1) risk drinking (>3 drinks in 1 day or >7 drinks in a

week), (2) risk of pregnancy (any occurrence of vaginal inter-

course without effective contraception including condoms), (3)

HIV risk (any occurrence of vaginal or anal sex without a

condom), (4) AEP risk (any occurrence of risk drinking plus

any occurrence of vaginal intercourse without effective contra-

ception during the same time period), and (5) TEP risk (any

smoking plus any occurrence of vaginal intercourse without

effective contraception during the same period).

Client Satisfaction Questionnaire–8 (CSQ-8). Client satisfaction was measured using the CSQ-8 (Attkisson & Zwick, 1982).

This standardized measure consists of eight questions followed

by a 4-point Likert-type scale, with possible scores ranging

between 8 and 32, and higher scores indicating higher levels

of satisfaction. This questionnaire was administered, along

with five open-ended questions about the intervention, using

the ACASI in a private setting at the end of the 3-month follow-

Assessed for eligibility (n=150)

Excluded (n= 122) ♦ Not meeting inclusion criteria (n= 83)

■ No risk of pregnancy (n=83) ■ No sex (n=64) ■ No risk drinking (n=84) ■ No smoking (n=83)

♦ Declined to participate (n= 3) ♦ Other reasons; program attrition (n= 6)

Lost to follow-up 1-month (n=1)

Lost o follow-up 3-months (n=0)

Allocated to intervention (n= 22) ■ Completed Counseling Session One (n=22) ■ Completed Adolescent Fellow Session (n=20) ■ Completed Counseling Session Two (n=20) ■ Accepted Smoking Referral (n=3) ■ Health Clinic Visit (n=7)

Program Attrition, Did Not Return (n=4)

Found Ineligible at Baseline (n=2)

Returned for Parental Permission/Assent (n= 28)

Figure 1. Study flow diagram.

Parrish et al. 621

up. The five open-ended questions solicited comments/sugges-

tions, what was liked about the intervention, what was liked

least about the intervention, suggestions for improvement, and

the most important aspects of the intervention.

Working-Alliance Inventory–Short (client/therapist). This measure is used to assess three key aspects of the therapeutic alliance—agree-

ment on the goals of therapy, tasks of therapy, and the develop-

ment of an affective bond (Hatcher & Gillaspy, 2006). This scale

consists of 12 items followed by a 7-point Likert-type scale, which

ranges from never to always. This scale was administered to both

the youth and the counselor at each of two counseling sessions.

Data Analysis

The Statistical Package for Social Sciences (SPSS Version 23)

was used to conduct all analyses. Descriptive statistics were

used to describe the sample, reductions in dichotomous risk of

AEP, TEP, and HIV among an all risk sample at baseline,

feasibility and acceptability measures, and responses to the

CSQ-8 at 3-month follow-up. Inferential statistics were not

used to assess behavior change, as all youth were considered

to be at risk of AEP, TEP, and HIV at baseline. A simple

thematic analysis was conducted of brief open-ended responses

concerning the acceptability of the intervention provided by the

youth when completing the CSQ-8 at 3-month follow up. These

questions asked about what was liked most and least about the

intervention and suggestions for improving the intervention.

Results

Participants ranged in age from 14 to 17, with a mean age of

16 years (SD¼ .89). Eighty-two percent were Hispanic/Latina, with 55% reporting Mexican origin. The sample was racially

Table 1. CHOICES-TEEN Intervention Session Components.

Session 1 Provided by Master’s Level Counselor

Session 2 Contraceptive/HIV Risk Reduction Counseling Provided by Adolescent Physician

Session 3 Provided by Master’s Level Counselor

Smoking Cessation Referral Provided by American Cancer Society’s Texas

State Quitline, Which Serves Adolescents 13 and Older

� Rapport building � Review of fact sheets: � Important things for young

women to know about alcohol, smoking, pregnancy, and birth control

� Important facts for young women about HIV/STDs

� Abstinence or safer sex � Introduce and encourage

contraceptive and HIV risk reduction counseling visit

� Advice and referral to smoking cessation program if currently smoking

� Decisional balance for pros and cons of � Drinking � Smoking � Contraceptive use � Condom use

� Complete Self-evaluation rulers addressing readiness to change drinking, smoking, condom use, and contraception

� Introduce Daily Journal for drinking, smoking, intercourse, and contraception (including condoms)

� Brochures on alcohol, smoking, HIV, contraceptive methods, and community resources

� Summarize session

� Discuss and answer questions about HIV transmission and ways to reduce risk

� Determine appropriate and suitable contraceptive methods including the option of abstinence

� Provide referral for HIV testing at most convenient testing site that provides condoms

� Complete a healthy behavior plan, which details plans/ referral for preventing pregnancy and HIV

� Provide condoms if desired (parental permission was required by site)

� Provide follow-up clinical care or referral as needed

� Provide personalized feedback (derived from baseline assessment)

� Discussion of temptation and confidence profiles for all four behaviors

� Review and discussion of information recorded in the Daily Journal

� Discuss contraception and counseling/HIV risk reduction visit

� Review smoking brochure and discuss smoking cessation referral (as applicable)

� Review of decisional balance exercises for each behavior

� Completion of initial goal statement and change plans for each behavior

� Provide community resource list (if applicable)

� Summarize session

� Determine readiness to change

� Provide behavioral counseling for smoking cessation

Note. STDs ¼ sexually transmitted diseases.

622 Research on Social Work Practice 29(6)

diverse with 18% Black, 18% White, 9% American Indian/ native Hawaiian, 4.5% multiracial, and 27% reporting race as Hispanic/Mexican American. The youth were all English

speaking. However, we did have a Spanish-speaking counse-

lor available to provide the intervention in Spanish if needed

and to communicate with Spanish-speaking parents/guar-

dians. Prior arrests ranged from 1 to 10 or more, with 59% only having 1 or 2. Participants reported prior arrests for the

following reasons: 45% assault, 41% petty theft, 27% truancy, 22% possession of marijuana or other drugs, 18% running away, and 14% trespassing. With regard to sexual orientation, 73% were heterosexual and 23% bisexual. All youth reported using drugs in the last 6 months, and among those who

smoked, five were daily smokers. The mean AUDIT score

was 2.5 (SD ¼ 2.87).

Risk of AEP, TEP, and HIV/STI

Of the 22 participants who received the intervention, one did

not complete the follow-up assessments. Reduction of AEP,

TEP, and HIV risk was based on the frequency of youth in the

at-risk or reduced risk category based on the TLFB at each

follow-up period. Successful change was categorized as

“reduced risk” instead of “no risk” because all contraception

methods, including condoms, fail a certain percentage of the

time even with perfect use. As noted previously, these data

were divided into 30-day increments to calculate the presence

of combined or single risk behaviors within each time frame

over a continuous 7-month period: 3-month baseline (3

months prior to baseline), 1-month follow-up (from baseline

to 1 month later), and 3-month follow-up (from 1 month to 3

months postbaseline). AEP risk was defined as the presence of

risk drinking and risk of unplanned pregnancy during the

same time period, TEP risk was defined as any smoking plus

risk of unplanned pregnancy during the same period, and

HIV/STI risk as any occurrence of vaginal or anal sex without

a condom.

Ninety percent (n ¼ 19) of participants were at reduced risk of AEP at 1 month, and 71.4% (n ¼ 15) were at reduced risk at 3 months. Using an intent-to-treat analysis (treating the drop

out as a failure), 86.4% were at reduced risk at 1 month and 68.2% were at reduced risk at 3 months.

Seventeen of the 22 (77%) participants were smokers and at risk of TEP at baseline. Of those at risk at baseline, 68.8% (n ¼ 11) were at reduced risk at 1 month and 50% (n ¼ 8) were at reduced risk at 3 months. With the intent-to-treat analysis,

64.7% were at reduced risk at 1 month and 47.1% were at reduced risk at 3 months. Of those who smoked at baseline,

71.4% reported currently smoking cigarettes at 1 month and 73.3% at 3 months.

All 22 participants who received the intervention were at

HIV/STI risk at the baseline. Fifty-two percent were at reduced

risk at 1 month, and 28.6% were at reduced risk at 3 months. Of the 11 who were not at risk of unplanned pregnancy at

3 months, only 2 were not using condoms while sexually active

and using another contraceptive method. Using an intent-to-

treat analysis, 50% were at reduced risk for HIV/STI at 1 month and 27.3% were at reduced risk at 3 months.

The route by which the youth reduced their AEP and TEP

risk is provided in Figure 2.

A = Used Effective Contraception/Abstinence A = Used Effective Contraception/Abstinence

B= Reduced Risk Drinking Only B= Smoking Cessation Only

AB = Reduced Both Risks AB = Reduced Both Risks

AB 33.3% (n=5)

B 26.7% (n=4)

A 40% (n=6)

B 36.8% (n=7)

AB 42.1% (n=8)

A 21.1% (n=4)

Routes of Reduced AEP Risk

1 month

3 months

Routes of Reduced TEP Risk

B 18.2% (n=2)

AB 27.3% (n=3)

A 54.5% (n=6)

A 75% (n=6)

AB 25% (n=2)

B (n=0)

Figure 2. Distribution of youth achieving reduced risk of alcohol-exposed pregnancy and tobacco-exposed pregnancy at 1 month and 3 months.

Parrish et al. 623

Feasibility

The CHOICES-TEEN intervention checklist indicated that all

aspects of the intervention were delivered and that the sessions

did not exceed the planned 45- to 60-min duration. The

CHOICES-TEEN MI Scale, which assessed the degree to

which counselors believed they emphasized various aspects

of an MI approach, was rated as over a 4 on a 1–5 scale for

all items. CHOICES-TEEN counselors indicated per structured

session notes that all participants appeared to comprehend ses-

sion tasks. The average per-item mean for youth on the task

(M¼ 5.99, SD¼ .97), bond (M¼ 6.04, SD¼ .95), and goal (M¼ 5.56, SD ¼ 1.12) subscales of the Working Alliance Inventory– Short ranged between 5 (often) and 7 (always) on a 1–7 scale.

Participant Acceptance/Satisfaction With Intervention

All except one of the 22 youth enrolled in the intervention

completed all three sessions delivered on site at a weekly

community-based probation program. In response to the anon-

ymously administered CSQ-8 at 3-month follow-up, female

youth (n ¼ 20) reported high levels of satisfaction (M ¼ 24, SD ¼ .71; average per-item mean ¼ 3) with the intervention, with scores ranging from 23 to 25. Specifically, 60% described the quality of services as “excellent” and 40% described the services as “good.” Despite being a nontreatment seeking pop-

ulation, fifty-five percent of youth indicated that they

“definitely” received the service desired, with 45% indicating they “generally” did. Sixty percent indicated “most” of their

needs have been met by the intervention, while 35% indicated “almost all” of their needs were met, and one youth indicated

their needs were not met. All youth indicated they would refer a

friend in need of similar help to the program. Ninety-five per-

cent of youth reported being “mostly” or “very” happy with the

amount of help they received. With regard to overall satisfac-

tion, 65% reported being very satisfied, and 35% mostly satis- fied. Ninety-five percent indicated they would return to the

program if they were to seek help again. Twenty of the 22

participants provided anonymous written feedback to the

open-ended questions that followed the CSQ-8. Responses

indicated that youth valued the opportunity to be honest in a

relational, confidential setting and that the counselors and doc-

tors provided useful information that they did not know or had

not considered. In particular, the youth appreciated the oppor-

tunity to have a conversation with a physician to obtain accu-

rate information about their options for preventing unplanned

pregnancy and HIV/STIs. Youth suggested the program may be

more successful if assistance was provided for transportation

and appointment setting with the health clinics. They also sug-

gested that the program expand to reduce the health and preg-

nancy risks associated with marijuana and other drugs.

Discussion

This one-arm feasibility study suggests that the CHOICES-

TEEN intervention is feasible, acceptable, and promising with

regard to reducing the risk of AEP, TEP, and HIV/STI among

female youth involved with the juvenile justice system. The

retention of youth who began the intervention was 91% for all three sessions, and youth reported feeling positively about the

intervention, suggesting that the intervention was acceptable.

With regard to feasibility, all intervention components were

completed with ease within the designated session time frames.

Taken together, these findings suggest that it is feasible to

target multiple health-risk behaviors (smoking, risk drinking,

contraception use, and condom use) simultaneously with this

high-risk population. However, future research with a control

group will be necessary to test the efficacy of this intervention.

The reductions in risk of AEP were comparable to reduc-

tions of risk found in CHOICES intervention studies with

women (Floyd et al., 2007; Velasquez et al., 2017). With regard

to TEP, the reduction of risk was 50% in this study and 69.8% in the CHOICES Plus study (Velasquez et al., 2017). However,

this sample only included five youth reporting daily smoking,

suggesting many of these youth may be engaging in light and

intermittent smoking which often mistakenly perceived by

youth as less harmful or addictive (Amrock & Weitzman,

2015). This may be one of the reasons that few youth accepted

and followed up with the smoking cessation referral. In addi-

tion, open-ended feedback from the youth suggested that smok-

ing was a temporary replacement for marijuana, while they

were being randomly drug tested by probation. This suggests

a need to better understand the patterns of smoking and mar-

ijuana use among high-risk females in these settings for pur-

poses of preventing substance-exposed pregnancy.

The proportions of youth reducing HIV/STI risk at 3-month

follow-up were not as high compared to AEP and TEP, which

is not surprising as there is only one way to reduce this risk—

condom use. While it is most ideal that youth reduce their risk

of pregnancy by either abstinence or using both condoms and

other contraceptive methods, it is encouraging that the large

majority of youth who reduced their risk of pregnancy in the

study were using condoms, which protect against both

unplanned pregnancy and HIV/STIs. In addition, HIV/STI pre-

vention research with juvenile justice populations has generally

resulted in more modest effect sizes for behavioral change

(Tolou-Shams, Stewart, Fasciano, & Brown, 2010), highlight-

ing a need to develop more robust interventions.

Despite encouraging findings, these results should be inter-

preted with some caution, given the small sample size and lack

of a control group. Also, while self-report measures are a major

data source for clinical and resource purposes, they have been

criticized for potential bias. However, retrospective self-reports

of behavior collected in settings which minimize these poten-

tial biases have been shown to be reliable and valid. Still, future

research would benefit by incorporating biological measures

that further substantiate self-report. Finally, given feedback

from the youth and the providers, it may be useful to expand

the CHOICES-TEEN model to incorporate marijuana and other

drugs as well as to explore the utility of providing all of the

aspects of the intervention in a postadjudication placement

624 Research on Social Work Practice 29(6)

setting to reduce client transportation challenges and the time

commitment for travel of providers.

Implications for Practice and/or Policy

Given the limited research on gender-sensitive interventions

with female youth in juvenile justice settings, this research

highlights several implications for practice and policy. First,

this is the first study to report on the prevalence of substance-

exposed pregnancy in a sample of female youth in the juvenile

justice system. Of the 150 youth screened, 25% were at risk of AEP in this study, which is much higher than the 3.4% at risk in the general population (Cannon et al., 2015). This finding,

combined with the aforementioned literature documenting

these overlapping risks in multiple, larger samples of female

youth, suggests an urgent need for interventions and/or policy

to reduce these risks. Specifically, programming should be

provided that informs female youth of these risks as well as

efficient, prevention interventions that have promise for broad

prevention impact. AEP is 100% preventable, has been recently estimated to be more prevalent than autism (May et al., 2018),

and can lead to costly lifelong cognitive, behavioral, emotional,

and adaptive functioning deficits. Smoking and HIV/STIs can

also severely affect the health of both female youth and their

children both during and after pregnancy (e.g., second-hand

smoke; HHS, 2014; Delpisheh et al., 2006; Kulig, 2005; Wie-

mann & Berenson, 1998). As such, the development of and

funding for early prevention programs for one of the society’s

highest risk populations that rarely receives integrated health

care are essential.

Second, this study suggests integrated, multirisk bundled

motivational enhancement interventions provided at opportu-

nistic times can be feasible, acceptable, and potentially promis-

ing for female youth in the juvenile justice system. As such,

programs that focus on more than just one risk behavior during

times of detention or community probation may be more effi-

cient and cost-effective. Finally, youth appreciated the oppor-

tunity to receive individualized information about their sexual

health and substance use in an accepting and supportive con-

text. Such efforts can be further bolstered by ensuring better

access to referrals by providing transportation to follow-up

medical visits, as this can be a major service barrier for this

population. Finally, none of the youth in this study accepted the

incoming smoking cessation Quitline referral phone calls. As

such, nontelephonic options, such as the U.S. Health and

Human Service’s QuitSTART technology application, may

be a better fit for some youth.

Conclusions

CHOICES-TEEN is acceptable and feasible and appears pro-

mising for reducing overlapping, bundled health risks—AEP,

TEP, and HIV—among high-risk female youth in juvenile jus-

tice settings. Given the potential for impacting multiple, over-

lapping health risks in an opportunistic manner, future research

should examine the efficacy of this intervention with a more

robust sample.

Acknowledgments

Harris County Juvenile Probation provided essential support of this

project by facilitating essential partnerships and space in the field.

Robin Harris provided coordination of the project in the field, and

Barbie Atkinson, Matiko Bivens and Lisa Connelly were the

CHOICES-TEEN counselors. Rebecca Beyda, M.D. and Laura

Grubb M.D., provided the Adolescent Medicine risk reduction coun-

seling sessions. Alicia Kowalchuk, M.D. provided Motivational

Interviewing training for the Adolescent Medicine Fellows, and

Nanette Stephens provided fidelity monitoring and training for the

CHOICES-TEEN counselors. Ralph DiClemente, Ph.D. and Carrie

Randall, Ph.D. provided consultation to support the implementation

of this project.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the

research, authorship, and/or publication of this article: This study was

funded by Grant Number 1R03DA034099 from the National Institute

of Drug Abuse, National Institutes of Health.

References

Amrock, S. M., & Weitzman, M. (2015). Adolescents’ perceptions of

light and intermittent smoking in the United States. Pediatrics,

132, 246–254. doi:10.1542/peds.2014-2502

Attkisson, C. C., & Zwick, R. (1982). The client satisfaction ques-

tionnaire: Psychometric properties and correlations with service

utilization and psychotherapy outcome. Evaluation Programming

and Planning, 5, 233–237. doi:10.1016/0149-7189(82)90074-X

Babor, T. F., de la Fuente, J. R., Saunders, J., & Grant, M. (1992). The

alcohol use disorders identfication test: Guidelines for primary

health care. Genevea, Switzerland: World Health Organization.

Belenko, S., Dembo, R., Weiland, D., Rollie, M., Salvatore, C., &

Childs, K. (2008). Recently arrested adolescents are at high risk

for sexually transmitted diseases. Sexually Transmitted Diseases,

35, 758–763. doi:10.1097/OLQ.0b013e31816d1f94

Belzer, M., Rogers, A. S., Camarca, M., Fuchs, D., Peralta, L., &

Durako, S. J. (2001). Contraceptive choices in HIV infected and

HIV at-risk adolescent females. Journal of Adolescent Health, 29,

93–100.

Broaddus, M. R., & Bryan, A. (2008). Consistent condom use among

juvenile detainees: The role of individual differences, social bond-

ing, and health beliefs. AIDS and Behavior, 12, 59–67.

doi:10.1007/s10461-007-9260-5

Cannon, M. J., Guo, J., Denny, C. H., Green, P. P., Miracle, H.,

Sniezek, J. E., & Floyd, R. L. (2015). Prevalence and characteris-

tics of women at risk for an alcohol-exposed pregnancy (AEP) in

the United States: Estimates from the National Survey of Family

Growth. Maternal and Child Health Journal, 19, 776–782.

doi:10.1007/s10995-014-1563-3

Parrish et al. 625

Centers for Disease Control and Prevention. (2018a). HIV among

pregnant women, infants, and children. Atlanta, GA. Retrieved

from https://www.cdc.gov/hiv/group/gender/pregnantwomen/

index.html

Centers for Disease Control and Prevention. (2018b). HIV among

youth. Atlanta, GA. Retreived from https://www.cdc.gov/hiv/

group/age/youth/index.html

Cnattingius, S. (2004). The epidemiology of smoking during preg-

nancy: Smoking prevalence, maternal characteristics, and preg-

nancy outcomes. Nicotine & Tobacco Research, 6, S125–S140.

doi:10.1080/14622200410001669187

Committee on Pedatric AIDS 2003-2004. (2006). Reducing the risk of

HIV infection associated with illicit drug use. Pediatrics, 117,

566–571. doi:10.1542/peds.2005-2750

Cornelius, M. D., Richardson, G. A., Day, N. L., Cornelius, J. R.,

Geva, D., & Taylor, P. M. (1994). A comparison of prenatal drink-

ing in two recent samples of adolescents and adults. Journal of

Studies on Alcohol and Drugs, 55, 412–419. doi:10.15288/

jsa.1994.55.412

Cropsey, K. L., Linker, J. A., & Waite, D. E. (2008). An analysis of

racial and sex differences for smoking among adolescents in a

juvenile correctional center. Drug and Alcohol Dependence, 92,

156–163. doi:10.1016/j.drugalcdep.2007.07.018

Crosby, R., Salazar, L. F., Diclemente, R. J., Yarber, W. L., Caliendo,

A. M., & Staples-Horne, M. (2004). Health risk factors among

detained adolescent females. American Journal of Preventative

Medicine, 27, 404–410. doi:10.1016/j.amepre.2004.07.017

De Genna, N. M., Larkby, C., & Cornelius, M. D. (2007). Early and

adverse experiences with sex and alcohol are associated with

adolescent drinking before and during pregnancy. Addictive

Behaviors, 32, 2799–2810. doi:10.1016/j.addbeh.2007.04.018

Delpisheh, A., Attia, E., Drammond, S., & Brabin, BJ. (2006). Ado-

lescent smoking in pregnancy and birth outcomes. The European

Journal of Public Health, 16, 168–172. doi:10.1093/eurpub/cki219

DiClemente, R. J., Davis, T. L., Swartzendruber, A., Fasula, A. M.,

Boyce, L., & Staples-Home, M. (2014). Efficacy of an HIV/STI

sexual risk-reduction intervention for African American adoles-

cent girls in juvenile detention centers: A randomized controlled

trial. Women & Health, 54, 726–749.

Domalanta, D. D., Risser, W. L., Roberts, R. E., & Risser, J. M.

(2003). Prevalence of depression and other psychiatric disorders

among incarcerated youths. Journal of the American Academy of

Child & Adolescent Psychiatry, 42, 477–484. doi:10.1097/

01.CHI.0000046819.95464.0BS0890-8567(09)60920-5

Finer, L. B., & Zolna, M. R. (2016). Declines in unitended pregnancy

in the United States, 2008-2011. The New England Journal of

Medicine, 374, 843–852. doi:10.1056/NEJMsa1506575

Floyd, R. L., Sobell, M., Velasquez, M. M., Ingersoll, K., Nettleman,

M., & Sobell, L., & Project CHOICES Efficacy Group. (2007).

Preventing alcohol-exposed pregnancies: A randomized controlled

trial. American Journal of Preventative Medicine, 32, 1–10.

doi:10.1016/j.amepre.2006.08.028

Forray, A., Merry, B., Lin, H., Ruger, J. P., & Yoners, K. A. (2015).

Perinatal substance use: A prospective evaluation of abstinence

and relapse. Drug and Alcohol Dependence, 150, 147–155.

Geller, K., Lippke, S., & Nigg, C. R. (2017). Future directions of

multiple behavior change research. Journal of Behavioral Medi-

cine, 40, 194–202. doi:10.1007/s10865-016-9809-8

Hatcher, R. L., & Gillaspy, J. A. (2006). Development and valida-

tion of a revised short version of the working alliance inven-

tory. Psychotherapy Research, 16, 12–25. doi:10.1080/

10503300500352500

Helstrom, A., Bryan, A., Hutchison, K. E., Riggs, P. D., & Blechman,

E. A. (2004). Tobacco and alcohol use as an explanation for the

association between externalizing behavior and illicit drug use

among delinquent adolescents. Prevention Science, 5, 267–277.

doi:10.1023/B: PREV.0000045360.23290.8f

Howard, D. E., & Wang, M. Q. (2004). The relationship between

substance use and STD/HIV-related sexual risk behaviors among

U.S. adolescents. Journal of HIV/AIDS Prevention in Children &

Youth, 6, 65–82.

Ickovics, J. R. (2008). “Bundling” HIV prevention: Integrating

services to promote synergistic gain. Preventative Medicine, 46,

222–225. doi:10.1016/j.ypmed.2007.09.006

Kelly, P. J., Lesser, J., & Paper, B. (2008). Detained adolescents’

attitudes about pregnancy and parenthood. Journal of Pediatric

Health Care, 22, 240–245. doi:10.1016/j.pedhc.2007.07.005

Kingree, J. B., Braithwaite, R., & Woodring, T. (2000). Unprotected

sex as a function of alcohol and marijuana use among adolescent

detainees. Journal of Adolescent Health, 27, 179–185.

doi:10.1016/s1054-139x(00)00101-4

Kulig, J. W. (2005). Clinical report: Guidance for the clinician in

rendering pediatric care: Tobacco, alcohol, and other drugs: The

role of the pediatrician in prevention, identification, and manage-

ment of substance abuse. Pediatrics, 115, 816–821. doi:10.1542/

peds.20042841

Lawrence, J. S. S., Snodgrass, C. E., Robertson, A., & Baird-Thomas,

C. (2008). Minimizing the risk of pregnancy, sexually transmitted

siseases, and HIV among incarcerated adolescent girls. Criminal

Justice and Behavior, 35, 1500–1514. doi:10.1177/009385480

8324669

Lederman, C. S., Dakof, G. A., Larrea, M. A., & Li, H. (2004). Char-

acteristics of adolescent females in juvenile detention. Interna-

tional Journal of Law and Psychiatry, 27, 321–337. doi:10.1016/

j.ijlp.2004.03.009S0160-2527(04)00051-2

May, P. A., Chambers, C. D., Kalberg, W. O., Zellner, J., Feldmen, H.,

Buckley, D., & Hoyme, H. E. (2018). Prevalence of fetal alcohol

spectrum disorders in 4 US communities. Journal of the American

Medical Association, 319, 474–482. doi:10.1001/jama.2017.21896

Nigg, C. R., Allegrante, J. P., & Ory, M. (2002). Theory-comparison

and multiple-behavior research: Common themes advancing health

behavior research. Health Education Research, 17, 670–679.

doi:10.1093/her/17.5.670

Parrish, D., von Sternberg, K., Velasquez, M., Cochran, J., Sampson,

M., & Mullen, P. (2011). Characteristics and factors associated

with the risk of a nicotine exposed pregnancy: Expanding the

CHOICES preconception counseling model to tobacco. Maternal

and Child Health Journal, 16, 1224–1231. doi:10.1007/s10995-

011-0848-z

Project CHOICES Intervention Research Group. (2003). Reducing the

risk of alcohol-exposed pregnancies: A study of a motivational

626 Research on Social Work Practice 29(6)

intervention in community settings. Pediatrics, 111, 1131–1335.

Retrieved from http://pediatrics.aappublications.org/content/111/

Supplement_1/1131.long

Robertson, A. A., Stein, J. A., & Baird-Thomas, C. (2006). Gender

differences in the prediction of condom use among incarcerated

juvenile offenders: Testing the Information-Motivation-Behavior

Skills (IMB) model. Journal of Adolescent Health. 38, 18–25.

Rosengard, C., Stein, L. A., Barnett, N. P., Monti, P. M., Golembeske,

C., & Lebeau-Craven, R. (2006). Co-occurring sexual risk and

substance use behaviors among incarcerated adolescents. Journal

of Correctional Health Care, 12, 279–287. doi:10.1177/

1078345806296169

Rounsaville, B. J., Carroll, K. M., & Onken, L. S. (2001). A stage

model of behavioral therapies research: Getting started and moving

on from stage I. Clinical Psychology: Science and Practice, 8,

133–142. doi:10.1093/clipsy.8.2.133

Schmiege, S. J., Broaddus, M. R., Levin, M., & Bryan, A. D. (2009).

Randomized trial of group interventions to reduce HIV/STD risk

and change theoretical mediators among detained adolescents.

Journal of Consulting and Clinical Psychology, 77, 38–50.

doi:10.1037/a0014513

Sobell, L. C., Brown, J., Leo, G. I., & Sobell, M. B. (1996). The

reliability of the alcohol timeline followback when administered

by telephone and by computer. Drug and Alcohol Dependence, 42,

49–54. doi:10.1016/0376-8716(96)01263-x

Teplin, L. A., Mericle, A. A., McClelland, G. M., & Abram, K. M.

(2003). HIV and AIDS risk behaviors in juvenile detainees: Impli-

cations for public health policy. American Journal of Public

Health, 93, 906–912. doi:10.2105/AJPH.93.6.906

Tolou-Shams, M., Stewart, A., Fasciano, J., & Brown, L. K. (2010). A

review of HIV prevention interventions for juvenile offenders. Jour-

nal of Pediatric Psychology, 35, 250–261. doi:10.1093/jpepsy/jsp069

U.S. Department of Health and Human Services (HHS) (2014).

Let’s make the next generation tobacco free: Your guide to the

50th anniversary Surgeon General’s report on smoking and

health. Atlanta: U.S. Department of Health and Human Ser-

vices, Centers for Disease Control and Prevention, National

Center for Chronic Disease Prevention and Health Promotion,

Office on Smoking and Health. Retrieved May 25, 2018, from

https://sergeongeneral.gov/library/reports/50-years-of-progress/

consumer-guide.pdf

Velasquez, M. M., Ingersoll, K. S., Sobell, M. B., Floyd, R. L., Sobel,

L. C., & von Sternberg, K. (2010). A dual-focus motivational

intervention to reduce the risk of alcohol-exposed pregnancy. Cog-

nitive and Behavioral Practice, 17, 203–212. doi:10.1016/

j.cbpra.2009.02.004

Velasquez, M. M., von Sternberg, K. L., Floyd, L., Parrish, D., Kowal-

chuk, A., Stephens, N. S., & Mullen, P. D. (2017). Preventing

alcohol- and tobacco-exposed pregnancies: CHOICES plus in pri-

mary care. American Journal of Preventative Medicine, 53, 85–95.

doi:10.1016/j.amepre.2017.02.012

Velasquez, M. M., von Sternberg, K., & Parrish, D. (2013).

CHOICES: An integrated behavioral intervention to prevent

alcohol-exposed pregnancies among high-risk women in commu-

nity settings. Social Work in Public Health, 28, 224–233.

doi:10.1080/19371918.2013.759011

Werch, C. (2007). The behavior-image model: A paradigm for inte-

grating prevention and health promotion in brief interventions.

Health Education Research, 22, 677–690. doi:10.1093/her/

cyl146

Wiemann, C. M., & Berenson, A. B. (1998). Factors associated with

recent and discontinued alcohol use by pregnant adolescents.

Journal of Adolescent Health, 22, 417–423. doi:10.1016/S1054-

139X(97)00215-2

Parrish et al. 627