Essay Social

O R I G I N A L P A P E R

HIV-Risk Reduction with Juvenile Offenders on Probation

Geri R. Donenberg • Erin Emerson •

Mary Ellen Mackesy-Amiti • Wadiya Udell

Published online: 14 May 2014

� Springer Science+Business Media New York 2014

Abstract Youth involved in the juvenile justice system are

at elevated risk for HIV as a result of high rates of sexual risk

taking, substance use, mental health problems and sexually

transmitted infections. Yet few HIV prevention programs

exist for young offenders. This pilot study examined change

in juvenile offenders’ sexual activity, drug/alcohol use, HIV

testing and counseling, and theoretical mediators of risk

taking following participation in preventing HIV/AIDS

among teens (PHAT Life), an HIV-prevention program for

teens on probation. Participants (N = 54) were 13–17 year-

old arrested males and females remanded to a detention

alternative setting. Youth participated in a uniquely tailored

HIV prevention intervention and completed a baseline and

3-month follow up assessment of their HIV and substance

use knowledge, attitudes, beliefs, and behaviors. At 3-month

follow up, teens reported less alcohol use, more positive

attitudes toward peers with HIV, greater ability to resist

temptation to use substances, and for males, improved HIV

prevention self-efficacy and peer norms supporting preven-

tion. Teens were also more likely to seek HIV counseling and

males were more likely to get tested for HIV. Effect sizes

revealed moderate change in sexual behavior. Findings

support PHAT Life as a promising intervention to reduce

HIV-risk among youth in juvenile justice.

Keywords Juvenile offenders � HIV/AIDS � Substance use � Prevention

Introduction

In 2009, approximately 1.5 million youth under age

18 years were involved in the criminal justice system, and

a disproportionate number were African American (US

Department of Justice 2010). Higher rates of undiagnosed

sexually transmitted infections (STI) exist among young

offenders compared to youth in the general population

(Belenko et al. 2008), and untreated STI increase the risk

for HIV/AIDS fivefold [centers for disease control (CDC)

2010]. Eighty percent of arrested youth are released on

probation (i.e., community supervision), but compared to

detained or incarcerated teens, probation youth rarely

receive medical care, diagnostic evaluations, or treatment

(Snyder and Sickmund 2006; Stahl et al. 2006). As a result,

probation teens who continue to engage in sexual activity

amplify the risk of STI and HIV in their communities and

further contribute to health disparities in the most disad-

vantaged neighborhoods.

STI are exacerbated by high rates of risky sexual behavior

(Dembo et al. 2009; Teplin et al. 2003), mental illness (Fazel

et al. 2008; Teplin et al. 2002; Vermeiren et al. 2006), and

substance use (Bryan et al. 2007; Teplin et al. 2003, 2005)

among youth in the criminal justice system. More than a third

of juvenile offenders report unprotected sex when drunk or

high (Teplin et al. 2003), and alcohol use can compromise

intentions to use condoms and diminish skills to negotiate

safer sex (Bryan et al. 2009). Most of these data reflect

detained or incarcerated youth, and less is known about

probation teens. Poor emotion regulation (e.g., affective

lability, lack of flexibility), a proxy and indicator of mental

G. R. Donenberg (&) � E. Emerson � M. E. Mackesy-Amiti Division of Epidemiology and Biostatistics, School of Public

Health, University of Illinois at Chicago, 1603 West Taylor

Street, Chicago, IL 60612, USA

e-mail: [email protected]

W. Udell

Community Psychology Program, School of Interdisciplinary

Arts and Sciences, University of Washington Bothell, Bothell,

WA 98011, USA

123

J Child Fam Stud (2015) 24:1672–1684

DOI 10.1007/s10826-014-9970-z

health problems, is associated with increased substance use

and risky sexual behavior (Caspi et al. 1997; Lescano et al.

2007), and juvenile offenders lack skills to manage affective

arousal (Otto-Salaj et al. 2002). The linkages across STI,

mental illness, and substance use pose significant challenges

for HIV prevention, as few programs address their comor-

bidity, particularly for criminally involved youth.

HIV prevention programs for juvenile offenders typically

rely on social-cognitive theory and address HIV/AIDS and

substance use knowledge, attitudes, beliefs, and safer sex skills.

Research supports these targets; young offenders evidence

significant HIV (Katz et al. 1995) and substance use (Leeming

et al. 2002) knowledge deficits, negative perceptions of con-

doms, aversive feelings toward safe-sex practices (Carney et al.

1997; Crosby et al. 2004), low personal vulnerability to HIV

(Carney et al. 1997), and diminished self-efficacy for HIV

prevention (Kasen et al. 1992). Peer norms, attitudes, and

behavior influence adolescent sexual activity and substance use

(Donenberg et al. 2001), and compared to non-offenders, jus-

tice involved youth report lower peer norms for safer-sex

(Nader et al. 1989), and their perceptions of peer norms are

related to inconsistent condom use (Robertson et al. 2006).

Research on broader contextual factors related to risk

behavior among young offenders is sparse, but findings for

non-offending youth with mental health and substance use

problems point to poor affect regulation (Brown et al.

2012) and diminished partner communication as poten-

tially important intervention targets. For example, among

youth with significant mental health problems, affect dys-

regulation was related to non-condom use at last sex and a

history of substance use (Brown et al. 2012), while talking

to partners about safer sex predicts increased condom use

among incarcerated adolescents (Rickman et al. 1994).

Still, few HIV prevention programs have targeted

juvenile offenders (Tolou-Shams et al. 2010), and among

those that have, published reports have yielded small

effects on behavior, low retention rates (Bryan et al. 2009;

Goldberg et al. 2009; Robertson et al. 2011; Rosengard

et al. 2007; Schmiege et al. 2009; Tolou-Shams et al.

2011), and intervention decay (Tolou-Shams et al. 2010).

By contrast, a review of HIV prevention interventions for

juvenile offenders concluded that changes in theoretical

mediators of risk (e.g., HIV knowledge and attitudes) are

consistently strong (Tolou-Shams et al. 2010).

Methodological factors in intervention research with

criminally involved youth hamper general conclusions. For

example, Hurd et al. (2010) compared the effectiveness of a

4- versus 8-session intervention, and found change in atti-

tudes immediately after the intervention, but there were no

risk behavior outcomes or follow-up data. Another pilot

study tested an HIV prevention program for incarcerated

males (Mouttapa et al. 2010), but excluded youth with

mental illness and drug dependency, significantly restricting

the target population and limiting generalizability. The

authors reported increased condom use in the intervention

condition, but there were no group differences in HIV

transmission knowledge, sex while using drugs or alcohol, or

attitudes toward condoms at follow up. The most compre-

hensive randomized trial to date (Bryan et al. 2009) evalu-

ated a 3-arm sexual and alcohol risk reduction program for

detained youth, and followed participants for 3-, 6-, 9-, and

12-months. All three conditions involved a single session

lasting between 2 and 4 h delivered in a group format with

1–10 participants. Youth in the two experimental arms

reported less risky sexual behavior than youth in the control

group, but effects were small and behavioral outcomes did

not differ between the two active interventions. However, the

impact of the intervention on theoretical mechanisms was

strong, and two of these, self-efficacy and intentions, medi-

ated the reductions in sexual risk. Unfortunately, very low

retention (65 %) calls into question the representativeness of

the sample and external validity of the findings.

Finally, the interventions reviewed above focused on

incarcerated and detained teens, even though the majority of

arrested youth are placed on probation (i.e., community

supervision). None of the interventions addressed comorbid

mental health, substance use, and sexual risk present in many

criminally involved youth, especially those on probation. One

study evaluated an intervention for non-incarcerated young

offenders remanded to drug court but found no significant

differences between the experimental and control groups at the

3-month follow-up (Tolou-Shams et al. 2011). Prevention

programs that target multiple risk factors among juvenile

offenders are an urgent public health priority. This study reports

the outcomes of a small pilot study testing a uniquely tailored

HIV/AIDS, mental health, and substance use prevention pro-

gram (preventing HIV/AIDS among teens; PHAT Life) for

juvenile offenders on probation. We hypothesized that at the

3-month follow up relative to baseline, youth would report

increased HIV knowledge, improved attitudes toward HIV

prevention, greater self-efficacy to prevent HIV transmission

and abstain from substance use, stronger intentions to engage in

prevention behavior, less temptation to use substances, and

decreased risk taking (i.e., less unprotected sex, fewer occasions

of drug and alcohol use, reduced likelihood of having sex while

using substances). We also hypothesized that teens would

report increased affect regulation, a proxy for improved mental

health, and greater HIV testing and counseling behavior.

Method

Participants

Figure 1 shows the participant flow from initial recruitment

through the 3-month follow up. All youth present at the

J Child Fam Stud (2015) 24:1672–1684 1673

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Evening Reporting Centers (ERC) during recruitment

(N = 89) were informed of the project and evaluated for

eligibility. Youth were eligible to participate if they:

(a) understood the consent/assent process; (b) spoke Eng-

lish (the assessments are normed for English speakers);

(c) provided assent to participate; (d) had consent to par-

ticipate by a legal guardian; (e) would be in attendance at

the ERC for at least three of the eight intervention sessions

based on days remanded to the ERC by court order; and

(f) completed baseline assessments. Of the 89 youth pre-

sented the study, 17 % (N = 15) were ineligible, primarily

as a result of detainment prior to enrollment. Of the

remaining 74 youth, 64 teens and parents provided assent

and consent (86 %), and 61 youth completed the baseline

assessment (three youth were withdrawn by ERC staff for

behavioral problems prior to baseline). Of the remaining 61

youth who completed the baseline assessment, six were

detained or withdrawn by the ERC before the first inter-

vention session, and one youth declined to participate

further. Hence, the final sample that participated in the

intervention (N = 54) was 59 % male, ages 13–17 years

old (M = 15.7, SD = 1.04), and 93 % African American.

The remaining 7 % were Latino (5 %) and White (2 %).

The majority of youth (71 %) lived with their biological

mother, 11 % with their grandmother, 8 % with other rel-

atives (i.e., aunt, step father, and great grandmother), 6 %

with a foster parent, and 4 % with their biological father.

Ninety percent scored in the first three levels of the Hol-

lingshead index (1975), indicating low to middle incomes.

Targeted recruitment from the female programs produced

approximately equal representation of males and females.

All of the youth who participated in the intervention

(N = 54; 100 %) were retained at the 3-month follow-up.

Six months into the study, we introduced a self-report

measure of youth offenses, and thus, data are only available

for a subset of the sample (N = 45). These reports indicate

that 42 % of the teens were charged with assault or battery,

33 % with theft, 9 % with trespassing or vandalism, 7 %

with sale or possession of drugs, 7 % with an armed

offense or gun possession, and 7 % with probation viola-

tion. Youth were able to report more than one offense.

These rates are comparable to those for youth on probation

nationally (Puzzanchera et al. 2012). Specifically, in 2009,

youth on probation were arrested for person-related crimes

(i.e., assault and battery) (26 %), property-related crimes

(i.e. theft, trespassing) (36 %), drugs (13 %), and public

order offenses (e.g., gun possession) (25 %) (Puzzanchera

et al. 2012).

Procedure

Participants were recruited from Chicago Cook County’s

ERC, a community-based probation service that is an

alternative to detention following arrest. Minors from all

city calendars can be ordered by the court to participate in

the ERC from 5 to 28 days in lieu of Juvenile Temporary

Detention Center placement, but no specific criteria exist to

determine who will be given this judicial order. Many of

the minors assigned to the ERC have been charged in

violation of a pre-existing probation and awaiting hearing

or disposition or on a warrant and presented to the court for

disposition of the warrant. No formal data exist on youth

remanded to the ERC, but teens have a range of offenses

(M. Spooner, Operations Analyst, personal Communica-

tion, March 5, 2014). The ERC offer single-sex, on-site,

after school supervision and programming for up to

28 days while teens await sentencing. The ERC are sub-

contracted to an external agency whose stated goals are to

help youth (1) remain arrest-free, (2) minimize risk-taking

and delinquent behaviors during and beyond ERC partici-

pation, (3) reduce recidivism and the likelihood of re-

arrest, and (4) ensure that teens attend their scheduled court

appearance. Unlike detention, youth attending the ERC

typically live at home, and transportation to and from the

ERC is provided by the Department of Juvenile Probation

and Court Services.

Research staff presented the project to all youth present

at the ERC as a group, and interested teens provided

parental contact information to obtain consent. Written

assent and parental consent was obtained for all partici-

pants. Youths completed a 2-h baseline interview and

3-month follow up assessment for which they were com-

pensated $50, but they were not paid to participate in the

intervention. The 8-session intervention was delivered at

the ERC over 2 weeks by trained co-facilitators with a

background in HIV prevention, group therapy, and ado-

lescents. All study procedures were approved by the Uni-

versity of Illinois at Chicago’s Institutional Review Board,

with special attention to vulnerable populations.

Measures

Risky Sexual Behavior and Drug and Alcohol Use

The AIDS-risk behavior assessment (ARBA) (Donenberg

et al. 2001) assesses teens’ self-reported sexual behavior

and drug and alcohol use via audio-computer assisted self-

interview (ACASI) to increase anonymity and privacy.

Self-reported sexual behavior closely approximates actual

behavior (Harrison 1995), especially when questions are

administered using computer technology (Romer et al.

1997) as in the present study. The ARBA has been used

extensively with ethnically diverse low-income youth in

psychiatric care (Brown et al. 2010; Donenberg et al. 2003;

Starr et al. 2012). Youth reported on their baseline and

3-month follow up sexual behavior and substance use. Data

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analyses evaluated the following outcomes in the past

3 months (i.e., since baseline): (1) any vaginal/anal sex

(yes/no), (2) any unprotected vaginal/anal sex (yes/no), (3)

sex while using drugs and/or alcohol (yes/no), (4) any

alcohol use (yes/no), (5) any marijuana use (yes/no), (6)

number of days using alcohol, and (7) number of times

using marijuana.

HIV Counseling and Testing

At baseline, participants indicated whether they had been

tested and sought counseling for HIV in the previous

6 months, and at follow-up, they reported whether they

were tested and sought counseling for HIV in the previous

3 months.

Substance Use Attitudes and Beliefs

Context influences youth’s substance use (DiClemente

et al. 1994), and thus, the adapted Alcohol Abstinence Self-

Efficacy Scale (AASE) (Upchurch et al. 1999) assessed

how tempted (1 = not at all tempted to 5 = extremely

tempted) teens would be to drink or to use drugs generally

and in a given situation (i.e., during negative affect, social

interactions, withdrawal, and physical/other concerns).

Sample items include: ‘‘How tempted would you be to use

drugs or alcohol when you are feeling angry inside?’’ and

‘‘How tempted would you be to use drugs or alcohol when

you see others drinking or using drugs at a party?’’ Items

also assessed teens’ confidence (1 = not at all confident to

5 = extremely confident) that they would not drink or use

Assessed for eligibility (n=89) Ineligible (n=15)

¨ Detained (n=7) ¨ Out date too soon (n=3) ¨ Guardian didn’t speak English (n=2) ¨ Did not return signed consent in time (n=2) ¨ Cognitive disability (n=1)

Consented/Assented (n=64)

Recruited (n=74)

Administered Baseline (n=61) ¨ Completed (n=60) ¨ Partial completion (n=1)

Withdrawn by ERC staff ¨ Behavioral problems (n=3)

Not eligible for follow-up (n=7) Withdrew/Withdrawn during intervention (n=2) ¨ Youth withdrew (n=1) ¨ Withdrawn by ERC staff (n=1)

Did not attend intervention (n=5) ¨ Withdrawn by ERC staff (n=4) ¨ Detained (n=1)

Eligible for follow-up and completed at least one intervention session

(n=54)

Completed follow-up assessment (n=54)

Declined (n=10) ¨ Adolescent refusal (n=9) ¨ Parent refusal (n=1)

Fig. 1 Participant flow into PHAT Life

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drugs in that situation (e.g., ‘‘How sure are you that you

would not drink or use drugs when you are feeling angry

inside?’’ and ‘‘How sure are you that you would not drink

or use drugs when you see others drinking or using drugs at

a party?’’). Overall self-efficacy to abstain and temptation

scores were analyzed, in addition to the four subscales

related to each (negative affect, social situations, physical

or other concerns, withdrawal and urges). Each subscale

included five items, and scores ranged from 5 to 25. The

overall self-efficacy and temptation scores had a potential

range of 20–100. Internal reliability was strong for temp-

tation (a = 0.91) and for self-efficacy (a = 0.96), where higher scores indicated greater temptation to drink or use

drugs and self-efficacy to abstain. The AASE has been used

widely with teens (Owen et al. 2003; Schinke et al. 2009).

Internal reliability ranged from a = 0.70 to a = 0.93 for the subscale scores.

HIV Knowledge, Attitudes, and Behavioral Skills

HIV Knowledge Teens indicated true or false on 35 items

about HIV transmission and prevention (Donenberg et al.

2005). The scaled score indicated number correct and had

moderate internal consistency (a = 0.65). Sample items are ‘‘Keeping in good physical condition is the best way to

prevent getting the AIDS virus,’’ and ‘‘Having sex without a

condom increases a person’s risk of getting the AIDS virus.’’

HIV Attitudes Three scales evaluated teens’ general attitudes

and motivation to prevent HIV transmission (Donenberg

et al. 2005; Mustanski et al. 2006), and one examined peer

support for risky behavior. Four-items surveyed general

attitudes toward peers with HIV/AIDS (e.g., ‘‘I would be

willing to go to class with a kid who has AIDS’’). Responses

were rated on a scale from 1 = strongly agree to

4 = strongly disagree, and lower scores reflected more

positive attitudes (a = 0.89). Six-items assessed peer norms regarding HIV/AIDS prevention (e.g., ‘‘Friends that I respect

think I should use condoms every time, if I have sex’’) on a

scale from 1 = very untrue to 5 = very true (a = 0.75). High scores indicated strong peer support for HIV/AIDS

prevention. Three-items evaluated intentionsto prevent HIV/

AIDS (e.g., ‘‘If I have sex in the next 2 months, I’m planning

to use condoms every time.’’). Responses were ranked from

1 = very untrue to 5 = very true, and higher scores indi-

cated very likely to engage in HIV prevention (a = 0.74). Youth also answered six questions from the widely used

school-based Health Questionnaire (Jessor and Jessor 1977)

assessing peer approval of sexual behavior, and alcohol,

marijuana and cigarette use (a = 0.80). Item responses were rated on a 1–4 scale, with high scores indicating most

friends use drugs, approve of drug use, and have had sex

(Donenberg et al. 2001, 2003). Sample peer approval items

are: ‘‘How many of your friends drink alcohol fairly

regularly,’’ and ‘‘Think of all your friends who are the same

sex as you. How many of them have had sexual intercourse

(‘‘gone all the way’’) with someone of the opposite sex.’’

Youth also indicated their intentions to have vaginal, anal, or

oral sex in the next 6 months (yes/no) and if yes, their

intentions to always use a condom in the next 6 months

(‘‘How often do you think you will use condoms when you

have vaginal, anal, or oral sex’’; always/less than always).

HIV Behavioral Skills Two scales examined youth behav-

ioral skills: (a) Twelve items measured youths’ self-efficacy

to prevent HIV transmission (e.g., ‘‘If you decide to have

sexual intercourse with your partner, how sure are you that

you could talk to your partner about safer sex’’) on a scale

from 1 = very sure to 4 = couldn’t do it, with high scores

indicating lower self-efficacy for HIV prevention

(a = 0.86). (b) Thirteen items assessed condom use self- efficacy (e.g., ‘‘How sure are you that you could use a con-

dom when your partner doesn’t want to use one,’’ and ‘‘How

sure are you that you could use a condom when you have

been using alcohol or drugs’’) on a scale from 1 = definitely

could to 4 = definitely could not. High scores indicated less

self-efficacy for condom use (a = 0.92). These measures of HIV knowledge, attitudes and behavioral skills have been

widely used with adolescents (Mustanski et al. 2006;

Donenberg et al. 2005).

Affect Regulation

Teens completed the 20-item Toronto Alexithymia Scale

(TAS), a widely used measure of emotion regulation

(Parker et al. 2003). Responses range from strongly dis-

agree = 1 to strongly agree = 5. Sample items include ‘‘I

am often confused about what emotions I am feeling’’ and

‘‘I find it hard to describe how I feel about people.’’ A total

score was used in the analyses, with higher scores reflect-

ing more difficulty regulating affect. Internal consistency

was strong (a = 0.83).

Partner Sexual Communication

Teens indicated whether they talked to a partner(s) in the

past 6 months (baseline) or past 3 months (follow-up) about

using condoms (‘‘Did you talk to a partner about using

condoms during vaginal, anal, or oral sex’’; yes/no) and

HIV/AIDS/STI (‘‘Did you talk to a partner about HIV/AIDS

or STIs’’; yes/no). Items were adapted from the Sexual Risk

Behavior Questionnaire (El-Bassel et al. 1995) and a sexual

communication measure by Miller et al. (1998).

Mental Health Symptoms

Teens self-reported their mental health symptoms on the

Youth Self-Report (YSR; Achenbach 1991), a widely-used

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measure of adolescent behavioral and emotional problems

with extensive evidence of reliability and validity

(Achenbach et al. 1987). Normed for children age

11–18 years, the YSR generates raw and T-scores for

internalizing (e.g., depression, anxiety) and externalizing

(e.g., rule breaking and aggressive behavior) syndromes.

Sample items include ‘‘I cry a lot’’ for internalizing and ‘‘I

break rules at home, school or elsewhere’’ for

externalizing.

Intervention

Intervention Development

PHAT Life was adapted from three empirically-supported

interventions for high-risk youth: Rikers Health Advocacy

Program (Magura et al. 1994), Street Smart (Rotheram-

Borus et al. 2003), and Project STYLE (Donenberg et al.

2012). Guided by a combination of social learning theory

(Bandura 1986) and a Social-Personal Framework

(Donenberg and Pao 2005), PHAT Life was designed to

target broad psychosocial factors implicated in HIV-risk

behavior, including knowledge, attitudes, and beliefs about

HIV/AIDS and substance use, emotion regulation, peer

influence, and partner relationships.

Program development and modifications followed sev-

eral steps with careful attention to cultural context and

input from youth and adult advisory boards. First, we

conducted four focus groups with young offenders (three

male and one female) to identify important themes related

to sexual risk taking, and these data informed the first set of

curriculum revisions. We selected and adapted materials

for relevance to African American and Latino youth,

including videos, pictures, and role-plays, as they represent

the majority of young offenders on probation in Cook

County. Second, we pilot tested the intervention with one

group of males (N = 8) and one group of females (N = 6),

and we solicited feedback about program content, process,

and logistics. Youth feedback was discussed with the

advisory board and suggestions guided a second set of

curriculum modifications. Revisions were relatively minor;

no new content or constructs were added and no content or

constructs were eliminated. The majority of revisions

consisted of adjusting the amount of time allocated to

activities, reordering the sequence of activities within a

given session, and additional instructions for facilitators.

For several of the sessions, revisions involved replacing

activities (e.g., games focusing on understanding and

controlling affect) with new activities designed to foster the

same knowledge and skills. With the exception of one

session (i.e., the first session), the goals and objectives of

each session remained the same from the first and second

pilot. We enrolled 40 young probationers in a second pilot

test of the intervention. Teens from both pilot tests

(N = 54) completed the 3-month follow up assessment and

were included in the current study.

PHAT Life Description

PHAT Life is an interactive, comprehensive sex education

program that also addresses mental health and substance

use. Delivered in a group-format, PHAT Life employs role-

plays, videos, games, and skill development activities (e.g.,

assertive communication) to facilitate information uptake.

The group format is an effective strategy to challenge

negative peer norms and provide social support when dis-

cussing sensitive topics (Burleson et al. 2006). PHAT Life

targets theoretical factors associated with sexual and

alcohol/drug risk behavior. It promotes positive attitudes

toward HIV prevention, self-efficacy to reduce risk, emo-

tion regulation, optimism about the future, and less sub-

stance use and sexual risk taking. Youth identify and

anticipate risk-related triggers and develop plans to address

the people, places, situations, and moods that prompt risk

taking. Teens use a feeling thermometer to evaluate the

impact of their ‘‘hot’’ and ‘‘cold’’ feelings on their deci-

sions and risk behavior, and they learn strategies to manage

their feelings more effectively. Condom demonstrations

and practice reinforce and encourage condom use in real

life settings, and the impact of drugs and alcohol on

accurate condom use is illustrated. Videos with ethnically

matched and representative youth were carefully selected

for cultural relevance, and healthy versus unhealthy rela-

tionships are discussed. Ample practice is provided for

effective communication with peers and partners to avoid

risk and increase prevention behavior (e.g., condom use,

drug refusal). Importantly, recognizing the transience of

youth in the juvenile justice system and the possibility that

teens may not attend the full program (e.g., differing pro-

bation lengths, sentencing from probation to detention),

each PHAT Life session was designed stand alone,

whereby attendance at prior sessions was not required to

understand or benefit from the current session. Specifically,

each session began with the same two tasks (i.e., inside/

outside check-in and learning goal), a review of group

expectations, and an invitation to post questions on the

‘‘parking lot’’ poster for later discussion. Next, each session

targeted unique theoretical issues related to HIV-risk.

Facilitator Training

Individuals with a background in psychology and previous

experience working with youth co-facilitated each group.

Group facilitators received over 30 h of training in group

dynamics, delivering manualized interventions, basic HIV/

STI knowledge, and intervention content. Facilitators

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participated in multiple practice sessions, alternating

between leading the session and being a participant. Each

facilitator conducted all of the sessions following a detailed

manual, received extensive feedback, and was deemed

fully trained by the first author. Sessions were observed by

a third trained facilitator and rated for fidelity to the

manual. Facilitators were male and female for the boys’

groups. However, due to high rates of previous sexual

trauma exposure among probation girls (Wilson et al.

2013), only female facilitators were used for the girls’

groups. An independent observer rated facilitators on

fidelity to the curriculum. Across all sessions mean ratings

indicated 95 % fidelity.

Data Analyses

Analyses were conducted using Stata version 11.2. Chan-

ges from baseline to 3-month follow-up were tested with

regression analyses using generalized estimating equations

for linear, negative binomial, and logistic models. For

linear and negative binomial regression models, robust

standard errors were estimated. Age was included as a

covariate in all models. For each dependent variable, we

tested gender by time interactions; interaction effects with

p \ 0.20 were retained and gender-specific time effects were computed using the-lincom-post-estimation proce-

dure. Given the small sample size, effect sizes were cal-

culated to determine the magnitude of change. Odds ratios

represent the effect size for dichotomous outcomes, and for

continuous outcomes, we calculated Cohen’s d (1988) from

the marginal means obtained after estimating linear

regressions.

Results

Consistent with previous research, criminally involved

youth reported high rates of sexual risk taking, alcohol and

marijuana use, and mental health problems at baseline. The

majority of males (75 %, n = 24) and half of females

(n = 11) endorsed lifetime sexual activity. Among sexu-

ally active youth, 31 % (n = 11) did not use a condom at

last sex, and 37 % (n = 13) reported alcohol and/or mar-

ijuana use at last sex. Rates of alcohol and marijuana use

were over 60 % and self-reported mental health symptoms

were similarly high with 43 % revealing clinically signif-

icant levels of aggression and rule breaking.

Eighty-nine percent of youth (n = 48) completed at

least four sessions, and 13 % (n = 7) received all eight

sessions; the average number of sessions completed was

5.53 (SD = 1.72). At the end of each session, boys and

girls rated ‘‘How much fun did you have today?’’ and

‘‘How much did you learn today?’’ on a scale from 0 = No

Fun/Nothing learned to 10 = A lot of fun/A lot learned.

The average session rating for ‘‘fun’’ and ‘‘amount

learned’’ was high for girls (M = 8.49, SD = 1.04;

M = 9.27, SD = 0.46) and boys (M = 7.27, SD = 1.62;

M = 8.54; SD = 0.99), suggesting all youth enjoyed the

intervention and learned quite a bit.

The results of analyses on sexual behavior, substance

use, and HIV counseling and testing are shown in Table 1.

Overall, there were no statistically significant changes in

sexual behavior and no significant time by gender inter-

actions. However, among sexually active youth (n = 33),

the likelihood of reporting unprotected sex decreased by

49 % (OR 0.51, 95 % CI 0.18–1.44, p = 0.20), and the

likelihood of having sex while drinking or using drugs

decreased by 65 % (OR 0.35, 95 % CI 0.10–1.29,

p = 0.11). These effect sizes are generally larger than

previous reports of sexual behavior change following an

HIV prevention program for juvenile offenders (Tolou-

Shams et al. 2010). Alcohol use in the past 3 months sig-

nificantly decreased from baseline to follow-up by 59 %

(OR 0.41, 95 % CI 0.20–0.835, p = 0.014). Changes in the

number of days using alcohol varied by gender (OR 3.22,

p = 0.16). Days using alcohol decreased significantly for

girls from 2.6 days (range 0–25) to 0.4 days (range 0–5),

an 83 % decrease, whereas boys’ alcohol use increased by

42 %, from 1.7 days (range 0–10) to 2.4 days (range

0–19). There were no significant changes in marijuana use

and no significant time by gender interaction.

Table 1 Changes in sexual behavior, substance use, and HIV coun- seling and testing at 3-month follow-up (N = 54)

OR SE 95 % CI z p

Any recent vaginal or

anal sex

0.93 0.24 0.56 1.54 -0.30 0.765

Any recent unprotected

sex

0.59 0.24 0.26 1.33 -1.28 0.200

Any recent sex while

drinking/drugs

0.59 0.29 0.23 1.55 -1.07 0.287

Sought HIV counseling

last 6/3 months

3.67 1.49 1.66 8.11 3.21 0.001

Tested for HIV last 6/3 months �

Female 1.00 0.57 0.33 3.06 0.00 1.000

Male 2.99 1.14 1.42 6.31 2.88 0.004

IRR SE 95 % CI z p

Days used alcohol

past 3 months a�

Female 0.17 0.12 0.04 0.72 -2.41 0.016

Male 1.42 0.63 0.60 3.41 0.79 0.427

Days used marijuana

past 3 months a

0.78 0.25 0.42 1.45 -0.78 0.433

� Gender 9 time interaction, p \ 0.20

a Negative binomial regression

1678 J Child Fam Stud (2015) 24:1672–1684

123

Participants were over three times more likely to have

sought HIV counseling at 3-month follow-up (p = 0.001);

19 % of participants (n = 10) sought HIV counseling in

the 6 months prior to baseline, and 44 % (n = 24) sought

HIV counseling in the 3-months after baseline. Changes in

HIV testing varied by gender (OR 2.99, p = 0.11). HIV

testing increased among males only (p = 0.004); 19 %

(n = 6) of boys reported being tested for HIV in the pre-

vious 6 months at baseline, compared to 41 % (n = 13)

who reported an HIV test in the previous 3 months at

follow-up. Among girls, 36 % (n = 8) reported being tes-

ted for HIV at both time points.

Changes in self-efficacy to abstain and temptation to use

alcohol and drugs are shown in Table 2. Ratings of temp-

tation to use drugs or alcohol declined overall (d = 0.36),

and specifically for situations involving negative affect

(d = 0.38), and for social situations (d = 0.29). However,

there were no significant changes in ratings of self-efficacy

to abstain from using drugs or alcohol and no significant

time by gender interactions; effect sizes ranged from

d = 0.11 to d = 0.16. Changes in HIV knowledge, atti-

tudes, and behavioral skills are shown in Table 3. HIV

knowledge increased significantly (d = 0.40). In contrast,

of the four measures of prevention motivation, only two

showed statistically significant improvement. General HIV

attitudes improved among both girls (d = 1.30) and boys

(d = 0.48), although more so among girls (B = 2.25,

p = 0.04). There was no time by gender interaction for

general HIV attitudes. Peer norms supporting prevention

improved among boys (d = 0.51), but declined slightly

among girls (d = 0.33) (interaction, B = -0.69,

p = 0.15). Behavioral intentions (d = 0.04) and peer

approval of sexual behavior and substance use (d = 0.06)

did not change nor did youth intentions to have sex (OR

1.68, 95 % CI 0.86–3.30) or intentions to always use a

condom among youth who intended to have sex (n = 44;

OR 1.29, 95 % CI 0.59–2.83). There were no time by

gender interactions for these variables. Although there

were no statistically significant changes in self-rated

behavioral skills, HIV prevention self-efficacy improved

(d = 0.30) overall. The gender by time interaction was not

statistically significant (B = -3.66, p = 0.12), but

improvement in HIV prevention self-efficacy was evident

among boys (d = 0.54), while girls’ scores did not change.

Total Toronto Alexithymia Scale scores measuring affect

regulation were stable over time, with a mean of 47.1

(SE = 1.53) at baseline and 46.3 (SE = 1.61) at follow-up.

There was no significant gender difference. There was also

no statistically significant change in partner communica-

tion or differences in change by gender. However, partic-

ipants were 84 % more likely to have talked to a sex

partner about using condoms (OR 1.84, 95 % CI

0.92–3.71), and 75 % more likely to have talked about

HIV/AIDS or STI (OR 1.75, 95 % CI 0.80–3.86) at follow-

up compared to baseline.

Youth attended an average of 5.53 sessions

(SD = 1.72). Those who attended five or more sessions

showed an average increase of 2.6 points on HIV knowl-

edge (p \ 0.001) at 3-month follow-up. The dose effects on HIV knowledge remained after adjusting for baseline

differences in behavioral intentions, behavioral skills, and

prevention attitudes among youth who attended more ver-

sus fewer sessions. No dose effects were found on any

other outcomes.

Table 2 Changes in self-efficacy to abstain, and temptation to use alcohol and drugs

Pretest Posttest Coef. Semi-robust

SE

95 % CI z p N

Marginal mean

(SE)

Marginal mean

(SE)

Self-efficacy to abstain from using 75.29 (3.66) 72.21 (4.09) -3.07 4.99 -12.84 6.70 -0.62 0.538 47

Self-efficacy to abstain, negative affect 18.20 (0.93) 17.54 (1.05) -0.67 1.35 -3.32 1.99 -0.49 0.622 54

Self-efficacy to abstain, social situations 16.72 (1.00) 17.57 (1.13) 0.85 1.44 -1.92 3.73 0.63 0.531 49

Self-efficacy to abstain, withdrawal and

urges

20.35 (1.01) 19.12 (1.14) -1.23 1.42 -4.00 1.55 -0.87 0.387 48

Self-efficacy to abstain, physical or other

concerns

20.98 (0.81) 19.94 (1.03) -1.04 1.15 -3.29 1.22 -0.90 0.367 54

Temptation to use drugs or alcohol 38.26 (2.55) 32.37 (2.13) -5.90 2.69 -11.17 -0.63 -2.19 0.028 49

Temptation to use, negative affect 10.98 (0.93) 8.76 (0.65) -2.22 1.08 -4.33 -0.12 -2.07 0.039 54

Temptation to use, social situations 11.02 (0.79) 9.45 (0.66) -1.57 0.79 -3.11 -0.03 -2.00 0.046 51

Temptation to use, withdrawal and urges 8.03 (0.61) 7.65 (0.54) -0.38 0.72 -1.79 1.03 -0.53 0.595 49

Temptation to use, physical or other

concerns

7.22 (0.55) 6.89 (0.58) -0.33 0.70 -1.70 1.03 -0.48 0.632 54

J Child Fam Stud (2015) 24:1672–1684 1679

123

Discussion

This study presents preliminary outcome data from a small

pilot study testing an innovative and uniquely tailored HIV/

AIDS, substance use, and mental health prevention pro-

gram (PHAT Life) for juvenile offenders on probation.

Following a carefully staged process of development,

PHAT Life was delivered to 54 recently arrested males and

females remanded to a community-based detention alter-

native. Even with the small sample size and varied expo-

sure to sessions, all 54 youth were retained at the three-

month follow-up. Results revealed significant improvement

in theoretically important mechanisms linked to risk

behavior, less alcohol use, and more HIV testing and

counseling. Compared to baseline, teens reported more

HIV knowledge, more positive attitudes and beliefs toward

HIV prevention and people with HIV, less temptation to

use drugs and alcohol, and less alcohol use. Consistent with

recommendations by Durlak (2009), study effect sizes

suggest moderate change in sexual behavior [see Tolou-

Shams et al. (2010) for a review of HIV prevention pro-

gram effect sizes for juvenile offenders] from baseline,

suggesting preliminary efficacy of the intervention.

This pilot study advances HIV prevention research in

important ways. Few programs target young offenders, in

part because they are difficult to engage in formal inter-

ventions and health services. In this research, the majority

of youth attended at least four sessions and reported having

fun and learning a lot. It is possible that careful attention to

curriculum development, including cultural relevance,

ethnically matched videos, and extensive vetting among

young offenders, contributed to its high acceptability.

Moreover, follow-up retention at 3-months was excellent

for the youth who participated in the intervention (100 %),

and this may reflect their positive experience in the pro-

gram. PHAT Life was designed with the knowledge that

youth exposure to sessions would vary (i.e., each session

was able to stand alone), and thus, we explored the dose–

response relationship with theoretical mediators and

behavioral outcomes. Findings indicated that receiving

more sessions was linked to increased knowledge of HIV

but no other outcome or mediator. Unfortunately, the

sample size was too small to determine the key number of

sessions related to the largest improvement, an important

direction for future research.

Effect sizes revealed moderate reductions in risky sexual

behavior and substance use. Among sexually active youth,

for example, the likelihood of reporting unprotected sex at

follow up decreased by 49 %, and the likelihood of having

sex while drinking or using drugs decreased by 65 %. In a

summary of previous HIV prevention research with young

offenders, Tolou-Shams et al. (2010) reported an average

effect size of d = 0.23 for pre/post research designs. In this

context, the observed changes in sexual risk are promising

(Durlak 2009). Consistent with previous research (Gold-

berg et al. 2009; Needels et al. 2005), PHAT Life had a

positive impact on alcohol use, especially for girls who

reported less alcohol use in general, and fewer days using

alcohol over the past 3 months. It is possible that programs

that target the range of comorbid problems for young

Table 3 Changes in HIV knowledge, attitudes, and behavioral skills (N = 54)

Pretest Posttest Coef. Robust SE 95 % CI z p

Mean (SE) Mean (SE)

Information

HIV knowledge 18.30 (0.50) 20.04 (0.68) 1.74 0.60 0.56 2.92 2.89 0.004

Motivation

General HIV attitudes �

Female 11.15 (0.77) 6.74 (0.71) -4.41 0.76 -5.91 -2.91 -5.77 0.000

Male 10.80 (0.79) 8.64 (0.82) -2.16 0.79 -3.70 -0.61 -2.74 0.006

Peer norms for HIV/AIDS prevention �

Female 23.97 (0.78) 22.60 (0.99) -1.36 0.72 -2.78 0.05 -1.89 0.059

Male 19.43 (0.98) 22.37 (1.09) 2.94 1.33 0.33 5.55 2.21 0.027

Intentions to prevent HIV/AIDS 11.39 (0.41) 11.26 (0.39) -0.13 0.49 -1.08 0.82 -0.27 0.790

Peer approval of risk behavior 3.19 (0.19) 3.28 (0.24) 0.09 0.24 -0.38 0.57 0.38 0.701

Behavioral skills

HIV prevention self-efficacy �

Female 17.64 (1.11) 17.86 (1.60) 0.23 2.00 -3.70 4.15 0.11 0.91

Male 19.66 (1.30) 16.22 (0.96) -3.44 1.19 -5.77 -1.10 -2.88 0.004

Condom use self-efficacy 1.39 (0.08) 1.32 (0.07) -0.07 0.08 -0.23 0.09 -0.86 0.388

� Gender 9 time interaction, p \ 0.20

1680 J Child Fam Stud (2015) 24:1672–1684

123

offenders may lead to better short-term outcomes. Longer

follow-up time periods will be essential to determine the

maintenance of positive outcomes.

It is particularly noteworthy that youth reported signif-

icantly increased HIV testing and counseling at follow up.

Recent data showing that individuals with an undetectable

viral load are unlikely to transmit HIV (Cohen et al. 2011)

have led to a growing emphasis on testing, counseling, and

treatment as prevention (Smith et al. 2011). To our

knowledge, this study is among the first to suggest a

positive impact of an intervention on criminally involved

youths’ HIV testing behaviors.

Like other HIV prevention programs, PHAT Life dem-

onstrated strong positive effects on theoretical mediators of

risk at 3-month follow up (Bryan et al. 2009; Tolou-Shams

et al. 2010), but with 100 % retention among youth who

participated in the program, these findings support

increased relevance to probation youth. Boys and girls

improved their HIV knowledge and reported more positive

attitudes toward HIV, including greater acceptance of

people with AIDS, and for males, more positive peer norms

for prevention. These findings are consistent with previous

data on detained youth (Bryan et al. 2009), and extend the

research to probation youth, criminally involved girls, and

a sample with strong retention.

Findings also revealed improvements in attitudes toward

substance use at follow up, namely less temptation to use

drugs and alcohol, less temptation to use drugs or alcohol

when experiencing negative affect, and less temptation to

use drugs and alcohol during social situations. Reductions

in the temptation to use drugs and alcohol under ‘‘tempt-

ing’’ conditions provide new directions to interrupt the link

between sexual risk and substance use. Moreover, these

findings support evidence that comprehensive interventions

for criminally involved youth that target multiple negative

health behaviors simultaneously may change key substance

use attitudes. The small sample size prohibits testing

pathways of risk, an important consideration in future

research.

In contrast to previous research (Rosengard et al. 2007;

St. Lawrence et al. 1999), findings yielded no change in

teens’ affect regulation. Still, youth were 84 % more likely

to have talked to a sex partner about using condoms, and

75 % more likely to have talked about HIV/AIDS or STI at

follow up. The change in partner communication, a well-

known mediator of reduced risk (Widman et al. 2006), may

lead to less risk taking over time. Longitudinal studies are

needed to test this hypothesis.

It is important to consider gender differences in the

effects of PHAT Life on risk behaviors and theoretical

mediators (Wingood and DiClemente 2000). Specifically,

the number of days girls used alcohol decreased by 83 %

from baseline to 3-month follow-up, while boys reported

an increase in alcohol use by 42 %. Similarly, PHAT Life

was associated with a 22 % increase in HIV testing among

boys, but no change among girls. The mechanisms

responsible for these differences are not clear. However, it

is possible that girls (more than boys) recognized their

unique increased vulnerability associated with alcohol use

(e.g., rape), and this influenced their behavior. Likewise,

there may be barriers to HIV testing for girls that do not

exist for boys (Amaro and Raj 2000; Wingood and Di-

Clemente 1998, 2000). For example, relationship power

differentials may interfere with girls seeking testing if their

male partners are not in favor of it (Pulerwitz et al. 2002).

Further research is needed to fully understand the factors

driving gender differences in this population.

This pilot study reflects a number of methodological

advances over previous research. PHAT Life was based on

strong theoretical principles and three promising interven-

tions. Curriculum development occurred following a

carefully staged process with input from young proba-

tioners and diverse stakeholders, and simultaneously

addressed three comorbid concerns (i.e., mental health,

substance use, and risky sexual behavior) rather than a

single problem. This study, albeit a small pilot, achieved

100 % retention among youth who participated in the

intervention enhancing confidence in the representativeness

of the findings. We targeted teens on probation in contrast

to the vast majority of research on incarcerated and

detained youth. While there are similar risk profiles across

the two populations (Donenberg et al., unpublished man-

uscript), the former have more opportunities to engage in

risk behavior following arrest and therefore, may more

accurately reflect program impact.

Nevertheless, important study limitations exist. We did

not include a control group to compare effects against the

natural history following arrest. Although, extensive evi-

dence documents poor long-term trajectories for criminally

involved youth without intervention (Abram et al. 2009;

Schmiege et al. 2009), the lack of a control group limits our

ability to determine how much of the changes observed in

this study can be attributed to PHAT Life specifically or

other factors associated with participation in an interven-

tion (e.g., time or attention). Future work should include a

control group to distinguish these effects. As a group-based

program, there is the possibility of iatrogenic effects

(Dishion et al. 1999). We chose a group-format to chal-

lenge negative peer norms, a well-known mediator of

adolescent risk behavior. PHAT Life’s structure and ma-

nualized approach diminished opportunities for iatrogenic

influences. The study focused solely on youth, even though

families can play a critical role in reducing risk among

young offenders (Udell et al. 2011) and help sustain short-

term effects of HIV prevention programs (Donenberg et al.

2006). Findings are based on youth self-reports and these

J Child Fam Stud (2015) 24:1672–1684 1681

123

may be subject to biases such as social desirability. How-

ever, follow up assessments were conducted by individuals

who did not lead the intervention, and data were collected

via audio-computer assisted technology decreasing the

likelihood of embarrassment in answering sensitive ques-

tions. Finally, eight potential participants (12.5 %) were

withdrawn from the study due to behavioral problems

associated with the ERC prior to PHAT Life implementa-

tion. It is possible that these youth represent a unique

subgroup whose outcomes are not represented here.

Despite these limitations, the preliminary data are prom-

ising, particularly for a population sorely neglected and

difficult to engage.

This study points to several directions for future

research. Understanding the full effects of PHAT Life on

risk behavior and HIV testing and counseling will depend

on larger samples, comparison to a control group, and

mediation and moderation analyses to identify change

mechanisms (Schmiege et al. 2011). Future research should

also consider the role of technology in HIV prevention for

young offenders given its omnipresence among youth.

Lightfoot et al. (2007) evaluated a computerized interven-

tion versus a group-based program for incarcerated youth

and found greater reductions in sexual activity and number

of partners for youth in the computer condition. It will be

important to understand how computerized interventions

impact the full range of HIV-risk and mental health, par-

ticularly over time. This study underscores the utility of

intervening with youth awaiting sentencing; probation is a

‘‘teachable moment’’ when they are faced with the crisis of

potential jail time or other serious consequences (Schmiege

et al. 2009; Tolou-Shams et al. 2010). Finally, the growing

number of girls in juvenile justice (Cauffman 2008) com-

bined with higher rates of STI (Belenko et al. 2008; Dembo

et al. 2009) and poorer long-term outcomes for young

female offenders (Cauffman 2008), make gender-based

interventions a public health priority. The negative trajec-

tories of juvenile offenders (Abram et al. 2009) have pro-

found costs to society and lasting effects on community

well-being and neighborhood health (Piquero and Brame

2008). This study provides preliminary evidence that PHAT

Life, a targeted program that addresses comorbid health

issues (e.g., substance use, risky sex, mental health prob-

lems), may alter important theoretical mediators of health

behavior and may influence negative health outcomes.

Acknowledgments This research was supported by a grant from the National Institute of Mental Health (R34MH075628). We thank all

collaborating institutions in the conduct of this study (Cook County

Juvenile Probation’s Detention Alternative Division, Cook County

Circuit Court, Cook County Juvenile Justices, and the Cook County

Chief Public Defender). We also thank the youth and families for

their participation.

References

Abram, K. M., Choe, J. Y., Washburn, J. J., Romero, E. G., & Teplin,

L. A. (2009). Functional impairment in youth three years after

detention. Journal of Adolescent Health, 44, 528–535.

Achenbach, T. M. (1991) Integrative guide for the 1991 CBCL/4-18,

YSR and TRF profiles. Burlington, VT: University of Vermont,

Department of Psychiatry.

Achenbach, T. M., McConaughy, S. H., & Howell, C. T. (1987).

Child/adolescent behavioral and emotional problems: Implica-

tions of cross-informant correlations for situational specificity.

Psychological Bulletin, 101, 213–232.

Amaro, H., & Raj, A. (2000). On the margin: Power and women’s

HIV risk reduction strategies. Sex Roles, 42, 723–749.

Bandura, A. (1986). Social foundations of thought and action. Upper

Saddle River, NJ: Prentice Hall.

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

Hanlon, A., et al. (2008). Recently arrested adolescents are at

high risk for sexually transmitted diseases. Sexually Transmitted

Diseases, 35(8), 758–763. doi:10.1097/Olq.0b013e31816d1f94.

Brown, L. K., Hadley, W., Stewart, A., Lescano, C., Whitely, L.,

Donenberg, G., et al. (2010). Psychiatric disorders and sexual

risk among adolescents in mental health treatment. Journal of

Consulting and Clinical Psychology, 78, 590–597.

Brown, L. K., Houck, C., Lescano, C., Donenberg, G., Tolou-Shams,

M., & Mello, J. (2012). Affect regulation and HIV risk among

youth in therapeutic schools. AIDS and Behavior, 16(8),

2272–2278. doi:10.1007/s10461-012-0220-3.

Bryan, A., Ray, L., & Cooper, M. L. (2007). Alcohol use and

protective sexual behaviors among high-risk adolescents. Jour-

nal of Studies on Alcohol and Drugs, 68, 327–335.

Bryan, A., Schmiege, S. J., & Broaddus, M. R. (2009). HIV risk

reduction among detained adolescents: A randomized, controlled

trial. Pediatrics, 124(6), e1180–e1188. doi:10.1542/peds.2009-

0679.

Burleson, J. A., Kaminer, Y., & Dennis, M. L. (2006). Absence of

iatrogenic or contagion effects in adolescent group therapy:

Findings from the Cannabis Youth Treatment (CYT) study.

American Journal on Addiction, 15(Suppl 1), 4–15. doi:10.1080/

10550490601003656.

Carney, J. S., Werth, J. L., & Morris, R. L. (1997). AIDS-related

knowledge and beliefs among incarcerated adolescent males.

Criminal Justice and Behavior, 24(1), 96–113. doi:10.1177/

0093854897024001006.

Caspi, A., Begg, D., Dickson, N., Harrington, H., Langley, J., Moffitt,

T. E., et al. (1997). Personality differences predict health-risk

behaviors in young adulthood: Evidence from a longitudinal

study. Journal of Personality and Social Psychology, 73(5),

1052–1063.

Cauffman, E. (2008). Understanding the female offender. The Future

of Children, 18(2), 119–142.

Centers for Disease Control and Prevention. (2010). The role of STD

detection and treatment in HIV prevention—CDC fact sheet.

http://www.cdc.gov/std/hiv/stdfact-std-hiv.htm.

Cohen, J. (1988). Statistical power analysis for the behavioral

sciences (2nd ed.). Hillsdale, NJ: Erlbaum.

Cohen, M. S., Chen, Y. Q., McCauley, M., Gamble, T., Hosseinipour,

M. C., Kumarasamy, N., et al. (2011). Prevention of HIV-1

infection with early antiretroviral therapy. New England Journal

of Medicine, 365(6), 493–505. doi:10.1056/NEJMoa1105243.

Crosby, R., Salazar, L. F., & DiClemente, R. J. (2004). Lack of recent

condom use among detained adolescent males: A multilevel

investigation. Sexually Transmitted Infections, 80(6), 425–429.

Dembo, R., Belenko, S., Childs, K., Wareham, J., & Schmeidler, J.

(2009). Individual and community risk factors and sexually

1682 J Child Fam Stud (2015) 24:1672–1684

123

transmitted diseases among arrested youths: A two level

analysis. Journal of Behavioral Medicine, 32(4), 303–316.

DiClemente, C. C., Carbonari, J. P., Montgomery, R. P. G., &

Hughes, S. O. (1994). The alcohol abstinence self-efficacy scale.

Journal of Studies on Alcohol, 55, 141–148.

Dishion, T. J., McCord, J., & Poulin, F. (1999). When interventions

harm: Peer groups and problem behavior. American Psycholo-

gist, 54(9), 755–764. doi:10.1037//0003-066x.54.9.755.

Donenberg, G. R., Brown, L. K., Hadley, W., Kapungu, C., &

Lescano, C. (2012). Family-based HIV-Prevention Program for

adolescents with psychiatric disorders. In W. Pequegnat & C.

Bell (Eds.), Families and HIV/AIDS: Culture and contextual

issues in prevention and treatment. New York: Springer.

Donenberg, G. R., Bryant, F. B., Emerson, E., Wilson, H. W., &

Pasch, K. E. (2003). Tracing the roots of early sexual debut

among adolescents in psychiatric care. Journal of the American

Academy of Child and Adolescent Psychiatry, 42(5), 594–608.

doi:10.1097/01.Chi.0000046833.09750.91.

Donenberg, G. R., Emerson, E., Bryant, F. B., Wilson, H., & Weber-

Shifrin, E. (2001). Understanding AIDS-risk behavior among

adolescents in psychiatric care: Links to psychopathology and

peer relationships. Journal of the American Academy of Child

and Adolescent Psychiatry, 40(6), 642–653. doi:10.1097/

00004583-200106000-00008.

Donenberg, G. R., Emerson, E., Mackesy-Amiti, M., Udell, W., &

Floyd, B. Gender differences in HIV-risk mechanisms among

juvenile offenders on probation. Unpublished manuscript.

Donenberg, G. R., Paikoff, R., & Pequegnat, W. (2006). Introduction

to the special issue on families and HIV: First generation

prevention programs. Journal of Pediatric Psychology, 41,

869–873.

Donenberg, G. R., & Pao, M. (2005). Youths and HIV/AIDS:

Psychiatry’s role in a changing epidemic. Journal of the

American Academy of Child and Adolescent Psychiatry, 44(8),

728–747. doi:10.1097/01.chi.0000166381.68392.02.

Donenberg, G. R., Schwartz, R. M., Emerson, E., Wilson, H. W.,

Bryant, F. B., & Coleman, G. (2005). Applying a cognitive-

behavioral model of HIV risk to youths in psychiatric care. AIDS

Education and Prevention, 17(3), 200–216. doi:10.1521/aeap.17.

4.200.66532.

Durlak, J. A. (2009). How to select, calculate, and interpret effect

sizes. Journal of Pediatric Psychology, 34(9), 917–928. doi:10.

1093/jpepsy/jsp004.

El-Bassel, N., Ivanoff, A., Schilling, R. F., Gilbert, L., Bourne, D., &

Chen, D. (1995). Preventing HIV/AIDS in drug-abusing incar-

cerated women through skills-building and social support

enhancement: Preliminary outcomes. Social Work Research,

19(3), 131–141.

Fazel, S., Doll, H., & Langstrom, N. (2008). Mental disorders among

adolescents in juvenile detention and correctional facilities: A

systematic review and metaregression analysis of 25 surveys.

Journal of the American Academy of Child and Adolescent

Psychiatry, 47(9), 1010–1019. doi:10.1097/CHI.

ObO13e31817eecf3.

Goldberg, E., Millson, P., Rivers, S., Manning, S. J., Leslie, K., Read,

S., et al. (2009). A human immunodeficiency virus risk reduction

intervention for incarcerated youth: A randomized controlled

trial. Journal of Adolescent Health, 44(2), 136–145. doi:10.1016/

j.jadohealth.2008.07.021.

Harrison, L. D. (1995). The validity of self-reported data on drug use.

Journal of Drug Issues, 25, 91–111.

Hollingshead, A. B. (1975). Four factor index of social status.

Unpublished manuscript, Yale University, New Haven, CT.

Hurd, N. M., Valerio, M. A., Garcia, N. M., & Scott, A. A. (2010).

Adapting an HIV prevention intervention for high-risk,

incarcerated adolescents. Health Education and Behavior, 37(1), 37–50. doi:10.1177/1090198109335655.

Jessor, R., & Jessor, S. L. (1977). Problem behavior and psychosocial

development: A longitudinal study of youth. New York:

Academic.

Kasen, S., Vaughan, R. D., & Walter, H. J. (1992). Self-efficacy for

AIDS preventive behaviors among tenth grade students. Health

Education Quarterly, 19(2), 187–202.

Katz, R. C., Mills, K., Singh, N. N., & Best, A. M. (1995). Knowledge

and attitudes about aids: A comparison of public high-school-

students, incarcerated delinquents, and emotionally-disturbed

adolescents. Journal of Youth and Adolescence, 24(1), 117–131.

doi:10.1007/Bf01537563.

Leeming, D., Hanley, M., & Lyttle, S. (2002). Young people’s images

of cigarettes, alcohol and drugs. Drugs: Education, Prevention

and Policy, 9(2), 169–185.

Lescano, C., Brown, L., Miller, P., & Puster, K. (2007). Unsafe sex:

Do feelings matter? Journal of Prevention and Intervention in

the Community, 33, 51–62.

Lightfoot, M., Comulada, W. S., & Stover, G. (2007). Computerized

HIV preventive intervention for adolescents: Indications of

efficacy. American Journal of Public Health, 97(6), 1027–1030.

doi:10.2105/AJPH.2005.072652.

Magura, S., Kang, S. Y., & Shapiro, J. L. (1994). Outcomes of

intensive AIDS education for male adolescent drug users in jail.

Journal of Adolescent Health, 15(6), 457–463.

Miller, K. S., Levin, M. L., Whitaker, D. J., & Xu, X. H. (1998).

Patterns of condom use among adolescents: The impact of

mother-adolescent communication. American Journal of Public

Health, 88(10), 1542–1544. doi:10.2105/Ajph.88.10.1542.

Mouttapa, M., Watson, D. W., McCuller, W. J., Reiber, C., Tsai, W.,

& Plug, M. (2010). HIV prevention among incarcerated male

adolescents in an alternative school setting. Journal of Correc-

tional Health Care, 16(1), 27–38. doi:10.1177/

1078345809348202.

Mustanski, B., Donenberg, G., & Emerson, E. (2006). I can use a

condom, I just don’t: The importance of motivation to prevent

HIV in adolescents seeking psychiatric care. AIDS and Behavior,

10(6), 753–762.

Nader, P. R., Wexler, D. B., Patterson, T. L., Mckusick, L., & Coates, T.

(1989). Comparison of beliefs about aids among urban, suburban,

incarcerated, and gay adolescents. Journal of Adolescent Health,

10(5), 413–418. doi:10.1016/0197-0070(89)90221-0.

Needels, K., James-Burdumy, S., & Burghardt, J. (2005). Community

case management for former jail inmates: Its impacts on rearrest,

drug use, and HIV risk. Journal of Urban Health, 82, 420–433.

Otto-Salaj, L. L., Gore-Felton, C., McGarvey, E., & Canterbury, R. J.

(2002). Psychiatric functioning and substance use: Factors

associated with HIV risk among incarcerated adolescents. Child

Psychiatry and Human Development, 33(2), 91–106.

Owen, P. L., Slaymaker, V., Tonigan, J. S., McCrady, B. S., Epstein,

E. E., Kaskutas, L. A., et al. (2003). Participation in alcoholics

anonymous: Intended and unintended change mechanisms.

Alcoholism, Clinical and Experimental Research, 27, 524–532.

Parker, J. D. A., Taylor, G. J., & Bagby, R. M. (2003). The 20-item

Toronto alexithymia scale III. Reliability and factorial validity in

a community population. Journal of Psychosomatic Research,

55(3), 269–275.

Piquero, A. R., & Brame, R. W. (2008). Assessing the race-crime and

ethnicity-crime relationship in a sample of serious adolescent

delinquents. Crime and Delinquency, 54(3), 390–422. doi:10.

1177/0011128707307219.

Pulerwitz, J., Amaro, H., De Jong, W., Gortmaker, S. L., & Rudd, R.

(2002). Relationship power, condom use and HIV risk among

women in the USA. AIDS Care, 14, 789–800.

J Child Fam Stud (2015) 24:1672–1684 1683

123

Puzzanchera, C., Adams, B., & Hockenberry, S. (2012). Juvenile

court statistics 2009. Pittsburgh, PA: National Center for

Juvenile Justice.

Rickman, R. L., Lodico, M., Diclemente, R. J., Morris, R., Baker, C.,

& Huscroft, S. (1994). Sexual communication is associated with

condom use by sexually active incarcerated adolescents. Journal

of Adolescent Health, 15(5), 383–388. doi:10.1016/1054-

139x(94)90261-5.

Robertson, A. A., St Lawrence, J., Morse, D. T., Baird-Thomas, C.,

Liew, H., & Gresham, K. (2011). The Healthy Teen Girls

project: Comparison of health education and STD risk reduction

intervention for incarcerated adolescent females. Health Educa-

tion and Behavior, 38(3), 241–250. doi:10.1177/

1090198110372332.

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.

Romer, D., Hornik, R., Stanton, B., Black, M., Li, X. M., Ricardo, I.,

et al. (1997). ‘‘Talking’’ computers: A reliable and private

method to conduct interviews on sensitive topics with children.

Journal of Sex Research, 34(1), 3–9.

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

C., & Lebeau-Craven, R. (2007). Randomized clinical trial of

motivational enhancement of substance use treatment among

incarcerated adolescents: Post-release condom non-use. Journal

of HIV/AIDS Prevention in Children and Youth, 8, 45–64.

Rotheram-Borus, M. J., Song, J., Gwadz, M., Lee, M., Van Rossem,

R., & Koopman, C. (2003). Reductions in HIV risk among

runaway youth. Prevention Science, 4(3), 173–187.

Schinke, S. P., Cole, K., & Fang, L. (2009). Gender-specific

intervention to reduce underage drinking among early adolescent

girls: A test of a computer-mediated, mother–daughter program.

Journal of Studies on Alcohol and Drugs, 70(1), 70–77.

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(1), 38–50.

doi:10.1037/A0014513.

Schmiege, S. J., Feldstein Ewing, S. W., Hendershot, C. S., & Bryan,

A. D. (2011). Positive outlook as a moderator of the effective-

ness of an HIV/STI intervention with adolescents in detention.

Health Education Research, 26(3), 432–442. doi:10.1093/her/

cyq060.

Smith, K., Powers, K. A., Kashuba, A. D. M., & Cohen, M. S. (2011).

HIV-1 treatment as prevention: The good, the bad, and the

challenges. Current Opinion in HIV and AIDS, 6(4), 315–325.

doi:10.1097/Coh.0b013e32834788e7.

Snyder, H. N., & Sickmund, M. (2006). Juvenile offenders, victims:

2006 national report. Washington, DC: U.S. Department of

Justice, Office of Juvenile Justice Programs, Office of Juvenile

Justice and Delinquency Prevention.

St. Lawrence, J. S., Crosby, R. A., Belcher, L., Yazdani, N., &

Brasfield, T. L. (1999). Sexual risk reduction and anger

management interventions for incarcerated male adolescents: A

randomized controlled trial of two interventions. Journal of Sex

Education and Therapy, 24(1–2), 9–17.

Stahl, A., Finnegan, T., & Kang, W. (2006). Easy access to juvenile

court statistics: 1985–2003. http://ojjdp.ncjrs.gov/ojstatbb/

ezajcs.

Starr, L., Donenberg, G., & Emerson, E. (2012). Bidirectional

linkages between psychological symptoms and sexual activities

among African American adolescent girls in psychiatric care.

Journal of Clinical Child and Adolescent Psychology, 41,

811–821.

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

Mericle, A. A. (2002). Psychiatric disorders in youth in juvenile

detention. Archives of General Psychiatry, 59(12), 1133–1143.

Teplin, L. A., Elkington, K. S., McClelland, G. M., Abram, K. M.,

Mericle, A. A., & Washburn, J. J. (2005). Major mental

disorders, substance use disorders, comorbidity, and HIV-AIDS

risk behaviors in juvenile detainees. Psychiatric Services, 56(7),

823–828. doi:10.1176/appi.ps.56.7.823. Teplin, L. A., Mericle, A. A., McClelland, G. M., & Abram, K. M.

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

Implications for public health policy. American Journal of

Public Health, 93(6), 906–912.

Tolou-Shams, M., Houck, C., Conrad, S. M., Tarantino, N., Stein, L.

A., & Brown, L. K. (2011). HIV prevention for juvenile drug

court offenders: A randomized controlled trial focusing on affect

management. Journal of Correctional Health Care, 17(3),

226–232. doi:10.1177/1078345811401357.

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

review of HIV prevention interventions for juvenile offenders.

Journal of Pediatric Psychology, 35(3), 250–261. doi:10.1093/

jpepsy/jsp069.

Udell, W., Donenberg, G., & Emerson, E. (2011). Parents matter in

HIV-risk among probation youth. Journal of Family Psychology,

25(5), 785–789. doi:10.1037/A0024987.

Upchurch, D., Aneshensel, C., Sucoff, C., & Levy-Storms, L. (1999).

Neighborhood and family contexts of adolescent sexual activity.

Journal of Marriage and the Family, 61, 920–933.

US Department of Justice. (2010). Crime in the United States, 2009.

Retrieved April 17, 2013, from U.S. Department of Justice http://

www2.fbi.gov/ucr/cius2009/data/table_43.html.

Vermeiren, R., Jespers, I., & Moffitt, T. (2006). Mental health

problems in juvenile justice populations. Child Adolescent

Psychiatric Clinics of North America, 15(2), 333–351.

Widman, L., Welsh, D. P., McNulty, J. K., & Little, K. C. (2006).

Sexual communication and contraceptive use in adolescent

dating couples. Journal of Adolescent Health, 39(6), 893–899.

doi:10.1016/j.jadohealth.2006.06.003.

Wilson, H. W., Berent, E., Donenberg, G. R., Emerson, E. M.,

Rodriguez, E. M., & Sandesara, A. (2013). Trauma history and

PTSD symptoms in juvenile offenders on probation. Victims and

Offenders, 8. doi:10.1080/15564886.2013.835296.

Wingood, G., & DiClemente, R. (1998). Partner influences and

gender-related factors associated with noncomdom use among

young adult African American women. American Journal of

Community Psychology, 26, 29–51.

Wingood, G., & DiClemente, R. (2000). Application of the theory of

gender and power to examine HIV-related exposures, risk

factors, and effective interventions for women. Health Education

and Behavior, 27, 539–565.

1684 J Child Fam Stud (2015) 24:1672–1684

123

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