Treatment attrition among racial /ethnic minority adolescents participating in a brief motivational intervention for substance use problems: The influence of individual, social, cultural, and treatment factors

The present study has the primary aim of examining the predictors of treatment attrition among racial/ethnic minority adolescents with substance use problems. This study explores the potential differential influence of specific individual, social, cultural, and treatment factors on treatment attrition within three racial/ethnic subgroups of adolescents. Participants: A unique feature of the study is the use of a racial/ethnic minority sample (N=453), [U.S.-born Hispanics (n = 262), Foreign-born Hispanics (n = 117), and African-Americans (n = 74)]. Multivariate logit analyses were used to examine the influence of specific factors on treatment attrition among the full sample of adolescents, as well as within each racial/ethnic subgroup. Consistent with expectations, multivariate logit analyses reveal that, the specific factors associated with attrition varied across the three racial/ethnic subgroups. Having parents with problem substance use, being on the waitlist, and being court mandated to treatment emerged as predictors of attrition among the US-born Hispanics, while only Conduct Disorder was significantly associated with greater attrition among foreign-born Hispanics. Finally, among African-Americans, parental crack/cocaine use, parental abstinence from alcohol, and being on the waitlist were predictive of attrition. Multiple factors were associated with treatment attrition among racial/ethnic minority adolescents with specific factors differentially predicting attrition within each racial/ethnic subgroup. African-American youth were more than twice as likely as their Hispanic counterparts to leave treatment prematurely. It is critically important to understand the predictors of attrition among racial/ethnic minority youth in order to better meet the needs of youth most at risk of dropping out. ^

Treatment attrition among racial/ethnic minority adolescents participating in a brief motivational intervention for substance use problems : the influence of individual, social, cultural, and treatment factors

The present study has the primary aim of examining the predictors of treatment attrition among racial/ethnic minority adolescents with substance use problems. This study explores the potential differential influence of specific individual, social, cultural, and treatment factors on treatment attrition within three racial/ethnic subgroups of adolescents. Participants: A unique feature of the study is the use of a racial/ethnic minority sample (N=453), [U.S.-born Hispanics (n = 262), Foreign-born Hispanics (n = 117), and African- Americans (n = 74)]. Multivariate logit analyses were used to examine the influence of specific factors on treatment attrition among the full sample of adolescents, as well as within each racial/ethnic subgroup. Consistent with expectations, multivariate logit analyses reveal that, the specific factors associated with attrition varied across the three racial/ethnic subgroups. Having parents with problem substance use, being on the waitlist, and being court mandated to treatment emerged as predictors of attrition among the US-born Hispanics, while only Conduct Disorder was significantly associated with greater attrition among foreign-born Hispanics. Finally, among African-Americans, parental crack/cocaine use, parental abstinence from alcohol, and being on the waitlist were predictive of attrition. Multiple factors were associated with treatment attrition among racial/ethnic minority adolescents with specific factors differentially predicting attrition within each racial/ethnic subgroup. African-American youth were more than twice as likely as their Hispanic counterparts to leave treatment prematurely. It is critically important to understand the predictors of attrition among racial/ethnic minority youth in order to better meet the needs of youth most at risk of dropping out.

The use of treatment process variables to differentiate between completers and dropouts for a guided self -change adolescent substance abuse intervention

This study documented differences between substance using adolescent participants who either completed or dropped out of a brief motivational intervention. Therapeutic alliance, working alliance and patient involvement were used to describe differences in treatment process ratings in a sample of majority Latino males who either (a) completed a adolescent substance abuse intervention called Alcohol Treatment Targeting Adolescents In Need (ATTAIN) or (b) dropped out after the first or second Guided Self-Change therapy session. Fifteen-minute segments were copied from the midpoint of previously recorded audio-tapes of Guided Self-Change therapy sessions. Raters were trained to a criterion level of interrater reliability for both the Working Alliance Inventory-Short and Vanderbilt Psychotherapy Process Scale. Correlations among Working Alliance Inventory- Short and Vanderbilt Psychotherapy Process Scale subscales reflected a general similarity in the assignment of ratings to client-therapist dyads. Findings underscore why these concepts are often used interchangeably in the treatment process literature. The Vanderbilt Psychotherapy Process Scale patient participation subscale demonstrated substantial empirical differentiation from overall therapeutic alliance. Discriminant function analysis demonstrated the Working Alliance Inventory-Short goal subscale and the Vanderbilt Psychotherapy Process Scale patient participation and therapist warmth and friendliness subscales as successful classifiers of groups of mostly Latino youth based on completion status. Follow-up logistic regression analyses confirmed major findings and successfully predicted group membership. Treatment process constructs can be used as clinical tools to identify participants who may be susceptible to dropping out of treatment services. Further investigation of treatment process may enhance understanding of the influence of alliance between clients and Guided Self-Change therapists. Investigating the role of treatment process as a critical component of brief motivational interventions for substance-using adolescents will inform both practitioners and researchers regarding the effectiveness of community-based substance abuse interventions for adolescents.

Alcohol use and sexual victimization among Hispanic college women

Sexual victimization of young women typically occurs within a context of alcohol use, such that women are more likely to be victimized on days on which they consume alcohol compared to days on which no alcohol is consumed. Additionally, most research on sexual victimization of women has focused on forced sexual acts; consequently, little is known about forms sexual victimization that college women typically experience, such as brief (e.g., unwanted touching) or verbally coerced experiences (e.g., doing sexual things to prevent a partner from leaving). Finally, there is a need for more research on the processes underlying college women's drinking and the specific mechanisms through which drinking increases risk for sexual victimization. This dissertation sought to replicate recent findings of a temporal association between alcohol use and sexual victimization, and to investigate whether or not binge use increased risk for victimization, within a sample of young Hispanic college women, using repeated-measures logistic regression. This study also aimed to identify and explore typologies of victimization experiences in order to better understand types of sexual victimization common among young college women. Finally, the validity of a model of alcohol use and sexual victimization was investigated using structural equation modeling techniques. The results confirmed and extended previous research by demonstrating an increase in the conditional probability of sexual victimization on days of alcohol consumption compared with days of no alcohol consumption, and on days of binge alcohol consumption compared with days of moderate alcohol consumption. Sexual victimization experiences reported in this study were diverse, and cluster analysis was used to identify and explore specific typologies of victimization experiences, including intimate relationship victimization, brief victimization with stranger, prolonged victimization with acquaintance, and workplace victimization. The results from structural equation modeling (SEM) analyses were complex and helped to illuminate the relationships between reasons for drinking, alcohol use, childhood sexual abuse, sexual victimization, psychopathology, and acculturation-related factors among Hispanic college women. These findings have implications for the design of university-based prevention and intervention efforts aimed at reducing rates of alcohol-related sexual victimization within Hispanic populations.

The Influence of Psychological Predictors and Cognitive Behavioral Stress Management Intervention on Antiretroviral Therapy (ART) Adherence Among HIV-Positive Female Haitian Alcohol Users

Purpose: Over half the HIV-infected persons in the Caribbean, the second most HIV-impacted region in the world, live in Haiti. Using secondary data from a parent study, this research assessed the effects of psychological and social factors on antiretroviral therapy (ART) adherence among Haitian, HIV-positive, female alcohol users. Theoretical Foundation and Research Questions: Using the Theory of Planned Behavior/Reasoned Action and the Information, Motivation, Behavior skills model as guiding theoretical frameworks, the study examined the effectiveness of an adapted cognitive behavioral stress management (CBSM-A) intervention in improving ART adherence. The effect of psychological factors (depression, anxiety, beliefs about medicine, and social support), social factors (stigma, relationship status, and educational attainment), and alcohol on adherence to ART was assessed. Methods: The sample consisted of 116 female ART patients who were randomly assigned to the CBSM-A intervention or the wait-list control group. Participants completed intervention sessions as well as pre- and post-test assessments. Analyses of variance, t-tests, and point biserial correlations were used to test hypotheses. Results: Surprisingly, ART adherence rates significantly decreased for both groups combined [F (1, 108) = 8.79, p = .004]; there was no significant difference between the intervention and control groups with regard to the magnitude of change between baseline and post assessment. On average, depression decreased significantly among participants in the CBSM-A group only [(t (62) = 5.54, p < .001)]. For both groups combined, alcohol use significantly decreased between baseline and post-assessment [(F (1, 78) = 34.70, p < .001)]; there was no significant difference between the intervention and control groups with regard to the magnitude of change between baseline and post-assessment. None of the variables were significantly correlated with ART adherence. Discussion: Adherence to ART did not improve in this sample, nor were any of the variables significantly associated with adherence. The findings suggest that additional supportive and psychological services may be needed in order to promote higher adherence to ART among HIV-positive females. More research may be needed on this sample; a focus on mental health issues, partner conflict, family and sexual history may allow for better targeting and more successful interventions.

Longitudinal effects of family factors on alcohol use and alcohol-related problems among males from pre-adolescence to adulthood

The goal of this study was to examine the longitudinal effects of five family factors on alcohol use among adolescent males. The family factors included familism (family pride, loyalty, and cohesion), parent derogation (being put down by parents), parent/child communication, family alcohol problems and family drug problems. The study focused on the effects of the family factors reported by a sample of 451 White-non-Hispanic and African American males during early and mid-adolescence on (1) the intensity of alcohol use in mid-adolescence, and (2) the number of problems associated with alcohol use during the transition to young adulthood. The study also explored racial differences in the effects of the family factors. The data for this study were derived from a two-phase longitudinal epidemiologic cohort study of male and female adolescents enrolled in middle schools in Miami, FL. Data were collected at four points between 1990 and 2001. Linear and logistical regressions were used to analyze the effects of the family variables on the dependent variables. ^ The results of the analyses indicated that all of the family variables except family drug problems were statistically significant predictors of the level of alcohol use and alcohol-related problems. Familism had a moderate influence on both of the dependent variables at all data points, while parent derogation, parent/child communication and family alcohol problems were weak predictors. While the family factors varied by race, their impact on the dependent variables did not vary substantially. ^ This study had methodological shortcomings related to measurement and design that may have contributed to the weak influence of the variables. Future studies should explore possible mediating effects of these variables, and should employ more sensitive measures that are culturally appropriate. The results suggest that, since early family factors have long-term effects on children's substance-using behaviors, the family environment should be addressed in prevention and intervention efforts. ^

Evaluation of a mentored self -help intervention for the management of psychotic symptoms

Cognitive behavioral therapy has been shown to be promising for the treatment of individuals experiencing psychotic symptoms, who are often diagnosed with schizophrenia. Using a non-random non-equivalent comparison group design (n = 26), this study explores whether an individually mentored self-help and self-paced intervention based upon cognitive behavioral approaches to auditory hallucinations or "hearing voices" makes a significant positive difference for individuals with major mental disorder diagnoses and psychotic symptoms who are residing in the community and receiving community mental health services. The mentored self-help intervention uses a workbook (Coleman & Smith, 1997) that stemmed from the British psychiatric survivor and "voice hearers"' movements and from cognitive behavioral approaches to treating psychotic symptoms. Thirty individuals entered the study. Pre- and post-intervention assessments of 15 participants in the intervention group and 11 participants in the comparison group were carried out using standardized instruments, including the Rosenberg Self-Esteem Scale, the Brief Psychiatric Rating Scale, and the Hoosier Assurance Plan Inventory - Adult. Four specific research questions address whether levels of self-esteem, overall psychotic symptoms, depression-anxiety, and disruption in life improved in the intervention group, relative to the comparison group. Pre- and post-assessment scores were analyzed using repeated measures analysis of variance. Results showed no significant difference on any measure, with the exception of the Brief Psychiatric Rating subscale for Anxious Depression, which showed a statistically significant pre-post difference with a strong effect size. A conservative interpretation of this single positive result is that it is due to chance. An alternative interpretation is that the mentored self-help intervention made an actual improvement in the level of depression-anxiety experienced by participants. If so, this is particularly important given high levels of depression and suicide among individuals diagnosed with schizophrenia. This alternative interpretation supports further research on the intervention utilized in this study. ^

An investigation of the relationship between maltreatment and alcohol and other drug (AOD) problems in African -American and Hispanic adolescent girls

Maltreatment experienced in childhood or adolescence is a known risk factor for later problem alcohol and/or other drug (AOD) use (Bailey & McCloskey, 2005; Shin, Edwards, Heeren, 2009). A growing body of empirical work has found significant associations between adolescent girls’ AOD use and maltreatment experiences. However, questions remain as to how this relation unfolds with African-American and Hispanic adolescent girls. Guided by four relational models that have been proposed in the literature, this study examined the links between maltreatment, trauma symptoms, and alcohol and/or other drug (AOD) problems in a sample of 170 African-American and Hispanic adolescent girls who were participants in a school-based AOD use intervention. Results of this study revealed that maltreatment experiences (physical and emotional abuse) were positively related to trauma symptoms, which were positively related to AOD problem severity, alcohol abuse, alcohol dependency, drug abuse, and drug dependency. Perceived discrimination moderated this relation between sexual abuse and trauma symptoms, such that more perceived discrimination resulted in a stronger effect of sexual abuse on trauma symptoms. Ethnic identity moderated the relation between sexual abuse and AOD problem severity, such that ethnic identity demonstrated protective properties in the relation between sexual abuse and AOD problem severity. My research adds to extant knowledge on the relation between maltreatment and AOD use in adolescent girls and suggests the importance of developing interventions targeting maltreatment and AOD use concurrently.

The influence of neurocognitive impairment, alcohol and other drug (AOD) use, and psychosocial factors on antiretroviral treatment adherence, service utilization and viral load among HIV-seropositive adults

Among people living with HIV (PLWH), adherence to antiretroviral therapy (ART) can be affected by problems of neurocognitive (NC) impairment, stress, alcohol and other drug (AOD) abuse, and other barriers. The aims of this research were to: (1) examine factors associated with NC impairment, (2) explore relationships between psychosocial variables with ART adherence and viral load (VL), and (3) evaluate the efficacy of an evidence-based intervention in improving ART adherence, increasing service utilization, and decreasing VL. The first study (n=370) was cross sectional and used structural equation modeling to test whether AOD use, years living with HIV, and time from HIV diagnosis to seeking care were associated with poorer NC functioning. The second study (n=246) used similar methods to test the hypothesis that stress, barriers to adherence, NC impairment, poor social support, and AOD use were related to lower VL mediated by ART adherence. The third study (n=243) evaluated an evidence-based, eight-session program to improve ART adherence, reduce VL, and increase service utilization in a randomized controlled trial. Study participants were PLWH living in South Florida, 18 to 60 years old, with a history of alcohol abuse enrolled from January 2009 through November 2012. Secondary analysis of available data showed: (1) scores on interference with executive functioning increased by 0.32 for each day of marijuana use and 1.18 for each year living with HIV, but no association was found between alcohol use and NC functioning; (2) each barrier to adherence was associated with a 10% decrease in adherence to ART and a 0.42 unit increase in VL (log10) and the relationship between barriers and VL was partially mediated by ART adherence; (3) participants in the evidence-based program were more likely than the comparison group to report an undetectable VL (OR=2.25, p<0.01) at 6 months, but not 3 months, post-intervention. Psychosocial factors affect VL, but ART adherence is essential in achieving an undetectable VL in PLWH.

Statistical dialog management for health interventions

Research endeavors on spoken dialogue systems in the 1990s and 2000s have led to the deployment of commercial spoken dialogue systems (SDS) in microdomains such as customer service automation, reservation/booking and question answering systems. Recent research in SDS has been focused on the development of applications in different domains (e.g. virtual counseling, personal coaches, social companions) which requires more sophistication than the previous generation of commercial SDS. The focus of this research project is the delivery of behavior change interventions based on the brief intervention counseling style via spoken dialogue systems. ^ Brief interventions (BI) are evidence-based, short, well structured, one-on-one counseling sessions. Many challenges are involved in delivering BIs to people in need, such as finding the time to administer them in busy doctors' offices, obtaining the extra training that helps staff become comfortable providing these interventions, and managing the cost of delivering the interventions. Fortunately, recent developments in spoken dialogue systems make the development of systems that can deliver brief interventions possible. ^ The overall objective of this research is to develop a data-driven, adaptable dialogue system for brief interventions for problematic drinking behavior, based on reinforcement learning methods. The implications of this research project includes, but are not limited to, assessing the feasibility of delivering structured brief health interventions with a data-driven spoken dialogue system. Furthermore, while the experimental system focuses on harmful alcohol drinking as a target behavior in this project, the produced knowledge and experience may also lead to implementation of similarly structured health interventions and assessments other than the alcohol domain (e.g. obesity, drug use, lack of exercise), using statistical machine learning approaches. ^ In addition to designing a dialog system, the semantic and emotional meanings of user utterances have high impact on interaction. To perform domain specific reasoning and recognize concepts in user utterances, a named-entity recognizer and an ontology are designed and evaluated. To understand affective information conveyed through text, lexicons and sentiment analysis module are developed and tested.^

The influence of gene environment interaction on the risk of cognitive impairment: Reducing sexual risk behaviors and alcohol use in HIV-infected adults

Memory deficits and executive dysfunction are highly prevalent among HIV-infected adults. These conditions can affect their quality of life, antiretroviral adherence, and HIV risk behaviors. Several factors have been suggested including the role of genetics in relation to HIV disease progression. This dissertation aimed to determine whether genetic differences in HIV-infected individuals were correlated with impaired memory, cognitive flexibility and executive function and whether cognitive decline moderated alcohol use and sexual transmission risk behaviors among HIV-infected alcohol abusers participating in an NIH-funded clinical trial comparing the efficacy of the adapted Holistic Health Recovery Program (HHRP-A) intervention to a Health Promotion Control (HPC) condition in reducing risk behaviors. ^ A total of 267 individuals were genotyped for polymorphisms in the dopamine and serotonin gene systems. Results yielded significant associations for TPH2, GALM, DRD2 and DRD4 genetic variants with impaired executive function, cognitive flexibility and memory. SNPs TPH2 rs4570625 and DRD2 rs6277 showed a risk association with executive function (odds ratio = 2.5, p = .02; 3.6, p = .001). GALM rs6741892 was associated with impaired memory (odds ratio = 1.9, p = .006). At the six-month follow-up, HHRP-A participants were less likely to report trading sex for food, drugs and money (20.0%) and unprotected insertive or receptive oral (11.6%) or vaginal and/or anal sex (3.2%) than HPC participants (49.4%, p^

Acculturation and Hispanic identity/ethnicity as a predictor of change on the brief situational confidence questionnaire

The purpose of this study was to investigate whether level of acculturation among Hispanic adolescent males (n = 174) influenced treatment outcome in a substance abuse program, specifically on the Brief Situational Confidence Questionnaire (BSCQ) which measures relapse confidence. It was hypothesized that lower levels of acculturation were likely to be predictive of positive change, whereas higher levels of acculturation were likely to be predictive of no change or negative change. It was found that adolescents changed over time in BSCQ scores regardless of which acculturation variable was measured. Contrary to expectations, for those adolescents placed in family treatment, place of birth was not significantly associated with treatment response. However, both, U.S. and non-U.S. born adolescents demonstrated a change over time when receiving family treatment, suggesting that the family substance abuse treatment utilized in this intervention effected change over time.

The Influence of Gene Environment Interaction on the Risk of Cognitive Impairment: Reducing Sexual Risk Behaviors and Alcohol Use in HIV-infected Adults

Memory deficits and executive dysfunction are highly prevalent among HIV-infected adults. These conditions can affect their quality of life, antiretroviral adherence, and HIV risk behaviors. Several factors have been suggested including the role of genetics in relation to HIV disease progression. This dissertation aimed to determine whether genetic differences in HIV-infected individuals were correlated with impaired memory, cognitive flexibility and executive function and whether cognitive decline moderated alcohol use and sexual transmission risk behaviors among HIV-infected alcohol abusers participating in an NIH-funded clinical trial comparing the efficacy of the adapted Holistic Health Recovery Program (HHRP-A) intervention to a Health Promotion Control (HPC) condition in reducing risk behaviors. A total of 267 individuals were genotyped for polymorphisms in the dopamine and serotonin gene systems. Results yielded significant associations for TPH2, GALM, DRD2 and DRD4 genetic variants with impaired executive function, cognitive flexibility and memory. SNPs TPH2 rs4570625 and DRD2 rs6277 showed a risk association with executive function (odds ratio = 2.5, p = .02; 3.6, p = .001). GALM rs6741892 was associated with impaired memory (odds ratio = 1.9, p = .006). At the six-month follow-up, HHRP-A participants were less likely to report trading sex for food, drugs and money (20.0%) and unprotected insertive or receptive oral (11.6%) or vaginal and/or anal sex (3.2%) than HPC participants (49.4%, p

Statistical Dialog Management for Health Interventions

Research endeavors on spoken dialogue systems in the 1990s and 2000s have led to the deployment of commercial spoken dialogue systems (SDS) in microdomains such as customer service automation, reservation/booking and question answering systems. Recent research in SDS has been focused on the development of applications in different domains (e.g. virtual counseling, personal coaches, social companions) which requires more sophistication than the previous generation of commercial SDS. The focus of this research project is the delivery of behavior change interventions based on the brief intervention counseling style via spoken dialogue systems. Brief interventions (BI) are evidence-based, short, well structured, one-on-one counseling sessions. Many challenges are involved in delivering BIs to people in need, such as finding the time to administer them in busy doctors' offices, obtaining the extra training that helps staff become comfortable providing these interventions, and managing the cost of delivering the interventions. Fortunately, recent developments in spoken dialogue systems make the development of systems that can deliver brief interventions possible. The overall objective of this research is to develop a data-driven, adaptable dialogue system for brief interventions for problematic drinking behavior, based on reinforcement learning methods. The implications of this research project includes, but are not limited to, assessing the feasibility of delivering structured brief health interventions with a data-driven spoken dialogue system. Furthermore, while the experimental system focuses on harmful alcohol drinking as a target behavior in this project, the produced knowledge and experience may also lead to implementation of similarly structured health interventions and assessments other than the alcohol domain (e.g. obesity, drug use, lack of exercise), using statistical machine learning approaches. In addition to designing a dialog system, the semantic and emotional meanings of user utterances have high impact on interaction. To perform domain specific reasoning and recognize concepts in user utterances, a named-entity recognizer and an ontology are designed and evaluated. To understand affective information conveyed through text, lexicons and sentiment analysis module are developed and tested.

An Investigation of the Relationship Between Maltreatment and Alcohol and Other Drug (AOD) Use Among African-American and Hispanic Adolescent Girls

Maltreatment experienced in childhood or adolescence is a known risk factor for later problem alcohol and/or other drug (AOD) use (Bailey & McCloskey, 2005; Shin, Edwards, Heeren, 2009). A growing body of empirical work has found significant associations between adolescent girls’ AOD use and maltreatment experiences. However, questions remain as to how this relation unfolds with African-American and Hispanic adolescent girls. Guided by four relational models that have been proposed in the literature, this study examined the links between maltreatment, trauma symptoms, and alcohol and/or other drug (AOD) problems in a sample of 170 African-American and Hispanic adolescent girls who were participants in a school-based AOD use intervention. Results of this study revealed that maltreatment experiences (physical and emotional abuse) were positively related to trauma symptoms, which were positively related to AOD problem severity, alcohol abuse, alcohol dependency, drug abuse, and drug dependency. Perceived discrimination moderated this relation between sexual abuse and trauma symptoms, such that more perceived discrimination resulted in a stronger effect of sexual abuse on trauma symptoms. Ethnic identity moderated the relation between sexual abuse and AOD problem severity, such that ethnic identity demonstrated protective properties in the relation between sexual abuse and AOD problem severity. My research adds to extant knowledge on the relation between maltreatment and AOD use in adolescent girls and suggests the importance of developing interventions targeting maltreatment and AOD use concurrently.