Family and group cognitive behavior therapy: Evaluation of treatment outcome and treatment specificity

This dissertation examined the efficacy of family cognitive behavior treatment (FCBT) and group cognitive behavior treatment (GBCT) for reducing anxiety disorders in children and adolescents using several approaches: clinical significant change, equivalence testing, and analyses of variance. It also examined treatment specificity in terms of targeting family/parents (in FCBT) and peers/group (in GCBT) contextual variables using two main approaches: analyses of variance and structural equation modeling (SEM). The sample consisted of 143 children and their parents who presented to the Child Anxiety and Phobia Program housed within the Child and Family Psychosocial Research Center at Florida International University. Diagnostic interviews and questionnaires were administered to assess youth anxiety. Questionnaires were administered to assess child and parent views of family/parents and peers/group contextual variables. In terms of clinical significant change, results indicated that 84.6% of youth in FCBT and 71.2% of youth in GBCT no longer met diagnostic criteria for their primary/targeted anxiety disorder. In addition, results from analyses of variance indicated that FCBT and GCBT were both efficacious in reducing anxiety disorders in youth across both child and parent ratings. Results using both analyses of variance and structural equation modeling also indicated that there was no meaningful treatment specificity between FCBT and GCBT in terms of either family/parents or peers/group contextual variables. That is, child social skills improved in GCBT in which these skills were targeted and in FCBT in which these skills were not targeted; parenting skills improved in FCBT in which these skills were targeted and in GCBT in which these skills were not targeted. Clinical implications and future research recommendations are discussed.

Impact of a cognitive-behavioral weight control program on body weight, diet quality, and smoking cessation in weight-concerned female smokers

Many people use smoking as a weight control mechanism and do not want to quit because they fear weight gain. These weight-concerned smokers tend to be female, are significantly less likely to stop smoking, are less likely to join smoking cessation programs, and will relapse more often than smokers who are not weight-concerned. Research suggests that a woman’s confidence in her ability to control her weight after quitting relates positively with her intention to quit smoking. Likewise, success in smoking cessation has been associated with increased self-efficacy for weight control. It has been shown that success in changing one negative health behavior may trigger success in changing another, causing a synergistic effect. Recently research has focused on interventions for weight-concerned smokers who are ready to quit smoking. The present study investigated the effect of a cognitive based weight control program on self-efficacy for weight control and the effect on smoking behavior for a group of female weight concerned smokers. Two hundred and sixteen subjects who wanted to lose weight but who were not ready to quit smoking were recruited to participate in a 12-week, cognitive-behavioral weight control program consisting of twelve one-hour sessions. Subjects were randomly assigned to either (1) the weight-control program (intervention group), or (2) the control group. Results of this study demonstrated that subjects in the intervention group increased self-efficacy for weight control, which was associated with improved healthy eating index scores, weight loss, increased self-efficacy for quitting smoking, a decrease in number of cigarettes smoked and triggered positive movement in stage of change towards smoking cessation compared to the control subjects. For these subjects, positive changes in self-efficacy for one behavior (weight control) appeared to have a positive effect on their readiness to change another health behavior (smoking cessation). Further study of the psychological variables that influence weight-concerned female smokers’ decisions to initiate changes in these behaviors and their ability to maintain those changes are warranted.

An investigation of multiple pathways of developmental intervention change

Convergence among treatment, prevention, and developmental intervention approaches has led to the recognition of the need for evaluation models and research designs that employ a full range of evaluation information to provide an empirical basis for enhancing the efficiency, efficacy, and effectiveness of prevention and positive development interventions. This study reports an investigation of a positive youth development program using an Outcome Mediation Cascade (OMC) evaluation model, an integrated model for evaluating the empirical intersection between intervention and developmental processes. The Changing Lives Program (CLP) is a community supported positive youth development intervention implemented in a practice setting as a selective/indicated program for multi-ethnic, multi-problem at risk youth in urban alternative high schools. This study used a Relational Data Analysis integration of quantitative and qualitative data analysis strategies, including the use of both fixed and free response measures and a structural equation modeling approach, to construct and evaluate the hypothesized OMC model. Findings indicated that the hypothesized model fit the data (χ2 (7) = 6.991, p = .43; RMSEA = .00; CFI = 1.00; WRMR = .459). Findings also provided preliminary evidence consistent with the hypothesis that in addition to having effects on targeted positive outcomes, PYD interventions are likely to have progressive cascading effects on untargeted problem outcomes that operate through effects on positive outcomes. Furthermore, the general pattern of findings suggested the need to use methods capable of capturing both quantitative and qualitative change in order to increase the likelihood of identifying more complete theory informed empirically supported models of developmental intervention change processes.

Children as Change Agents: The Influence of Integrating Environmental Education into Home Learning Projects on Families and Community Members

Environmental education focusing on sustainability should be integrated into the elementary curriculum. Learning experiences should include home learning projects that are relevant to the students, involve active participation, and stimulate discussions with their families. Students can use their knowledge and skills to influence the attitudes and behavior of their parents and other community members.

Predictors of adolescent sexual intentions and behavior: Attitudes, parenting, and neighborhood risk

The current study was a cross-sectional examination of data collected during an HIV risk reduction intervention in south Florida. The purpose of the study was to explore the relationships between neighborhood stress, parenting, attitudes, and adolescent sexual intentions and behavior. The Theory of Planned Behavior was used as a model to guide variable selection and propose an interaction pathway between predictors and outcomes. Potential predictor variables measured for adolescents ages 13–18 (n=196) included communication about sex, parent-family connectedness, parental presence, parent-adolescent activity participation, attitudes about sex and condom use, neighborhood disorder, and exposure to violence. Outcomes were behavioral intentions and sexual behavior for the previous eight months. Neighborhood data was supplemented with ZIP Code level data from regional sources and included median household income, percentage of minority and Hispanic residents, and number of foreclosures. Statistical tests included t-tests, Pearson's correlations, and hierarchical linear regressions. Results showed that males and older adolescents reported less positive behavioral intentions than females and adolescents younger than 16. Intentions were associated with condom attitudes, sexual attitudes, and parental presence; unprotected sexual behavior was associated with parental presence. The best fit model for intentions included gender, sexual attitudes, condom attitudes, parental presence, and neighborhood disorder. The unsafe sexual behavior model included whether the participant lived with both natural parents in the previous year, and the percent of Hispanic residents in the neighborhood. Study findings indicate that more research on adolescent sexual behavior is warranted, specifically examining the differentials between variables that affect intentions and those that affect behavior. A focus on gender and age differences during intervention development may allow for better targeting and more efficacious interventions. Adding peer and media influences to the framework of attitudes, parenting, and neighborhood may offer more insight into patterns of adolescent sexual behavior risk.

Cognitive competence and life course change in multi-problem adolescents

The dissertation reports on two studies. The purpose of Study I was to develop and evaluate a measure of cognitive competence (the Critical Problem Solving Skills Scale – Qualitative Extension) using Relational Data Analysis (RDA) with a multi-ethnic, adolescent sample. My study builds on previous work that has been conducted to provide evidence for the reliability and validity of the RDA framework in evaluating youth development programs (Kurtines et al., 2008). Inter-coder percent agreement among the TOC and TCC coders for each of the category levels was moderate to high, with a range of .76 to .94. The Fleiss' kappa across all category levels was from substantial agreement to almost perfect agreement, with a range of .72 to .91. The correlation between the TOC and the TCC demonstrated medium to high correlation, with a range of r(40)=.68, p<.001 to r(40)=.79, p<.001. Study II reports an investigation of a positive youth development program using an Outcome Mediation Cascade (OMC) evaluation model, an integrated model for evaluating the empirical intersection between intervention and developmental processes. The Changing Lives Program (CLP) is a community supported positive youth development intervention implemented in a practice setting as a selective/indicated program for multi-ethnic, multi-problem at risk youth in urban alternative high schools in the Miami Dade County Public Schools (M-DCPS). The 259 participants for this study were drawn from the CLP's archival data file. The study used a structural equation modeling approach to construct and evaluate the hypothesized model. Findings indicated that the hypothesized model fit the data (χ2 (7) = 5.651, p = .83; RMSEA = .00; CFI = 1.00; WRMR = .319). My study built on previous research using the OMC evaluation model (Eichas, 2010), and the findings are consistent with the hypothesis that in addition to having effects on targeted positive outcomes, PYD interventions are likely to have progressive cascading effects on untargeted problem outcomes that operate through effects on positive outcomes.

The possible selves method in evaluating youth development interventions: The use of Integrated Qualitative /Quantitative Data Analytic Strategies (IQ -DAS)

This study investigated the feasibility of using qualitative methods to provide empirical documentation of the long-term qualitative change in the life course trajectories of “at risk” youth in a school based positive youth development program (the Changing Lives Program—CLP). This work draws from life course theory for a developmental framework and from recent advances in the use of qualitative methods in general and a grounded theory approach in particular. Grounded theory provided a methodological framework for conceptualizing the use of qualitative methods for assessing qualitative life change. The study investigated the feasibility of using the Possible Selves Questionnaire-Qualitative Extension (PSQ-QE) for evaluating the impact of the program on qualitative change in participants' life trajectory relative to a non-intervention control group. Integrated Qualitative/Quantitative Data Analytic Strategies (IQ-DAS) that we have been developing a part of our program of research provided the data analytic framework for the study. ^ Change was evaluated in 85 at risk high school students in CLP high school counseling groups over three assessment periods (pre, post, and follow-up), and a non-intervention control group of 23 students over two assessment periods (pre and post). Intervention gains and maintenance and the extent to which these patterns of change were moderated by gender and ethnicity were evaluated using a mixed design Repeated Measures Multivariate Analysis of Variance (RMANOVA) in which Time (pre, post) was the within (repeated) factor and Condition, Gender, and Ethnicity the between group factors. The trends for the direction of qualitative change were positive from pre to post and maintained at the year-end follow-up. More important, the 3-way interaction for Time x Gender x Ethnicity was significant, Roy's Θ =. 205, F(2, 37) = 3.80, p <.032, indicating that the overall pattern of positive change was significantly moderated by gender and ethnicity. Thus, the findings also provided preliminary evidence for a positive impact of the youth development program on long-term change in life course trajectory, and were suggestive with respect to the issue of amenability to treatment, i.e., the identification of subgroups of individuals in a target population who are likely to be the most amenable or responsive to a treatment. ^

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.

Efficacy of educational interventions to reduce homophobia on the *college campus

Homophobic attitudes, irrational fears and negative attitudes against gay men and lesbians exist on the college campus (Lance, 2002; Rankin, 2003). Educators wishing to change these attitudes need to know what types of intervention would be effective. This investigation empirically assessed the degree of homophobia in a group of college students, and changes in the degree of homophobia following two levels of educational intervention that were rooted in educational theories and social contact theory. A 25-item scale developed by Hudson and Ricketts to measure the degree of negative attitudes toward gay men and lesbians was used in English classes at a southeastern university. This study examined the relationship between different demographic groups and the degree of change obtained as a result of the interventions. ^ Findings did not suggest that either interaction with gay men and lesbians in the form of a speaker panel or viewing a “coming out” episode of the Ellen show reduced homophobia to a significant extent. Results did demonstrate the Caribbeans and right wing authoritarians tend to be more homophobic. Post hoc analysis investigated factors that may have contaminated the interventions. Speaker Identification was a significant predictor of change in degree of homophobia. ^

Functional near infrared spectroscopy study of language, joint attention and motor skills

Near infrared spectroscopy (NIRS) is an emerging non-invasive optical neuro imaging technique that monitors the hemodynamic response to brain activation with ms-scale temporal resolution and sub-cm spatial resolution. The overall goal of my dissertation was to develop and apply NIRS towards investigation of neurological response to language, joint attention and planning and execution of motor skills in healthy adults. Language studies were performed to investigate the hemodynamic response, synchrony and dominance feature of the frontal and fronto-temporal cortex of healthy adults in response to language reception and expression. The mathematical model developed based on granger causality explicated the directional flow of information during the processing of language stimuli by the fronto-temporal cortex. Joint attention and planning/ execution of motor skill studies were performed to investigate the hemodynamic response, synchrony and dominance feature of the frontal cortex of healthy adults and in children (5-8 years old) with autism (for joint attention studies) and individuals with cerebral palsy (for planning/execution of motor skills studies). The joint attention studies on healthy adults showed differences in activation as well as intensity and phase dependent connectivity in the frontal cortex during joint attention in comparison to rest. The joint attention studies on typically developing children showed differences in frontal cortical activation in comparison to that in children with autism. The planning and execution of motor skills studies on healthy adults and individuals with cerebral palsy (CP) showed difference in the frontal cortical dominance, that is, bilateral and ipsilateral dominance, respectively. The planning and execution of motor skills studies also demonstrated the plastic and learning behavior of brain wherein correlation was found between the relative change in total hemoglobin in the frontal cortex and the kinematics of the activity performed by the participants. Thus, during my dissertation the NIRS neuroimaging technique was successfully implemented to investigate the neurological response of language, joint attention and planning and execution of motor skills in healthy adults as well as preliminarily on children with autism and individuals with cerebral palsy. These NIRS studies have long-term potential for the design of early stage interventions in children with autism and customized rehabilitation in individuals with cerebral palsy.

Social capital, HIV risk behavior and substance use among recent Latino immigrants in South Florida

Social capital, or social cohesion or group connectedness, can influence both HIV risk behavior and substance use. Because recent immigrants undergo a change in environment, one of the consequences can be a change in social capital. There may be an association among changes in social capital, and HIV risk behavior and substance use post immigration. The dissertation focused on the interface of these three variables among recent Latino immigrants (RLIs) in South Florida. The first manuscript is a systematic review of social capital and HIV risk behavior, and served as a partial background for the second and third manuscripts. Twelve papers with a measure of social capital as an independent variable and HIV risk as the dependent variable were included in the analysis. Eleven studies measured social capital at the individual level, and one study measured social capital at the group level. HIV risk was influenced by social capital, but the type of influence was dependent on the type of social capital and on the study population. Cognitive social capital, or levels of collective action, was protective against HIV in both men and women. The role of structural social capital, or levels of civic engagement/group participation, on HIV risk was dependent on the type of structural social capital and varied by gender. Microfinance programs and functional group participation were protective for women, while dysfunctional group participation and peer-level support may have increased HIV risk among men. The second manuscript was an original study assessing changes in social capital and HIV risk behavior pre to post immigration among RLIs in South Florida (n=527). HIV risk behavior was assessed through the frequency of vaginal-penile condom use, and the number of sexual partners. It was a longitudinal study using secondary data analysis to assess changes in social capital and HIV risk behavior pre immigration to two years post immigration, and to determine if there was a relationship between the two variables. There was an 8% decrease in total social capital (p < .05). Reporting of 'Never use' of condoms in the past 90 days increased in all subcategories (p < .05). Single men had a decrease in number of sexual partners (p < .05). Lower social capital measured on the dimension of 'friend and other' was marginally associated with fewer sexual partners. The third manuscript was another original study looking at the association between social capital and substance use among RLIs in South Florida (n=527). Substance use with measured by frequency of hazardous alcoholic drinking, and illicit drug use. It was a longitudinal study of social capital and substance-use from pre to two years post immigration. Post-immigration, social capital, hazardous drinking and illicit drug use decreased (p<.001). After adjusting for time, compared to males, females were less likely to engage in hazardous drinking (OR=.31, p<.001), and less likely to engage in illicit drug use (OR=.67, p=.01). Documentation status was a moderator between social capital and illicit drug use. 'Business' and 'Agency' social capital were associated with changes in illicit drug use for documented immigrants. After adjusting for gender and marital status, on average, documented immigrants with a one-unit increase in 'business' social capital were 1.2 times more likely to engage in illicit drug use (p<.01), and documented immigrants with one-unit increase in 'agency' social capital were 38% less likely to engage in illicit drug use (p<.01). 'Friend and other' social capital was associated with a decrease in illicit drug use among undocumented immigrants. After adjusting for gender and marital status, on average, undocumented immigrants with a one-unit increase in 'friend and other' social capital were 45% less likely to engage in hazardous drinking and 44% less likely to use illicit drugs (p<.01, p<.05). Studying these three domains is relevant because HIV continues to be a public health issue, particularly in Miami-Dade County, which is ranked among other U.S. regions with high rates of HIV/AIDS prevalence. Substance use is associated with HIV risk behavior; in most studies, increased substance use is associated with increased chances of HIV risk behavior. Immigration, which is the hypothesized catalyst for the change in social capital, has an impact on the dynamic of a society. Greater immigration can be burdensome on the host country's societal resources; however immigrants are also potentially a source of additional skilled labor for the workforce. Therefore, successful adaption of immigrants can have a positive influence on receiving communities. With Florida being a major receiver of immigrants to the U.S, this dissertation attempts to address an important public health issue for South Florida and the U.S. at large.

Effects of an extreme temperature event on the behavior and age structure of an estuarine top predator, Carcharhinus leucas

The frequency of extreme environmental events is predicted to increase in the future. Understanding the short- and long-term impacts of these extreme events on large-bodied predators will provide insight into the spatial and temporal scales at which acute environmental disturbances in top-down processes may persist within and across ecosystems. Here, we use long-term studies of movements and age structure of an estuarine top predator—juvenile bull sharks Carcharhinus leucas—to identify the effects of an extreme ‘cold snap’ from 2 to 13 January 2010 over short (weeks) to intermediate (months) time scales. Juvenile bull sharks are typically year-round residents of the Shark River Estuary until they reach 3 to 5 yr of age. However, acoustic telemetry revealed that almost all sharks either permanently left the system or died during the cold snap. For 116 d after the cold snap, no sharks were detected in the system with telemetry or captured during longline sampling. Once sharks returned, both the size structure and abundance of the individuals present in the nursery had changed considerably. During 2010, individual longlines were 70% less likely to capture any sharks, and catch rates on successful longlines were 40% lower than during 2006−2009. Also, all sharks caught after the cold snap were young-of-the-year or neonates, suggesting that the majority of sharks in the estuary were new recruits and several cohorts had been largely lost from the nursery. The longer-term impacts of this change in bull shark abundance to the trophic dynamics of the estuary and the importance of episodic disturbances to bull shark population dynamics will require continued monitoring, but are of considerable interest because of the ecological roles of bull sharks within coastal estuaries and oceans.

Gender Differences in Medical Advice and Health Behavior of Obese African Americans With and Without Type 2 Diabetes

This study examined gender differences in medical advice related to diet and physical activity for obese African American adults (N = 470) with and without diabetes. Data from the 2007-2008 National Health and Nutrition Examination Survey were analyzed using logistic regression analyses. Even after sociodemographic adjustments, men were less likely to report receiving medical advice as compared with women. Both men and women given dietary and physical activity advice were more likely to follow it. Men were less likely to report currently reducing fat or calories, yet men withdiabetes were 5 times more likely to state that they were reducing fat and calories as compared with women with diabetes. Gender- and disease state-specific interventions are needed comparing standard care with enhanced patient education. Moreover, these findings necessitate studies that characterize the role of the health care professional in the diagnosis and treatment of obesity and underscore patient-provider relationships.

Ex Ante Cost Benefit Analyses of Community-Based DRR Interventions in the Caribbean

This report presents a study on the cost benefit analyses (CBA) and cost effectiveness analysis (CEA) of community-based disaster risk reduction (DRR) interventions in the Caribbean. The DRR interventions, implemented by the International Federation of Red Cross (IFRC), Port of Spain, in three Caribbean countries, Jamaica, Antigua & Barbuda, and Suriname, comprised the pilot phase of the Red Cross (RC) Project, Improving Climate Change Resilience of Caribbean Communities. This study is part of the endeavor by the DRR Program of Florida International University (FIU) and the United States Agency for International Development’s Office of the U.S. Foreign Disaster Assistance (USAID/OFDA) to develop and foster DRR measures in the Latin American and Caribbean region since 2008.

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.