Foster care, syndemic health disparities and associations with HIV/STI diagnoses among young adult substance users.

OBJECTIVES: Foster care history is associated with many health and social problems, including sexual risk behaviours, HIV and other sexually transmitted infections (STIs). This cross-sectional study compares sexual risk behaviours among a sample of young adult substance users in Miami (N=602) with and without foster care histories. METHODS: Participants completed a comprehensive assessment which included sections on foster care, sexual risk behaviours and related health and social problems. Logistic regression was used to examine the relationship between foster care history, associated syndemic vulnerabilities and increased likelihood of having a prior HIV/STI diagnosis. RESULTS: Bivariate analyses indicated that foster care alumni were more likely to report a prior HIV/STI diagnosis, higher condomless sex frequencies, being high on alcohol or drugs during sex, sexual victimisation and a history of homelessness compared with other participants in the sample (p<0.05). Multivariate analyses revealed that foster care history, sexual victimisation and group sex participation are associated with a prior HIV/STI diagnosis (p<0.05). Group sex participation doubled the odds of a prior HIV/STI diagnosis for foster care alumni, compared with other participants (p<0.5). CONCLUSIONS: This exploratory study identifies characteristics that distinguish foster care alumni from non-alumni and signals the need to better serve the sexual and related health needs of individuals with foster care histories. Clinicians and healthcare providers should provide foster care alumni with detailed HIV/STI risk reduction information and resources and services to address related syndemic vulnerabilities (eg, victimisation and homelessness).

Identifying strengths in youths at substance use treatment admission.

Background: Clinicians have been required to assess client strengths at substance use treatment admission for two decades. Yet little is known about identified strengths in this population that could make it easier for clients to accept having this illness. Objectives: This study explored the profile of clients' strengths and whether strengths varied by background characteristics and constructive use of time. Methods: Data were collected with validated instruments at treatment admission. Substance dependent youths (N = 195, 52% female, aged 14-17, 30% minority), their legal guardians, and admission counselors completed an open-ended prompt about client strengths. Qualitative responses of identified strengths were coded by theme. Univariate comparisons linked count of identified strengths and patient characteristics. Results: Youths had an average of three identified strengths (SD = 1.99) at admission, and 9% did not identify any strengths. Interpersonal strengths were most prevalent (73%), followed by generic intelligence (45%), and grit (31%). Female gender, not having a parent with a high school diploma, narcotic dependence, and shorter duration of consecutive days sober were associated with fewer strengths. Conclusion: Highly sociable, hard-working, and smart were prominent strengths in the sample. Each day sober corresponded with more identified strengths, which may encourage those in early recovery. Identifying strengths can help clients find meaningful sober recreation and may be particularly useful tools for girls and those with low parental education. Developing standards for using identified strengths in treatment planning and consensus on the taxonomy of strengths are topics for future research.

Residential Proximity to Electronic Dance Music Nightclubs and Associations with Substance Use, Sexual Behaviors, and Related Problems.

This study examines the association between proximity of place of residence to preferred nightclub and substance use, sexual risk behaviors, and related problems, among a sample of 498 young adult substance users in Miami who report regular nightclub participation. Hierarchal linear models and logistic regressions were constructed to examine the impact of residential proximity to preferred nightclub on risk behaviors. Compared with participants residing in closer proximity to their preferred nightclub, participants residing further away reported higher intensities of alcohol and cocaine use (p < .01), greater condomless vaginal sex frequencies (p < .001), and more substance dependence symptoms (p < .05). Conversely, participants residing in closer proximity to their preferred nightclub had higher likelihood of arrest history (p < .05) than participants residing further away. Results suggest that participants residing further from their preferred nightclubs may be more invested in the nightclub outing and, therefore, engage in more risk behaviors.

Alone on the Inside: The Impact of Social Isolation and Helping Others on AOD Use and Criminal Activity.

Because addiction is a socially isolating disease, social support for recovery is an important element of treatment planning. This study examines the relationship between social isolation, giving and receiving social support in Alcoholics Anonymous during treatment, and post-treatment outcomes among juvenile offenders court-referred to addiction treatment. Adolescents (N = 195) aged 14 to 18 years were prospectively assessed at treatment admission, treatment discharge, 6 months, and 12 months after treatment discharge. The influence of social isolation variables on relapse and severe criminal activity in the 12-months post-treatment was examined using negative binomial logistic regressions and event history methods. Juveniles entering treatment with social estrangement were significantly more likely to relapse, be incarcerated, and commit a violent crime in the 12-months post-treatment. Giving help to others in Alcoholics Anonymous during treatment significantly reduced the risk of relapse, incarceration, and violent crime in the 12-months post-treatment whereas receiving help did not.

Low Other-Regard and Adolescent Addiction.

Although 12-step literature posits inconsiderate behaviors to characterize alcoholics and addicts, there is little data to support this association among adolescent populations. Using a matched-pair study design with 579 youth aged 14-18 (52% female, 30% minority), a significant, dose-response relationship was found between greater alcohol and drug use severity and increased likelihood of driving under the influence, having unprotected sex with and without a history of sexually transmitted incidence, and low volunteerism among boys. Findings suggest that alcohol and drug use severity is associated with poor awareness of the impact of behaviors on others.

Social anxiety and peer helping in adolescent addiction treatment.

BACKGROUND: The developmental need to fit in may lead to higher alcohol and other drug use among socially anxious youths which exacerbates the drink/trouble cycle. In treatment, youths with social anxiety disorder (SAD) may avoid participating in therapeutic activities with risk of negative peer appraisal. Peer-helping is a low-intensity, social activity in the 12-step program associated with greater abstinence among treatment-seeking adults. This study examined the influence of SAD on clinical severity at intake, peer-helping during treatment, and outcomes in a large sample of adolescents court-referred to residential treatment. METHODS: Adolescents (N = 195; 52% female, 30% Black) aged 14 to 18 were prospectively assessed at treatment admission, treatment discharge, and 6 months after treatment discharge. Data were collected using rater-administered assessments, youth reports, clinician reports, medical charts, and electronic court records. The influence of SAD on peer-helping and outcomes was examined using hierarchical linear regression and event history methods. RESULTS: Forty-two percent of youths reported a persistent fear of being humiliated or scrutinized in social situations, and 15% met current diagnostic criteria for SAD. SAD onset preceded initial use for two-thirds of youths with SAD and substance dependency. SAD youths presented for treatment with greater clinical severity in terms of earlier age of first use (p < 0.01), greater lifetime use of heroin and polysubstance use (p < 0.05), incarceration history (p < 0.01), and lifetime trauma (p < 0.001). Twelve-step participation patterns during treatment did not differ between youths with and without SAD except for peer-helping, which was associated with reduced risk of relapse (p < 0.01) and incarceration (p < 0.05) in the 6 months posttreatment. CONCLUSIONS: This study found evidence of an association between SAD and earlier age of first use, greater lifetime use of heroin, incarceration history, and lifetime trauma. SAD was associated with higher service participation during treatment, which was associated with reduced risk of relapse and incarceration in the 6 months posttreatment. Findings indicate the benefits of service participation for juveniles with SAD which provides a nonjudgmental, task-focused venue for developing sober networks in the transition back into the community.

Risk factors of repeated infectious disease incidence among substance-dependent girls and boys court-referred to treatment.

BACKGROUND: A small portion of Americans account for a disproportionate amount of the incidences of sexually transmitted infection observed over a short period of time. Studies with adults have begun to characterize this population, yet there is very little data on adolescent sexually transmitted infection repeaters (STIR). This study explores characteristics associated with STIR among 102 girls and 93 boys (aged 14-18) court-referred for residential treatment. METHODS: Background characteristics, substance use disorders, risky and interpersonal behaviors, and history of sexually transmitted infections were collected at intake using valid and reliable instruments. A negative binomial logistic regression was performed to determine the background, risky behaviors, and social patterns associated with adolescent STIR. RESULTS: Approximately two out of three adolescents (62%) did not use contraception the last time they had sex, and 15% had at least one sexually transmitted infection recorded in their medical chart. Sexually transmitted infection repeaters entered treatment with higher rates of cocaine abuse (13%) than youth without multiple infections (3%, p < 0.05). History of sexual abuse, having sex with a person who said no, higher exhibitionism, and social estrangement increased the odds of adolescent STIR. Main effects of exhibitionism and social estrangement on increased odds of STIR were more pronounced for sexually abused adolescents. CONCLUSIONS: The findings suggest a need for incorporating HIV education during residential treatment to improve health outcomes and intervention strategies that further connectedness for youth and victims of sexual abuse.

Assessing youth participation in AA-related helping: validity of the Service to Others in Sobriety (SOS) questionnaire in an adolescent sample.

BACKGROUND AND OBJECTIVES: The positive outcomes derived from participation in Alcoholics Anonymous-related helping (AAH) found among adults has spurred study of AAH among minors with addiction. AAH includes acts of good citizenship in AA, formal service positions, public outreach, and transmitting personal experience to another fellow sufferer. Addiction research with adolescents is hindered by few validated assessments of 12-step activity among minors. This study provides psychometric findings of the "Service to Others in Sobriety (SOS)" questionnaire as completed by youths. METHODS: Multi-informant data was collected prospectively from youth self-reports, clinician-rated assessments, biomarkers, and medical chart records for youths (N = 195) after residential treatment. RESULTS: Few youths (7%) did not participate in any AAH during treatment. Results indicated the SOS as a unidimensional scale with adequate psychometric properties, including inter-informant reliability (r = .5), internal consistency (alpha = .90), and convergent validity (rs = -.3 to .3). Programmatic AAH activities distinguished abstinent youths in a random half-sample, and replicated on the other half-sample. The SOS cut-point of 40 indicated high AAH participation. CONCLUSIONS AND SIGNIFICANCE: The SOS appears to be a valid measure of AAH, suggesting clinical utility for enhancing treatment and identifying service opportunities salient to sobriety.

The 10-year course of Alcoholics Anonymous participation and long-term outcomes: a follow-up study of outpatient subjects in Project MATCH.

This study investigates the 10-year course and impact of Alcoholics Anonymous (AA)-related helping (AAH), step-work, and meeting attendance on long-term outcomes. Data were derived from 226 treatment-seeking alcoholics recruited from an outpatient site in Project MATCH and followed for 10 years post treatment. Alcohol consumption, AA participation, and other-oriented behavior were assessed at baseline, end of the 3-month treatment period, and 1, 3, and 10 years post treatment. Controlling for explanatory baseline and time-varying variables, results showed significant direct effects of AAH and meeting attendance on reduced alcohol outcomes and a direct effect of AAH on improved other-oriented interest.

Stressful life events predict eating disorder relapse following remission: six-year prospective outcomes.

OBJECTIVE: To examine prospectively the natural course of bulimia nervosa (BN) and eating disorder not-otherwise-specified (EDNOS) and test for the effects of stressful life events (SLE) on relapse after remission from these eating disorders. METHOD: 117 female patients with BN (N = 35) or EDNOS (N = 82) were prospectively followed for 72 months using structured interviews performed at baseline, 6- and 12-months, and then yearly thereafter. ED were assessed with the structured clinical interview for DSM-IV, and monitored over time with the longitudinal interval follow-up evaluation. Personality disorders were assessed with the diagnostic interview for DSM-IV-personality-disorders, and monitored over time with the follow-along-version. The occurrence and specific timing of SLE were assessed with the life events assessment interview. Cox proportional-hazard-regression-analyses tested associations between time-varying levels of SLE and ED relapse, controlling for comorbid psychiatric disorders, ED duration, and time-varying personality-disorder status. RESULTS: ED relapse probability was 43%; BN and EDNOS did not differ in time to relapse. Negative SLE significantly predicted ED relapse; elevated work and social stressors were significant predictors. Psychiatric comorbidity, ED duration, and time-varying personality-disorder status were not significant predictors. DISCUSSION: Higher work and social stress represent significant warning signs for triggering relapse for women with remitted BN and EDNOS.

Spirituality in recovery: a lagged mediational analysis of alcoholics anonymous' principal theoretical mechanism of behavior change.

BACKGROUND: Evidence indicates Alcoholics Anonymous (AA) can play a valuable role in recovery from alcohol use disorder. While AA itself purports it aids recovery through "spiritual" practices and beliefs, this claim remains contentious and has been only rarely formally investigated. Using a lagged, mediational analysis, with a large, clinical sample of adults with alcohol use disorder, this study examined the relationships among AA, spirituality/religiousness, and alcohol use, and tested whether the observed relation between AA and better alcohol outcomes can be explained by spiritual changes. METHOD: Adults (N = 1,726) participating in a randomized controlled trial of psychosocial treatments for alcohol use disorder (Project MATCH) were assessed at treatment intake, and 3, 6, 9, 12, and 15 months on their AA attendance, spiritual/religious practices, and alcohol use outcomes using validated measures. General linear modeling (GLM) and controlled lagged mediational analyses were utilized to test for mediational effects. RESULTS: Controlling for a variety of confounding variables, attending AA was associated with increases in spiritual practices, especially for those initially low on this measure at treatment intake. Results revealed AA was also consistently associated with better subsequent alcohol outcomes, which was partially mediated by increases in spirituality. This mediational effect was demonstrated across both outpatient and aftercare samples and both alcohol outcomes (proportion of abstinent days; drinks per drinking day). CONCLUSIONS: Findings suggest that AA leads to better alcohol use outcomes, in part, by enhancing individuals' spiritual practices and provides support for AA's own emphasis on increasing spiritual practices to facilitate recovery from alcohol use disorder.

Brief interventions for young adults who use drugs: The moderating effects of resilience and trauma.

Among participants in an intervention clinical trial (N = 602), we examined resilience as a moderator of substance use outcomes by intervention condition and between participants with and without severe traumatic stress (STS). Eligibility included men and women ages 18-39 with recent multidrug use; drug treatment enrollees were excluded. Outcome measures were past 90-day frequencies of substance use and abstinence. Putative moderators were measured using the Resilience Research Centre's Adult Resilience Measure (RRC-ARM) and the Traumatic Stress Scale from the Global Appraisal of Individual Needs (GAIN). Analyses employed hierarchical linear models. High resilience predicted better substance use outcomes, and the ordering of intervention effects for high resilience participants was stepwise by intervention condition intensity. Participants with low resilience scores had poorer outcomes, and those outcomes were largely unaffected by intervention condition. Participants without STS experienced the interventions similarly to the overall sample. Regardless of the level of resilience, however, participants with STS did not benefit from the interventions. The findings point to the importance of screening for both resilience and traumatic stress prior to intervention to maximize the impact of brief interventions for substance users, and also to link those needing more intensive approaches to additional services and professional care.

Kickbacks from helping others: health and recovery.

AA is often viewed as a spiritual organization, but it is less commonly recognized that helping others is a fundamental part of AA's conception of spirituality. Helping others by bringing AA's program to other alcoholics (articulated in Step 12) is understood as the culmination of AA's program and the behavioral manifestation of a spiritual awakening (Step 11). Also, members are encouraged to help in all stages of their involvement in AA's, and it is this helping that is thought to keep them sober. Accordingly, the current chapter addresses the question of whether helping benefits the helper from an empirical standpoint-and specifically, whether helping might contribute to recovery in the context of AA involvement. In addition to describing AA's approach to helping, we review research on associations between helping and (a) health outcomes in the general population, (b) recovery in diverse mutual help groups, and (c) recovery from chemical dependency within and outside of AA. We find evidence supporting benefits for helpers in each of these domains and tentatively conclude in favor of helper therapy principles. However, the work is limited by the lack of experimental studies and by problems in defining helping. Other concerns are that "over-helping" can be worse than not helping at all and that helping may sometimes harm the intended recipients. Recommendations for further research are to address these limitations. Particularly useful would be research designing and testing interventions aiming to increase helping, perhaps informed by social model programs and principles.

Psychometric characteristics of the Mobility Inventory in a longitudinal study of anxiety disorders: replicating and exploring a three component solution.

Psychometric characteristics of the Mobility Inventory (MI) were examined in 216 outpatients diagnosed with panic disorder with agoraphobia participating in a longitudinal study of anxiety disorders. An exploratory principal components analysis replicated a three-component solution for the MI reported in prior studies, with components corresponding to avoidance of public spaces, avoidance of enclosed spaces, and avoidance of open spaces. Correlational analyses suggested that the components tap unique but related areas of avoidance that were remarkably stable across periods of 1, 3, and 5 years between administrations. Implications of these results for future studies of agoraphobia are discussed.

A randomized trial of brief assessment interventions for young adults who use drugs in the club scene.

BACKGROUND: Efficacious interventions to reduce drug use and its consequences for club drug using populations are not apparent in the literature. We tested interviewer- (CAPI) and self-administered (ACASI) comprehensive health and social risk assessments as distinct interventions compared to waitlist control. METHODS: 750 men and women ages 18-39 with multidrug use and heterosexual behavior were randomized in equal proportions to the three conditions. Instrumentation included well-tested measures of drug use, risky sex, mental distress and substance dependence. RESULTS: The sample was 56% male; mean age=25. Reported risk behaviors and health consequences did not differ by assessment modality. Adjusted HLM analyses showed a significant main effect of assigned condition on all outcomes. CAPI participants had greater reductions in drug use, risky sex, mental distress and substance dependence symptoms, and greater increases in abstinence, compared to ACASI intervention or control participants at 12months, except that the CAPI and ACASI conditions had similar efficacy for reductions in drug use. Effect sizes for CAPI versus ACASI participants were d=0.2-0.3, and between CAPI and controls d=0.2-0.4. Effect sizes for improved outcomes between ACASI compared to controls were small to non-significant. CONCLUSIONS: The study established the therapeutic benefit of interviewer interaction in reducing risky behavior among this young drug using population. The study demonstrated the efficacy and acceptability of a low threshold intervention in reducing drug use, sexual risk and related co-morbidities among a not-in-treatment young adult population that exhibits severe and complex levels of drug use, but that is also highly resistant to intervention.

Heroin use onset among nonmedical prescription opioid users in the club scene.

BACKGROUND: Nonmedical prescription opioid use (NMPOU) is well documented among participants in the club scene, yet prior studies have not examined transition to heroin use. We prospectively examined heroin initiation among a sample of young adults with drug involvement associated with participation in the club scene, to understand factors that influence transition from NMPOU to heroin and to identify opportunities for intervention. METHODS: Data were drawn from a randomized trial that enrolled 750 Miami-based club and prescription drug users through respondent driven sampling, and tested the efficacy of assessment interventions in reducing risk. Participants reported current substance use at baseline, 3, 6, and 12 month follow-ups. We examined predictors of heroin initiation among participants reporting NMPOU at baseline, with no lifetime history of heroin use (N=323). RESULTS: The mean age was 25.0 years; 67.5% met DSM-IV criteria for substance dependence. About 1 in 13 participants (7.7%) initiated heroin use at follow-up. In univariable comparisons, frequent LSD use, history of drug overdose, high frequency NMPOU, using oral tampering methods, and endorsing a primary medical source for prescription opioids were associated with greater likelihood of heroin initiation. LSD use, oral tampering, and primary medical source were significant predictors in a Cox regression model. CONCLUSIONS: Heroin initiation of 7.7% suggests a high level of vulnerability for transition among young adult NMPO users in the club scene. The importance of oral tampering methods in the trajectory of NMPOU may indicate a need to further examine the role of abuse deterrent formulations in prevention efforts.

A 12-month follow-up study of the course of body dysmorphic disorder.

OBJECTIVE: This study investigated the course of body dysmorphic disorder (BDD), a relatively common and severe disorder, in the first prospective follow-up study, to the authors' knowledge. METHOD: In this study, the authors obtained data with the Longitudinal Interval Follow-Up Evaluation on weekly BDD symptom status and treatment received over 1 year for 183 broadly ascertained subjects. Probabilities of full remission, partial remission, and relapse during this year were examined. Full remission was defined as minimal or no BDD symptoms and partial remission, as meeting less than full DSM-IV criteria for at least 8 consecutive weeks. Relapse was defined as meeting full BDD criteria for at least 2 consecutive weeks after attaining partial or full remission from BDD. RESULTS: Over 1 year, the probability of full remission from BDD was only 0.09, and the probability of partial remission was 0.21. Although 84.2% of the subjects received mental health treatment during the 1-year period, mean BDD severity scores during the year reflected full DSM-IV criteria for BDD, and the mean proportion of time that the subjects met full BDD criteria was 80%. Gender and ethnicity did not significantly predict remission from BDD. Among the subjects whose BDD symptoms partially or fully remitted, the probability of relapse was 0.15. CONCLUSIONS: These findings indicate that BDD tends to be chronic. Remission probabilities were lower than reported for mood disorders, most anxiety disorders, and personality disorders in studies with similar methods.

The Brown Longitudinal Obsessive Compulsive Study: clinical features and symptoms of the sample at intake.

OBJECTIVE: This article describes the method and intake findings of the Brown Longitudinal Obsessive Compulsive Study, the first comprehensive prospective investigation of the naturalistic course of obsessive-compulsive disorder (OCD) in a large clinical sample using longitudinal research methodology. METHOD: Intake data, collected between June 2001 and October 2004, are presented for 293 adult participants in a prospective, naturalistic study of OCD. Participants had a primary diagnosis of DSM-IV OCD and had sought treatment for the disorder. RESULTS: Our findings indicate that OCD typically has a gradual onset and a continuous course regardless of age at onset. There is a substantial lag between the onset of the disorder and initiation of treatment. OCD, which almost always coexists with other psychiatric symptoms, leads to serious social and occupational impairment. Compared with participants with late-onset OCD, early-onset participants had higher rates of lifetime panic disorder, eating disorders, and obsessive-compulsive personality disorder. The groups also differed on the types of obsessive-compulsive symptoms that were first noticed, as well as on rates of current obsessions and compulsions. CONCLUSION: The demographics, clinical characteristics, comorbidity rates, and symptom presentation of the sample are consistent with those reported for cross-sectional studies of OCD, including the DSM-IV Field Trial. The current sample has a number of advantages over previously collected prospective samples of OCD in that it is large, diagnostically well characterized, recruited from multiple settings, and treatment seeking. This unique data set will contribute to the identification of meaningful phenotypes in OCD based on stability of symptom dimensions, prospective course patterns, and treatment response.

Clinical features of body dysmorphic disorder in adolescents and adults.

Body dysmorphic disorder (BDD) usually begins during adolescence, but its clinical features have received little investigation in this age group. Two hundred individuals with BDD (36 adolescents; 164 adults) completed interviewer-administered and self-report measures. Adolescents were preoccupied with numerous aspects of their appearance, most often their skin, hair, and stomach. Among the adolescents, 94.3% reported moderate, severe, or extreme distress due to BDD, 80.6% had a history of suicidal ideation, and 44.4% had attempted suicide. Adolescents experienced high rates and levels of impairment in school, work, and other aspects of psychosocial functioning. Adolescents and adults were comparable on most variables, although adolescents had significantly more delusional BDD beliefs and a higher lifetime rate of suicide attempts. Thus, adolescents with BDD have high levels of distress and rates of functional impairment, suicidal ideation, and suicide attempts. BDD's clinical features in adolescents appear largely similar to those in adults.

Clarifying the convergence between obsessive compulsive personality disorder criteria and obsessive compulsive disorder.

In this study we examined the convergence between obsessive-compulsive personality disorder (OCPD) criteria and obsessive-compulsive disorder (OCD). Baseline assessments of 629 participants of the Collaborative Longitudinal Personality Disorders Study were used to examine the associations between OCPD criteria and diagnoses of OCD. Three of the eight OCPD criteria--hoarding, perfectionism, and preoccupation with details--were significantly more frequent in subjects with OCD (n = 89) than in subjects without OCD (n = 540). Logistic regressions were used to predict the probability of each OCPD criterion as a function of Axis I diagnoses (OCD, additional anxiety disorders, and major depressive disorder). Associations between OCD and these three OCPD criteria remained significant in the logistic regressions, showing unique associations with OCD and odds ratios ranging from 2.71 to 2.99. In addition, other anxiety disorders and major depressive disorder showed few associations with specific OCPD criteria. This study suggests variability in the strength of the relationships between specific OCPD criteria and OCD. The findings also support a unique relationship between OCPD symptoms and OCD, compared to other anxiety disorders or major depression. Future efforts to explore the link between Axis I and Axis II disorders may be enriched by conducting analyses at the symptom level.