Research Presentations
The SAHM 2021 Virtual Annual Meeting Recordings package includes the following research presentation sessions. All abstracts accepted for presentation were published in the Journal of Adolescent Health special February 2021 supplement.
Platform Research Presentations
Platform Research Presentation I: Charles E. Irwin Jr. New Investigators
View Abstracts
- Chronic Absenteeism among Middle School Students with High Exposure to Violence
- Missed Opportunities for Sexual History Documentation and STI Testing in the Pediatric Emergency Department
- Early Adolescents in Adversity: A latent class approach to understanding patterns of emotional and behavioral problems across low-resource urban settings worldwide
- “I knew that my dad was going to find out”: Dismantling Barriers and Transforming the Future of PrEP Uptake in Black and Latinx Sexual Gender Minority Youth (BLSGMY)
Platform Research Presentation III: Parenting and Youth Development
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- Latina Mothers’ Perspectives on Adverse Experiences and Protection of Latinx Youth in an Agricultural Community
- COVID-19 Impact on Parent/Young Adult Attitudes and Beliefs toward Vaccines for Adolescents and Young Adults
- “Difficult To Find, Stressful To Navigate”: Parents’ Experiences With Affirming Care For Gender Diverse Youth
- Youth Leadership in Action (YLIA): Feasibility of implementing a Youth Participatory Action Research program in inner-city public schools and communities
Platform Research IV: Salient topics in Adolescent Health
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- Does Tobacco Screening in Youth Primary Care Identify Youth Vaping?
- One-year Outcomes from a Multi-Center Randomized Controlled Trial (RCT) of Refeeding in Anorexia Nervosa: The Study of Refeeding to Optimize iNpatient Gains (StRONG)
- Associations Between Race-Based Discrimination and Past 30-Day Substance Use among Predominantly Black Youth Residing in Urban Neighborhoods
- Adolescent Perceptions of Menstruation on Twitter: Opportunities for Advocacy and Education
Poster Symposia
Poster Symposia I: Promoting Sexual and Genitourinary Health
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- Creating a Research Program to Promote Bladder Health in Adolescent Women
- The Probability of Anovulatory Cycles in Primary Dysmenorrhea in Adolescents
- Confidential Contraception Protections for Adolescents in Foster Care in Texas
- Sexual Minority Female Adolescents Are More Likely to Receive Sexually Explicit Messages and Experience Fear From Unwanted Messages Compared to Their Heterosexual Female Peers.
- Missed Opportunities to Provide Comprehensive Sexual and Reproductive Healthcare Among Hospitalized Adolescents
- Examining Disparities in STI/HIV Testing and Contraception Care Receipt among Sexually Active Adolescents Who Are Women of Color Who Have Sex with Women
Poster Symposia II: Violence Prevention and Juvenile Justice
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- Violence Perpetration Among Early Adolescents in an International Context
- Discordant Substance Use and the Daily Experience of Partner Violence in Adolescent and Emerging Adults with Previous Dating Violence
- Juvenile Corrections Officers’ Perceptions of Procedural Justice
- Exploring Adolescent-adult Connections, Coping, and Safety Among Youths in Neighborhoods Impacted by Community Violence
- Assessing Youth Perceptions of Staff: A Validational Analysis in Adjudicated Youth
- Future Orientation as a Cross-cutting Protective Factor Against Multiple Forms of Violence
Poster Symposia III: Screening, Measurement, and Consent in Adolescent Behavioral Health
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- Eating Disorder Screening and Treatment Experiences in Transgender and Gender Diverse Young Adults
- Impacts of COVID-19 on Health and Health Behaviors of Young Adults
- Public Stigma Towards Adolescents Experiencing Substance Use Disorders: Measurement development and preliminary examination
- An Intersectional Psychometric Evaluation of a Discrimination Scale Among Minority Youth: Is There Measurement Invariance by Gender?
- Changes in Markers of Toxic Stress and Resilience Among Youth Participating in an After-School Running and Mentorship Program, and their Association with Adverse Childhood Experiences.
- Mapping the Consent Process for Transgender Youth: A Content Analysis of Consent Forms for Gender-Related Care
Platform Research Presentation I: Charles E. Irwin Jr. New Investigators
#1. Chronic Absenteeism among Middle School Students with High Exposure to Violence
Jacquelin Rankine, MD, MS1, Barbara Fuhrman, PhD2, Ethan Copperman, BA2, Alison Culyba, MD, PhD1, Elizabeth Miller, MD, PhD1
1UPMC Children’s Hospital of Pittsburgh; 2University of Pittsburgh
Purpose: Chronic absenteeism, defined as missing 10% of school days, impacts over 7 million U.S. students with lasting effects on health and education. Chronic absenteeism in middle school predicts high school drop-out, which subsequently predicts poor health and increased overall mortality in adulthood. Prior studies have revealed associations between adverse childhood experiences and chronic absenteeism among samples with relatively low levels of both. Youth in areas of concentrated disadvantage experience higher rates of chronic absenteeism, which may be a function of their differential exposure to violence. We examined associations between violence exposure and chronic absenteeism among middle school students with identified risk of trauma.
Methods: We analyzed baseline data from an ongoing cluster-randomized trial of a teen dating violence and sexual violence prevention program in Pittsburgh, PA. Students were referred for participation in trauma-focused support groups by school personnel based on known or suspected history of trauma. Participants completed surveys identifying lifetime exposure to 10 types of violence and past 30-day school absence. Chronic absenteeism was operationalized as 2 or more days absent, equivalent to 10% missed school time. Generalized linear models based on a log-link function accounting for clustering at the school level were used to separately examine the association between 1) any history of violence exposure, 2) each of 10 types of violence exposure, and 3) summed exposure to different types of violence, and chronic absenteeism. Models were adjusted for age, gender, and race/ethnicity, and risk ratios were estimated.
Results: Participants (n=499) had a mean age of 13 years; 49.5% were female, and 48.5% identified as Black/African American. Exposure to violence was common with 71.5% experiencing violent events. The most common types of violence included seeing someone seriously injured or killed (42.7%) or having a close friend or family member murdered (35.1%). Rates of chronic absenteeism were also high with 45.5% missing 2 or more days of school in the past 30 days, including 9.8% missing 4-5 days and 9.4% missing 6 or more days. Having any history of violence exposure was significantly associated with chronic absenteeism (RR=1.43, 95%CI: 1.06-1.92). However, no individual type of violence exposure predicted chronic absenteeism. Comparing summed exposure to different types of violence to no violence exposure, exposure to 1 type of violence was associated with chronic absenteeism (RR=1.59, 95%CI: 1.15-2.20), with initially significant but decreasing association with greater summed exposure (2-3 types: RR=1.37, 95%CI: 1.00-1.88; ≥4 types: RR=1.31, 95%CI: 0.98-1.74).
Conclusions: Youth in our sample experienced both high rates of exposure to violence and chronic absenteeism. Prior exposure to any violence was associated with chronic absenteeism, but exposure to each individual type of violence or more types of violence did not increase this association. Resources and contextual support for youth exposed to family, school, or community violence may play a significant role in their school attendance, emphasizing the need for trauma-informed approaches to chronic absenteeism. Responses to chronic absenteeism which punish, exclude, or refer youth to the juvenile justice system may only increase violence exposure and further widen health and educational inequities.
Sources of Support: NIH 5T32HD087162-05 and 5R01CE002981-02
#2. Missed Opportunities for Sexual History Documentation and STI Testing in the Pediatric Emergency Department
Caryn Robertson, MD1, Amanda Thomas, MSPH1, Atsuko Koyama, MD, MPH2, Lauren Middlebrooks, MD1, Swaminathan Kansaswamy, PhD1, Evan Orenstein, MD1, Holly C. Gooding, MD, MSC1
1Emory University School of Medicine; 2University of Arizona, College of Medicine
Purpose: Sexually transmitted infections (STIs) are disproportionately prevalent in the adolescent population, and these patients often present to the pediatric emergency department (PED) for care. Despite practice recommendations, prior studies have found low rates of sexual history documentation and STI testing in the PED. However, these studies have had limited sample sizes due to the burden of manual review. We aimed to estimate the rate of sexual history documentation and identify factors associated with STI testing in a large cohort of adolescents using natural language processing (NLP).
Methods: We applied a validated NLP algorithm to all adolescent visits with a chief complaint potentially related to an STI over a three-year period to three PEDs in a large children’s healthcare organization in the southeastern United States. We utilized NLP to determine the prevalence of sexual history documentation and aspects of a sexual history documented for these patients. We applied logistic regression models to determine associations between patient demographic factors, sexual history documentation, and STI testing.
Results: Only 56% (1,108 of 1,987 included encounters) had a sexual history documented; of those, 61% (671 of 1,108) were identified as possibly sexually active, and 80% of those (534 of 671) had an STI test ordered. In contrast, a total of 265 patients (13% of the total sample) had STI testing ordered when either no sexual history was documented (n=115) or the provider documentation indicated the patient as not sexually active (n=150). The prevalence of CDC recommended elements of a sexual history varied widely; 5% documented sexual practices, 28.7% documented contraceptive use/nonuse, 41.2% documented condom use, and 62% documented partner gender. Patients were more likely to have a sexual history documented if they were of non-Hispanic Black race/ethnicity [(adjusted odds ratio [aOR] 2.82; 95% confidence interval [CI] (2.13-3.73)], >15 years of age [aOR 2.33; CI (1.86-2.91)], had non-private insurance [aOR 2.05; CI (1.59-2.65)], and had a trainee involved in their care [aOR 3.38; CI (2.63-4.35)]. In total, 40% of all symptomatic adolescent patients were tested for STIs. Patients were more likely to be tested for STIs if they had a sexual history documented (adjusted odds ratio [aOR] 7.19; CI (5.64-9.17)], were of non-Hispanic Black race/ethnicity [aOR 1.91; CI (1.38-2.66)], >15 years of age [aOR 2.46; CI (1.91-3.18)], and had non-private insurance [aOR 1.63; CI (1.21-2.89)]. Of patients tested (n=728), 25% were positive for an STI.
Conclusions: Despite presenting to the PED with symptoms potentially related to an STI, adolescents are not receiving recommended sexual health care, and there are demographic differences in which patients have sexual history documentation and STI testing. Utilizing NLP technology allowed us to examine a larger sample size than previously documented in the adolescent sexual health and PED literature. This study highlights critical opportunities to improve sexual health provision and equity of care provided in the PED. Future efforts to improve guideline-recommended sexual health care could benefit from automated methods to detect sexual history documentation and STI screening to improve adolescent health.
Sources of Support: None
#3. Early Adolescents in Adversity: A latent class approach to understanding patterns of emotional and behavioral problems across low-resource urban settings worldwide
Shoshanna L. Fine, MPH1, Robert W. Blum, MD, PhD1, Judith K. Bass, PhD1, Aimée M. Lulebo, MD, PhD2, William Stones, MD3, Anggriyani W. Pinandari, MPH4, Siswanto A. Wilopo, MD, ScD4, Xiayun Zuo, PhD5, Rashelle J. Musci, PhD1
1Johns Hopkins Bloomberg School of Public Health; 2Kinshasa School of Public Health; 3Malawi College of Medicine; 4University of Gadjah Mada; 5Fudan University
Purpose: Early adolescence (ages 10-14) is a critical period for psychosocial development. With a substantial proportion of lifetime mental health problems manifesting by age 14, poor psychosocial adjustment in early adolescence can set the stage for impairment throughout the life course. Youth living in low- and middle-income countries (LMICs) are at particular risk of experiencing emotional and behavioral problems, but little research on adolescent psychosocial development has been conducted in these settings. The aim of this study was to characterize prototypical patterns of emotional and behavioral problems among early adolescents living in four LMICs, and to explore the extent to which these patterns varied by country and sex.
Methods: This study used data from the Global Early Adolescent Study (GEAS). Participants were 10,437 early adolescents (51% girls) from six low-income urban settings in the Democratic Republic of Congo (DRC; n = 2,006), Malawi (n = 2,016), Indonesia (n = 4,657), and China (n = 1,758). Latent class analysis (LCA) was used to identify and classify patterns (i.e., classes) of emotional and behavioral problems separately by country, and utilized ten indicators related to depressive and anxiety symptoms, aggressive behaviors, peer victimization, and substance use. Within each setting, measurement invariance by sex was evaluated using a multiple group approach.
Results: LCA supported a four-class solution in DRC, Malawi, and Indonesia, and a three-class solution in China. Across countries, early adolescents fell into four general subgroups: a Well-Adjusted class (40-62%), with few emotional and behavioral problems; an Emotional Problems class (14-29%), with elevated symptoms of depression and anxiety; a Behavioral Problems class (15-22%; not present in China), with increased involvement in aggressive behaviors, peer victimization, and substance use; and a Maladjusted class (4-15%), with co-occurring emotional and behavioral problems. Despite the overall consistency of these patterns, there were some notable contextual differences. These included the lack of a Behavioral Problems class in China, as well as comparatively lower probabilities of depressive and anxiety symptoms in DRC and China and aggressive behaviors in China within the Maladjusted class. Further, tests of measurement invariance indicated that the prevalence and nature of these classes differed significantly by sex within each country.
Conclusions: Despite immense cultural and contextual variability across the four included countries, this study found striking similarities in patterns of emotional and behavioral problems during early adolescence. Tests of measurement invariance indicated that there were nuances between boys and girls within equivalent classes, suggesting the importance of gender in shaping the expression of psychosocial risk. Taken together, these findings can be used to support the tailoring of interventions targeting psychosocial adjustment among subgroups of early adolescents with increased vulnerability, and indicate that such programs may have wide utility across diverse cross-national settings.
Sources of Support: National Institute of Child Health and Human Development: Ruth L. Kirschstein National Research Service Award Individual Predoctoral Fellowship (F31)
#4. “I knew that my dad was going to find out”: Dismantling Barriers and Transforming the Future of PrEP Uptake in Black and Latinx Sexual Gender Minority Youth (BLSGMY)
Fiona Shorrock1, Aubrey Alvarenga1, William Vickroy2, Travis A. Cos, PhD, MS, BA3, Jennafer Kwait, PhD, MHS, BA4, Constance Trexler, BSN, MSHS2, Renata Arrington-Sanders, MD, MPH, ScM1, Kimberly Hailey-Fair, MPH CPH1
1Johns Hopkins School of Medicine; 2Children’s Hospital of Philadelphia; 3Public Health Management Corporation; 4Whitman-Walker Health
Purpose: Pre-exposure prophylaxis (PrEP) has the potential to transform HIV prevention in BLSGMY. Yet, uptake among BLSGMY remains low. Engagement in the HIV prevention cascade early is critical to reducing the burden of new infections in young people. In order to transform engagement in PrEP prevention in BLSGMY, healthcare providers and others involved in increasing access and direct care to PrEP will need to better understand and address the barriers of PrEP uptake. We sought to understand barriers, using an ecological framework, to PrEP uptake among BLSGMY at risk for or recently (last 5 years) diagnosed with HIV.
Methods: The study team conducted in-depth interviews were conducted with 33 BLSGMY (21 at-risk for and 12 recently diagnosed with HIV) ages 15-24 participating in a randomized control trial aimed at increasing PrEP and ART uptake and adherence. Interviews lasted 45-60 minutes and focused on barriers to and facilitators of prevention and treatment. Interviews were recorded and transcribed, then analyzed using inductive and deductive coding. We first created deductive codes a priori to capture information relating to established barriers to PrEP, and used inductive coding to further group codes and identify themes that emerged from the data. Coded transcripts were organized into individual, partner, family, community, and structural categories and then by HIV status. Emergent themes were grouped and categorized using a grounded theory approach.
Results: Among at-risk BLSGMY (n=21) nine (43%) reported having ever been prescribed PrEP, with five actively or recently taking PrEP, whereas only one of BLSGMY recently diagnosed with HIV was prescribed PrEP. Major themes emerged around individual, family, community, and structural PrEP barriers – individual level: themes arose around non-use due to fear of PrEP side effects, difficulty taking a daily pill, substance use hindering daily adherence, and personal views of medications (being addictive or not natural); family: fears family would find out about use and assume sexual orientation (SO), and family’s mistrust about medications; community: negative social media messages about PrEP; and structural: cost of medication, insurance (co-pays, disclosure of SO to parents via insurance claims, EOBs, and bills), and difficulty disclosing SO to provider. No significant barriers were observed relating to partners, in fact, partners with HIV commonly encouraged use. Among youth with HIV, all but one participant described not receiving information about PrEP prior to diagnosis. For both groups, PrEP was not trusted unless information came from a healthcare provider.
Conclusions: For youth to remain on a healthy life course, HIV preventative measures will need to be adopted early in adolescence. This work suggests that interventions will need to simultaneously address individual barriers, such as fear and stigma around PrEP, and community and structural barriers that relate to insurance, medication, and disclosure. Providers and health care teams will need to work together to educate and inform patients, to dismantle and demystify structural barriers related to health insurance coverage and unaffordable copays. Active work is needed to address health inequities seen in sexual, gender and racial minority groups to increase access to PrEP for all at-risk youth.
Sources of Support: NIDA-5R01DA043089 (Celentano/Sanders)
Platform Research Presentation III: Parenting and Youth Development
#9. Latina Mothers’ Perspectives on Adverse Experiences and Protection of Latinx Youth in an Agricultural Community
Deepika D. Parmar, MD, MPH1, Elodia Caballero, BA2, Alexandra M. Minnis, MPH, PhD3, Melissa S. Zerofsky, PhD1, Marissa Raymond-Flesch, MD, MPH1
1University of California San Francisco; 2UCSF School of Medicine; 3RTI International
Purpose: Adverse Childhood Experiences (ACEs) are a measure of childhood toxic stress with a dose-dependent relationship with many health outcomes in adulthood. While ACEs measure broad categories of neglect, abuse, and family dysfunction that have been validated across diverse populations, they do not capture the trauma that some adolescents experience as a result of race, ethnicity, immigration, and family history. Young Latinx are one of the fastest growing populations in the country. 54% of all Latinx youth in the United States are immigrants or children of immigrants, exposing them to distinctive personal and intergenerational trauma which are not captured by traditional ACEs. This study looks beyond ACEs to identify adverse and protective factors among Latinx youth in a rural agricultural community through the unique perspective of their mothers.
Methods: Twenty mothers of early adolescent participants in A Crecer: the Salinas Teen Health Study (a prospective cohort study of 599 adolescents) completed semi-structured interviews conducted in their preferred language. Interviews focused on mothers’ perspective on community resources and strengths, parenting strategies, their children’s positive attributes, future aspirations for their children, and parenting support systems. Interviews were transcribed verbatim and four research team members completed iterative rounds of thematic coding drawing from Garcia-Coll’s integrative model for the study of developmental competencies in minority children.
Results: Mothers in this study reported distinct layers of trauma experienced by themselves and their children including their own histories of trauma in childhood and adulthood, trauma experienced by their children, and trauma both mothers and children experience from structural factors unique to their social, political and cultural contexts. When identifying these layers of trauma, many did not fit within traditionally defined ACEs. These events included examples of systemic oppression related to migration and immigration resulting in family separation, loss of supports, and poverty. Mothers shared the impact of their own traumatic experiences on their acquisition of internal resources to trust and receive support in their community. Having experienced intergenerational trauma and systemic oppression, mothers discussed their strategies for interrupting cycles of violence, improving socioeconomic opportunities for their family, and accessing education. Language played a particularly nuanced role in family dynamics and access to structural resources, at times causing barriers not only in accessing services, but also in communication between parents and teens.
Conclusions: Latinx mothers’ provide valuable insight into protections from and exposures to trauma from their own childhood, migration, poverty, and the traumas directly experienced by their children which may have direct health implications for Latinx youth. Researcher need to further expand ACEs to include systemic disparities around immigration and race, as well as intergenerational trauma and cultural barriers to effectively screen diverse populations in the U.S. This would allow adolescent providers to identify young people at risk for developing an array of poor health outcomes and tailor interventions to reduce health disparities and promote health equity.
Sources of Support: The Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD075787, K23HD093839) and the UCSF John A. Watson Scholars Program.
#10 COVID-19 Impact on Parent/Young Adult Attitudes and Beliefs toward Vaccines for Adolescents and Young Adults
Judy K. Klein, BS1, Amy B. Middleman, MD, MSEd, MPH2, Jane R. Quinn, BS, MBA1
1Unity Consortium; 2University of Oklahoma Health Sciences Center
Purpose: The study (1) assesses the impact of COVID-19 on attitudes of parents and adolescents/young adults (AYAs) toward vaccines for AYAs and (2) captures perspectives through the phases of public health interventions, social behaviors, economic impact, and potential treatments and COVID-19 vaccines.
Methods: A multi-wave, on-line survey of two U.S. representative groups: (1) parents of AYAs ages 13-18 (n=500) and (2) AYAs ages 13-18 (n=300). Survey Wave 1 was fielded Aug 11-28, 2020. Two additional survey waves are planned during the 2020/21 flu season (Wave 2) and when COVID-19 vaccines are licensed (Wave 3). The survey replicates questions on vaccine and preventive health attitudes previously measured in Unity research conducted in 2016, generating pre-pandemic comparisons.
Results: Survey Wave 1 survey results indicate that confusion and fear around COVID-19 is impacting adolescent health beyond the risks associated with the pandemic. About half of parents report cancelled or postponed well visits due to the pandemic, translating to missing critical preventative health measures including vaccines and mental health check-ins. The data confirms that stress and anxiety are prominent in the teen pandemic experience as reported by teens and perceived by their parents. Influenza and a potential Covid-19 vaccine rate lower in importance compared to other routinely recommended adolescent vaccines. As other recent national polls of adults have reported, Wave 1 results confirm high proportions of parents of teens expect to “wait and see” about a new COVID-19 vaccine, and will actively seek assurance on vaccine safety and efficacy. Providers will be the primary, trusted source of COVID-19 vaccine information for parents while teens continue to rely on their parents for healthcare guidance and decisions. A significant proportion of teens are taking the pandemic seriously and perhaps even more so than their parents. Analyses of key responses by panel characteristics (e.g., personal experience with COVID-19, stress level, personal and household characteristics, etc.) and comparisons to Unity’s pre-pandemic survey responses will be shared.
Conclusions: This Unity survey series uniquely assesses the impact of COVID-19 on AYA preventive health and immunization. Wave 1 results reveal implications for increased and sustained urgency to catch-up and prioritize AYA missed and ongoing well-visits throughout the COVID-19 pandemic. The confusion and fear around COVID-19 is impacting adolescent health beyond the risks associated with the pandemic, highlighting the need for critical preventative health measures including vaccines and mental health check-ins. Uncertainty around the safety and efficacy of potential COVID-19 vaccines may hinder parents from vaccinating their AYAs, especially for those who believe AYA risk of severe illness is low. Vaccine stakeholders will need to unify and engage to build parent and AYA confidence to get both routine vaccines and future COVID-19 vaccine(s). This includes equipping HCPs to confidently, concisely and consistently recommend routine vaccines and addressing concerns around COVID-19 vaccine testing, safety and efficacy standards. Additional research implications include engaging AYAs to take ownership in routine vaccination and COVID-19 prevention, to positively influence their families and peers, and to create educational content for their peers.
Sources of Support: The survey is funded by Unity members including vaccine manufacturers.
#11. “Difficult To Find, Stressful To Navigate”: Parents’ Experiences With Affirming Care For Gender Diverse Youth
Kacie M. Kidd, MD1, Gina M. Sequeira, MD, MS2,Sabra L. Katz-Wise, PhD3, Molly Fechter-Leggett, PsyD4, Elizabeth Miller, MD, PhD1, Nadia Dowshen, MD, MSHP5
1UPMC Children’s Hospital of Pittsburgh; 2Seattle Children’s Hospital; 3Harvard Medical School; 4WVU Medicine; 5Perelman School of Medicine at the University of Pennsylvania
Purpose: Gender diverse youth (GDY) face significant health disparities which can be mitigated by parental support and access to gender-affirming care. Understanding parents’ perspectives as they seek guidance and care for their GDY may help improve patient and family experiences with care as well as health outcomes for GDY. The purpose of this study was to explore parent experiences with accessing affirming medical and mental health care for GDY.
Methods: We created and distributed a social media-based online survey to existing groups and listserves for parents of GDY in the United States (US) in February 2020. We asked about their experience with gender-affirming care in a single open-ended question. We also collected demographic information. Open-ended responses were coded by two authors using an iteratively developed codebook and adjudicated to reach consensus. These codes were used to identify key themes.
Results: We analyzed 273 responses from majority White (86.4%), female-identifying (90.0%), and geographically diverse (from 43 US states) parents. Themes included GDY thriving due to care, the components of positive experiences, and barriers associated with negative experiences. Participants shared that gender-affirming care was “literally live-saving” for their child and allowed their child to thrive (“His grades at school sky rocketed. He found his place in the world”). Parents cited feeling fortunate they were able to access care for their child and described positive experiences where providers focused on their needs as a family (“It made all the difference for my child to be seen, validated, and treated professionally with the medical care they needed”). Negative experiences centered around barriers to accessing care for their child, including: 1) lack of insurance coverage for care and/or high cost of care (“Our insurance copay for her blockers was $1600 and we hadn’t been able to do it”), 2) limited number of trained providers, (“Difficult to find. You have to know someone who knows someone”), provider ignorance (“They were traumatic visits with transphobia and mis-information”), and long wait times (“I called for an appointment in September when we saw signs that she was in puberty. They booked us nine months out”), 3) protocols and policies at the provider and clinic levels that undermined attempts to access care (“…Referral process for puberty blockers is very strict and conservative. It took us months to prove our case…”; “There has been a ‘one size fits all’ protocol that created problems”; “The endocrinologist’s office turned us away saying that she doesn’t do that”), and 4) geographic limitations for those living outside major cities, (“There is currently only one gender clinic in my state and we have to drive four hours one way to go to appointments with the team”).
Conclusions: While parents of GDY often described accessing gender-affirming care as positive, significant barriers remain, including cost, limited insurance coverage, a lack of trained providers, access-limiting protocols, and geography. Greater attention to provider education and focused efforts to eliminate barriers to care can help mitigate health inequities among GDY.
Sources of Support: Dr. Kidd is supported by NCATS, Award Number TL1TR001858.
#12. Youth Leadership in Action (YLIA): Feasibility of implementing a Youth Participatory Action Research program in inner-city public schools and communities
Namita Dwarakanath, Nicholas Szoko, MD, Elizabeth Miller, MD, PhD
University of Pittsburgh School of Medicine
Purpose: Youth Participatory Action Research (YPAR) is one type of community-partnered participatory research through which young people are engaged in the process of identifying, analyzing, and addressing challenges in their environment. We partnered with young people in Pittsburgh to implement Youth Leadership in Action (YLIA), a multisite initiative adopting a YPAR framework. We focused on recruitment of youth who would not historically be recognized as ‘leaders’ in their communities, including youth at risk for school ‘push out.’ Our primary goals were to promote youth empowerment, foster resilience, and generate contextual responses to youth-identified needs in their schools and communities. Longitudinal aims of this intervention include: increased academic achievement; greater self-efficacy, peer connectedness, and future orientation; and decreased mental and emotional stress from prior trauma.
Methods: We implemented YLIA at four sites, which included three urban schools (in-school and after-school) and one community center, in areas of concentrated disadvantage throughout Pittsburgh. Participants were recruited through school administrator referrals, word of mouth from peers, and outreach to existing youth violence prevention programs. Sessions occurred approximately once weekly over the course of the academic year. With the YLIA curriculum, youth performed a collaborative needs assessment, developed a proposed intervention, and worked with stakeholders to facilitate implementation of their project. These projects were the primary outcome. Additional outcomes included: feasibility/acceptability of programming; academic performance, school attendance, and disciplinary referrals; impact on personal development; and impact on interpersonal relationships. Data for secondary outcomes were gathered from de-identified school records, cross-sectional surveys, and semi-structured qualitative interviews. Descriptive statistics were used to summarize survey data. Narrative interviews were transcribed, coded, and analyzed using a content analysis approach.
Results: Approximately 80 youth participated across all sites; 63 respondents at three sites completed surveys. Median age was 15 (range 12-19). The majority of participants were referred by a friend (82%). Most attended greater than six sessions (58%). Projects emerging from YLIA included: a peer-led mental health support group; a trauma-sensitive decompression room; a food drive for surrounding neighborhoods; and artwork for the local community. Students in the in-school program had improved attendance, better academic performance, and reduced disciplinary referrals. Semi-structured interviews revealed high feasibility and acceptability, increased peer connectedness, and improved mental health among participants.
Conclusions: YLIA represents a promising initiative to generate meaningful and contextual social change. Programmatic outcomes from YLIA were diverse, as youth adapted their responses to their respective school or community needs. Participants and stakeholders noted high feasibility and acceptability of the program, highlighting impact on personal development and interpersonal relationships. YPAR models such as YLIA may have particular relevance in oppressed communities, among marginalized youth, especially those at risk for school ‘push out’ for whom participation in societal change has been profoundly constrained. Next steps include adapting this model to a virtual format and exploring additional implementation settings.
Sources of Support: None
Platform Research IV: Salient topics in Adolescent Health
#13. Does Tobacco Screening in Youth Primary Care Identify Youth Vaping?
Jessica Liu, MPH1, Bonnie Halpern-Felsher, PhD2, Sion Harris, PhD3
1Harvard T.H. Chan School of Public Health; 2Stanford University; 3Boston Children’s Hospital
Purpose: The significant rise in youth electronic cigarette (e-cigarette) use in recent years threatens to erase decades of progress in reducing youth tobacco use, as e-cigarette use significantly increases risk for combustible cigarette use. The increase began after the introduction of JUUL in 2015, and, according to national Youth Risk Behavior Survey data, past-30-day nicotine vaping rose from 13.2% in 2017 to 32.7% in 2019 among U.S. high school students. The primary care setting has long been an important venue for screening and brief intervention for tobacco use, and the U.S. Preventive Services Task Force continues to recommend tobacco screening in primary care. However, currently available validated adolescent substance use screening tools for use in primary care do not specifically inquire about e-cigarette use and instead use general questions about tobacco use. It is unknown the degree to which such a general question captures e-cigarette use. The purpose of this study was to evaluate the sensitivity of a previously validated adolescent tobacco use screening question, modified to include the word “e-cigarette,” in detecting past-12-month nicotine vaping and past-12-month tobacco product use inclusive of nicotine vaping, among adolescent patients.
Methods: We conducted secondary analysis of data collected from 2015-2017 during a previously published clinical trial of adolescent substance use screening and brief intervention in pediatric primary care. Participants aged 12-18 years (N=278) presenting for annual well-visits were consecutively recruited from 5 pediatricians’ offices in Boston. Study data consisted of (1) responses to a validated screening item where participants were told their responses could be seen by their clinician, modified to included e-cigarettes and worded: “During the past 12 months, on how many days did you use any tobacco products (for example, cigarettes, e-cigarettes, hookahs, or smokeless tobacco)?” and (2) responses to a confidential substance use survey collected for research purposes only. We analyzed data in R, assessing sensitivity of the clinical screening responses compared to the confidential survey responses (criterion measure).
Results: Median age of participants was 16 (interquartile range 15-17); 47.8% were girls; 74% had college-graduate parents; and the sample was racially/ethnically diverse (50.5% White non-Hispanic, 10.4% Black non-Hispanic, 25.3% Hispanic, and 13.8% Other race/Multi-racial). The screening question elicited a prevalence of 9.0% (n=25) with past-12-month tobacco product use (including e-cigarettes). On the criterion measure, 10.8% (n=30) endorsed past-12-month use of an electronic vapor product (an additional 3 participants who solely vaped marijuana were excluded), and 15.1% (n=42) reported past-12-month use of any tobacco product, inclusive of electronic vapor products. Compared to the criterion measure, the screening question identified 15 out of 30 (sensitivity 50.0%) who reported past-12-month e-cigarette use, and 25 out of 42 (sensitivity 59.5%) who reported any tobacco/e-cigarette use.
Conclusions: Among adolescents screened in pediatric primary care during the early years of the adolescent e-cigarette use epidemic, an existing validated tobacco use screening question had low sensitivity for identifying patients who used e-cigarettes. These findings support the need for a new validated tobacco product use screening measure that is sensitive for capturing e-cigarette or vaping product use.
Sources of Support: N/A
#14. One-year outcomes from a Multi-Center Randomized Controlled Trial (RCT) of Refeeding in Anorexia Nervosa: The Study of Refeeding to Optimize iNpatient Gains (StRONG)
Neville H. Golden, MD1, Jing Cheng, PhD2, Cynthia Kapphahn, MD, MPH1, Sara M. Buckelew, MD2, Vanessa I. Machen, MS, RD2, Anna A. Kreiter, PsyD1, Erin C. Accurso, PhD2, Sally H. Adams, PhD, RN2, Daniel Le Grange, PhD2, Anna-Barbara Moscicki, MD3, Allyson Sy, MS, RD1, Leslie S. Wilson, BS, RN, PhD2, Andrea K. Garber, PhD, RD2
1Stanford University School of Medicine; 2University of California, San Francisco; 3University of California, Los Angeles
Purpose: We recently reported the short-term results of this RCT, demonstrating that higher calorie refeeding (HCR) restored medical stability earlier with no increase in safety events, and significant savings associated with shorter length of stay as compared to lower calorie refeeding (LCR) in hospitalized adolescents and young adults with anorexia nervosa (AN). Here we report the one-year outcomes including rates of clinical remission, rehospitalization rate, number of readmissions, and total number of hospital days following the initial admission.
Methods: This RCT compared HCR and LCR in patients admitted to two large tertiary care eating disorder programs for medical instability. Inclusion criteria included age 12-24 y and diagnosis of AN or atypical AN. Exclusion criteria included diagnosis of ARFID or bulimia nervosa, extreme malnutrition (< 60% median BMI (mBMI)). Within 24 h of admission, participants were randomly assigned to HCR (2,000 kcals/d, increasing by 200 kcals/d) or LCR (1,400 kcals/d, increasing by 200 kcals every other day). Calories were provided by meals, with oral liquid replacement for food refusal. Data were collected prospectively by study personnel daily in hospital, and at day 10, month 1, 3, 6 and 12 after discharge. Clinical remission was defined as achieving weight restoration (≥ 95 % mBMI) plus an EDE-Q global score within 1 SD of community norms. Generalized linear mixed effect models examined differences in clinical remission over time. Fisher’s exact tests and Wilcoxon rank sum test compared categorical and continuous variables respectively. Data are presented as mean (SD).
Results: Of 120 participants enrolled, 111 were included in modified intention-to-treat analyses, 60 received HCR and 51 LCR. Participants were 91% female, 81% white, 78% non-Hispanic, 16.4 (2.5) yrs old and 84.9 (11.7) % mBMI at admission. Although clinical remission changed over time in both groups (P=0.0001), there was no evidence of significant group difference in change of remission over time (HCR 20%, 16.7%, 26.7%, and 30%, and LCR 15.7%, 25.5%, 19.6%, and 25.5% at 1, 3, 6, and 12 months after discharge, P=0.56). Rehospitalization rates within 12 months after the initial admission [31.7% (19/60) vs. 33.3% (17/51, p=.80], number of rehospitalizations [0.79 (1.7) vs. 0.71 (1.3), p = .86], and total number of days rehospitalized after initial stay [6.0 (14.8) vs. 5.1 (10.3) days, p= .81] did not differ by HCR vs. LCR .
Conclusions: In the first RCT in the U.S. to compare refeeding approaches in AN, we did not find evidence of difference between HCR and LCR in rates of clinical remission, rehospitalization, number of readmissions, and number of days hospitalized over 12-mo post discharge.
Sources of Support: National Institute Child Health & Human Development #R01HD082166; ClinicalTrials.gov Identifier NCT02488109
#15. Associations between Race-Based Discrimination and Past 30-Day Substance Use among Predominantly Black Youth Residing in Urban Neighborhoods
Lynissa R. Stokes, Ph.D., Alison J. Culyba, MD, Ph.D., MPH, Amber L. Hill, MSPH, Ph.D., Namita Dwarakanath, Jordan Pollard, BSW, Elizabeth L. Miller, MD, Ph.D., Ashley V. Hill, DrPH, MPH
University of Pittsburgh
Purpose: Experiences of race-based discrimination among Black and other minority youth may influence substance use behaviors, leading to adverse health and social outcomes. We examined associations between race-based discrimination and substance use among a predominantly Black sample of youth.
Methods: Adolescents aged 13 to 19 were recruited through youth-serving community agencies in Pittsburgh, PA from 2017-2019 to participate in one of two cluster-randomized trials comparing gender-transformative, community-based sexual violence prevention programs (Manhood 2.0 and Sisterhood 2.0) to job readiness training. Participants provided demographic information, completed a questionnaire about experiences with ten different discriminatory situations, and reported the frequency of past 30-day cigarette, alcohol, and marijuana use, which was then dichotomized to “use”/”non-use.” Logistic regression models were adjusted for age, race/ethnicity, suspension history, and intervention status.
Results: Manhood 2.0 data are presented first. Average participant age was 15.5 (SD = 1.6) and 15.2 (SD = 1.5). Most participants self-identified as Black/African American (71.6% and 61%) and heterosexual (79.5% and 61.5%). Most youth reported experiencing at least one race-based discriminatory encounter (82.1% and 82.9%). Being accused of something they didn’t do was reported by 63.6% and 66.7% of youth. Male and female youth reported similar rates of past 30-day alcohol (21.8% and 22.2%) and marijuana use (34.1% and 41.9%). A higher proportion of male (23.4%) compared to female youth (13.4%) reported past 30-day cigarette use. For males, overall discrimination was unrelated to past 30-day substance use. Being watched by a security guard was associated with greater odds of alcohol (adjusted odds ratio [AOR]=1.56;95% CI:1.02-2.39) and marijuana use (AOR= 1.62;95% CI:1.11-2.36). Witnessing a family member or friend being mistreated was associated with greater odds of alcohol use (AOR=1.73;95% CI:1.10-2.70). Unfair police treatment was associated with increased odds of cigarette (AOR=2.04;95% CI:1.34-3.11), alcohol (AOR, 1.81; 95% CI, 1.18 – 2.79), and marijuana use (AOR=2.17;95% CI:1.49-3.18). For females, overall discrimination was associated with greater odds of past 30-day marijuana use (AOR=1.11;95% CI:1.00-1.24). Being watched by a security guard was associated with greater odds of alcohol use (AOR=2.33;95% CI:1.05-5.13). Unfair police treatment was associated with greater odds of cigarette (AOR=3.70;95% CI:1.38-9.88), alcohol (AOR=3.04;95% CI:1.35-6.85), and marijuana use (AOR=3.20;95% CI:1.55-6.62).
Conclusions: Discriminatory experiences are common among youth of color in the U.S., and substance use may represent one coping strategy for stress induced by discrimination. Adolescent health professionals should consider assessing race-based discriminatory experiences and associated stress among youth of color who engage in substance use. Community-level and public health interventions designed to combat racism experienced by youth are needed.
Sources of Support: Funding for the original studies include: 1) Manhood 2.0 – Centers for Disease Control and Prevention (U01CE002528; PI: Miller) and 2) Sisterhood 2.0 – Department of Human Services (PI: Miller). The research was also supported by the National Institute of Child Health and Human Development (T32HD087162 to Lynissa R. Stokes; PI: Miller).
#16. Adolescent Perceptions of Menstruation on Twitter: Opportunities for Advocacy and Education
Shelby Hannah Davies, MD1, Miriam Langer, MD1, Ari Z. Klein, PhD2, Graciela Gonzalez-Hernandez, PhD2, Nadia Dowshen, MD, MSHP1
1Children’s Hospital of Philadelphia; 2University of Pennsylvania
Purpose: Menstrual health and hygiene is an important part of adolescent sexual and reproductive health. While many adolescents celebrate menstruation as an important rite of passage, many seek discretion around menstruation due to stigma. Social media sites like Twitter have the potential to benefit adolescents through the provision of social support and information but may also perpetuate myths and misinformation. Many youth have used Twitter and other social media to combat stigma and raise awareness about other culturally taboo topics, but previous work has not explored youth conversations regarding menstruation. The purpose of this study is to assess whether Twitter can provide useful insights into how youth perceive menstruation.
Methods: The research team searched 162,316,839 publicly available tweets of 71,443 users in the HLP Twitter Youth Cohort for tweets that matched menstruation-related keywords: a pad, my pad, my period, her period, your period, tampon, diva cup, menstruate, that time of the month. This cohort was previously identified by using birthday-related keywords to query the Twitter Streaming API from July to September of 2019, then using precise regular expressions to select users between the ages of 13 and 25, inclusive. The expressions were manually validated at 91% precision using a subset of 500 tweets. Twelve categories emerged from these tweets that were identified by content analysis using a grounded theory approach. Once identified, categories were sorted into three major themes.
Results: Analysis was conducted on 20,722 total tweets by adolescents in the cohorts searched. The three major themes that emerged included: health concerns, fostering menstrual stigma, and promotion of positivity. Within the theme of health concerns were the following categories: menstrual health and complications; sexual and reproductive health; LGBTQ health and biases; and education and misinformation. Categories of tweets that addressed fostering menstrual stigma included: inconvenience and limitations; self-deprivation or self-harm; shame and stigma; superstitions, folklore or religion; and access and affordability. The minority of tweets were related to the promotion of positivity and included the following categories: awareness, community and connectivity; strength and resilience; and environment and sustainability.
Conclusions: This qualitative content analysis of Twitter user posts about menstruation provides insights into the youth perceptions about their menstrual health and hygiene. The themes identify that Twitter may serve as a potential source of information for youth. Youth openly tweeted about issues that are typically perceived as sensitive and personal. There was also overwhelming emphasis placed on the negativity, inconvenience and shame that surrounds menstruation, including physical and emotional distress. There was rare mention of the celebratory aspects of menstruation as it reflects maturation, development, or positive reproductive potential. The majority of categories contained tweets that were directly or indirectly related to advocacy or education, which supports the potential use of Twitter as a platform to combat stigma and raise awareness regarding menstruation. Social media sites like Twitter may be a helpful tool to improve public health messaging regarding menstruation, transform health outcomes and promote equity among youth who menstruate.
Sources of Support: This study received grant funding from the University of Pennsylvania Center for Experimental Ethnography.
Poster Symposia I: Promoting Sexual and Genitourinary Health
#17. Creating a Research Program to Promote Bladder Health in Adolescent Women
Deepa R. Camenga, MD, MHS1 Amanda Berry, PhD, CRNP2, Melissa Constantine, PHD, MPA3, Sheila Gahagan, MD, MPH4, Diane Newman, DNP5, Kyle Rudser, PhD3, Tamera Coyne-Beasley, MD, MPH6, Lisa Kane-Low, PhD, RN, CNM7, David Shoham, PhD8, Peter Scal, MD, MPH3
1Yale School of Medicine; 2Children’s Hospital of Pennsylvania; 3University of Minnesota; 4Univeristy of California San Diego; 5University of Pennsylvania;
6University of Alabama Birmingham; 7University of Michigan; 8Loyola University
Purpose: The majority of women over the course of their lifetime eventually experience lower urinary tract symptoms (LUTS), such as dysuria, urgency, or incontinence. It is currently unknown how to best promote bladder health in women across the life course. The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium, funded by the National Institutes of Health, aims to identify factors that promote female bladder health from adolescence to older adulthood. PLUS recognizes the importance of adolescence as a critical period for prevention and the formation of lifelong bladder health behaviors. This research program description will introduce the PLUS Research Consortium and describe its adolescent-focused research components.
Methods: To foster a transdisciplinary, life course-informed research program, PLUS includes scientists, community advocates, and healthcare professionals from 8 U.S. research centers across a broad range of disciplines including adolescent health. Current components of adolescent-focused PLUS research include: a) national focus group studies of adolescent women to understand perceptions, language, and experiences around bladder health, b) measurement and validation studies focused on creating a psychometrically-sound instrument to assess bladder health, and c) secondary data analyses of the Avon Longitudinal Study of Parents and Children (ALSPAC) study. These research activities directly inform the design of a nationally-representative observational study of U.S. adolescent women to examine the prevalence and predictors of bladder health. Recognizing the valuable first-hand perspectives and expertise of youth, we incorporate a community engagement strategy that includes a Young Women’s Health Council, comprised of 13- to 21-year-old adolescent and young adult women from across the country, who meet regularly by videoconference.
Results: PLUS researchers collaborated to create a definition of bladder health that is applicable across the life course: “A complete state of physical, mental and social well-being related to bladder function, and not merely the absence of LUTS.” To date, we have completed 27 focus groups with socioeconomically and racial/ethnic diverse samples of 11- to 17-year-old adolescent women across the U.S. The data will inform the development of a novel adolescent bladder health instrument that will be used in a future observational study, as well as measures of knowledge, attitudes and beliefs, toileting practices and behaviors, and toileting environment. Secondary data analyses of the ALSPAC cohort have focused on bullying, school environments, and sexual health behaviors and their relationship to bladder health. The Young Women’s Health Council has met monthly for one year and helped provide feedback on the measurement study specifically.
Conclusions: Expertise from adolescent health researchers is critical for the transdisciplinary, life course-informed approach to PLUS research. Ultimately, PLUS research aims to catalyze the development of prevention interventions and policies that promote optimal bladder health in adolescent women. Ultimately, PLUS research aims to catalyze the development of prevention interventions and policies that promote optimal bladder health in adolescent women.
Sources of Support: N/A
#18. The Probability of Anovulatory Cycles in Primary Dysmenorrhea in Adolescents
Alkim Oden Akman, PhD1, Gurkan Bozdag2, Melis Kizilkan-Pehlivanturk2, Sinem Akgul, MD, PhD2, Orhan Derman, MD2, Nuray Kanbur, MD2
1Ankara City Hospital, Childrens’ Hospital; 2Hacettepe University School of Medicine
Purpose: Primary-Dysmenorrhea (PD) is believed to be caused in large part by the overproduction of uterine prostaglandins leading to the assumption “ovulation is necessary for the development of PD”. However several studies have reported the possibility of dysmenorrhea with anovulation. Although serial transvaginal ultrasound is the gold standard method for ovulation confirmation, it’s not a practical method in adolescents. Determining the luteal phase SP level could be the second-best method. When the literature is reviewed, the serum progesterone (SP) threshold value for the adolescent age group showing ovulation should be updated. Our study aimed to evaluate the presence of anovulation in adolescents with PD and determine a threshold SP level as a marker for ovulation in adolescents.
Methods: The ‘Numerical rating scale’ (NRS ≥4 PD group, <4 control group) was used to assess menstrual pain severity. Participant’s age, anthropometric measurements, menstrual, and family history of dysmenorrhea were recorded. Participants were evaluated 3 times during 1 menstrual cycle: suprapubic pelvic ultrasound at 12-18th days of menstruation (DOM), first SP level measurement at 21-24th DOM, and second measurement at 28-31st DOM. Among progesterone measurements at the second and third visits, the highest value was used for the analyses. The presence of ovulation in the PD and control groups was assessed based on both the two threshold references of 3 ng/mL and 5 ng/mL and the presence of follicles with sizes ≥10 or ≥11 mm on ultrasound.
Results: A total of 77 healthy adolescent girls were included in the study. No significant difference was found between the groups in terms of age, BMI, menstrual, and family history of dysmenorrhea. Anovulatory cycle rates according to 2 different references for SP threshold values (3 and 5 ng/mL) were; 31.7% and 44.4% in the PD group, and 36.6% and 55.6% in the control group, respectively (p=0.250, p=0,095). In the PD group NRS scores were similar for the ovulatory and anovulatory cycles for both SP threshold values (p=0.320, p=0.205). Among all participants (n=77) no significant difference was determined in terms of the presence of ≥ 10 mm and ≥ 11 mm follicles according to two SP threshold values. When the reference value for the SP threshold was accepted as ≥ 5 ng/mL, the NRS score was significantly higher in the ovulatory group (p=0.001). When the distribution percentages of SP levels were evaluated among all participants, the median value was 5.5 ng/mL.
Conclusions: Anovulatory cycles are not few in PD patients and pain severity is at the same level when compared with ovulatory cycles. This result is contrary to the classical information on the necessity of ovulation for PD, suggesting that further evidence-based studies are needed on this issue. In this study, the presence of ovulation was evaluated with SP levels and follicle sizes on suprapubic ultrasound in the adolescent age group, and it was found that a threshold value of 5 ng/mL has the highest diagnostic value.
Sources of Support: The budget of the study was provided by the scientific research project coordination unit of our hospital.
#19. Confidential Contraception Protections for Adolescents in Foster Care in Texas
Jenny K. Francis, M.D., MPH1, Justin Kramer, PhD2, Victoria K. Sanchez, M.S.2, Reshma Narain, Bachelor of Arts2, Heidi K. Roman, M.D.3, Jill D. McLeigh, PhD3, Simon Craddock Lee, PhD2
1University of Texas Southwestern Medical Center / Children’s Medical Center; 2University of Texas Southwestern Medical Center; 3Children’s Medical Center in Dallas
Purpose: We analyzed documents from regulatory agencies and national societies to determine the confidential protections in place for adolescents in foster care seeking contraception.
Methods: We used framework analysis to group relevant and publicly available documents into five levels: federal (3 documents from Title X, Code for Federal Regulations and HIPAA); state (8 documents from Texas Family Code, Health and Safety Code or Texas Department of State Health Services); local (10 documents from a tertiary care pediatric health system policy repository); foster care (7 documents from Texas Department of Family and Protective Services or TDFPS and reports from regional non-profit organizations); and medical society (10 statements/guidelines from national medical societies). Each document was coded for “yes” (i.e., explicit language noting confidential protections for adolescents who consent to contraception), “no” (i.e., explicit language noting lack of these confidential protections), “deferred” (i.e., language that deferred decision about confidential protections to another government body), or “ambiguous” (i.e. lack of explicit or implicit language about confidential protections). Documents were coded by two independent coders using NVivo 12 Pro (QSR International, AUS). Discordance was resolved by consensus.
Results: Of the 38 publicly available relevant documents examined, consistent confidential protections for adolescents was explicitly stated from federal documents alone. National medical societies also stated strong positions in favor of confidential protections, yet eight societies used deferral language: “adolescents’ legal rights to contraceptive services vary by state and change over time…refer patients to Title X-funded clinics for confidential contraceptive services if they are unable to provide confidential care” (ACOG, Committee Opinion 2017). Among state documents, we found explicit language to not support confidential protections for adolescents: “Minors must get a parent’s permission to receive prescription contraception.” (Texas Department of State Health Services, Adolescent Health: A Guide for Providers, 2016). Among local documents, we found no document that explicitly protected adolescent contraceptive services. Finally, among foster care documents, explicit language was used to protect confidential contraceptive services: “all Texas foster youth are eligible for Medicaid (via CHIP), which guarantees confidential access to contraception.” Of the remaining foster care documents, two did not reference contraception for adolescents, and three articulated ambiguous positions: “Texas law requires that you [caregiver] take part in all of the child’s health care appointments” (Medical Consent Training for Caregivers, 2020) yet does not guide the reader about adolescent confidential contraceptive services.
Conclusions: Few documents directly guide Texas providers about confidential contraception services for adolescents in general or in foster care. Patient funding source or site (i.e. Medicaid funding or Title X site) reflects the strongest pattern for when explicit language is consistently used to protect an adolescent’s confidential contraceptive service. We found absences in state and local level documents which suggests inconsistencies with federal documents. Thus, our results reflect an interpretation of a gap in guidance about confidential contraceptive services from state and local levels. Future research should explore how healthcare providers manage the gap between inconsistent priorities and guidance across levels to improve confidential contraceptive delivery for adolescents in Texas, including foster care.
Sources of Support: Children’s Health CCRAC; K23HD097291
#20. Sexual Minority Female Adolescents Are More Likely to Receive Sexually Explicit Messages and Experience Fear From Unwanted Messages Compared to Their Heterosexual Female Peers
Julie S. Downs, PhD1, Amie M. Ashcraft, PhD., MPH, MS2, Anna Maria Berta, MS1, Jason Chang, MS, BS3, Karin Coyle, PhD, MS, BA3, Mandy Beth Lanyon1, Susan C. Potter, MS3, Pamela J. Murray, MD, MHP, MS4
1Carnegie Mellon University; 2West Virginia University; 3ETR; 4Harvard University
Purpose: With the ubiquity of digital communication, adolescents are engaging in exchanges of digital text messages and images of a sexually explicit nature, also known as sexting. We explore the relationships between sexting, sexual orientation, and behavior among a cohort of female adolescents.
Methods: In a group randomized controlled trial of a behavioral intervention, baseline data were collected from N=864 female adolescents in groups of 4-14 across six states. Follow-up data are not included. Among other questions, the survey asked participants to self-report their sexuality (heterosexual, gay, lesbian, bisexual, or other), past sexual behavior (having ever engaged in vaginal sex, or having in the past 3 months had oral or anal sex), having ever sent or received explicit sexual messages, and demographics, including age (14-19) and racial and ethnic background (African American non-Hispanic 57.7%, Hispanic 17.6%, and Other non-Hispanic 24.7%). Four multilevel logistic analyses (youth within group) explored whether past sexual behavior and self-identification as non-heterosexual were related to participants having (1) sent sext messages (2) received sext messages, (3) received unwanted sexually explicit digital pictures, and (4) been contacted online by an unknown person and felt scared or uncomfortable. All models controlled for age and race/ethnicity. A second set of analyses explored age as a moderator by including an interaction term including age and orientation.
Results: Sexual orientation was significantly related to all four outcomes. Sexual behavior contributed unique variance to models addressing sending and receiving texts but was not significantly related to the two outcomes assessing unwanted contact. Adolescents identifying as non-heterosexual were more likely to report sending sexually explicit messages [37.6% vs. 22.3%, p<0.01, OR = 1.76 (95% CI: 1.16, 2.67)], receiving sexually explicit messages [72.9% vs. 52.7%, p<0.001, OR = 2.12 (95% CI: 1.42, 3.17)], receiving unwanted explicit pictures [40.7% vs. 30.0%, OR = 1.56 (95% CI: 1.10, 2.22)], and feeling scared or uncomfortable after being contacted online by an unknown person [48.4% vs. 25.3%, OR = 2.71 (95% CI: 1.93, 3.79)]. Participants reporting having engaged in any kind of sexual behavior were more likely to report sexting, including sending [47.2% vs. 12.6%, OR = 5.34 (95% CI: 3.49, 8.17)] and receiving [73.9% vs. 46.9%, OR = 2.95 (95% CI: 2.03, 4.29)] messages, and receiving unwanted pictures [37.2% vs. 29.8%, OR = 1.41 (95% CI: 1.00, 1.99). Age had no moderating effect. Similar patterns and significance levels held comparing heterosexual and other participants for all sexting outcomes when demographics were excluded, but sexual behavior was no longer significant for receiving unwanted sexual pictures.
Conclusions: Many adolescents in our sample report engaging in sexting. Consistent with existing studies, we found a significant relationship between sexting behavior and sexual orientation, with sexual minorities experiencing higher rates. Prior sexual behavior was related, but not if the sexting was unwanted. Youth in this sample who identify as non-heterosexual were more likely to experience unwanted messages. None of these relationships was moderated by age. These findings can inform messaging and programming to protect youth from the potential negative effects of sexting.
Sources of Support: N/A
#21. Missed Opportunities to Provide Comprehensive Sexual and Reproductive Healthcare Among Hospitalized Adolescents
Janna R. Gewirtz O’Brien, MD, Maura Shramko, MPP, PhD, Maya A. Sayarath, Elena Brown, MD, Taylor A. Argo, MD, Christy M. Boraas, MD, MPH, Annie-Laurie McRee, DrPH, MPH
University of Minnesota
Purpose: Despite reaching historic lows, adolescents continue to experience high rates of unintended pregnancy and account for roughly a quarter of all chlamydia and gonorrhea cases. Even when adolescents interface with the healthcare system, they often do not receive the recommended sexual and reproductive health (SRH) care, such as sexually transmitted infection (STI) screening and contraceptive counseling. Inpatient settings may be a feasible venue for addressing adolescent SRH. We sought to examine the delivery of sexual and reproductive healthcare among hospitalized adolescents and associations with long-term SRH outcomes.
Methods: We conducted a retrospective cohort study using electronic health records (EHR) from all birth-assigned female adolescents aged 12-20 years, admitted to a large urban healthcare system from January 2015 through December 2017, excluding obstetric admissions. We extracted quantitative data elements (demographics, STI testing, contraceptive methods, pregnancy testing), as well narrative notes. We examined delivery of sexual health services, including STI testing and pregnancy, during the initial hospitalization and then in follow-up encounters through August 2019. Drawing on previous studies, we used natural language processing technology to identify all adolescents with notes containing the term “sexual*”, our key search term indicating the provision of SRH history and/or counseling during initial admission. In this search term, the asterisk was used to capture words containing additional letters beyond the root word listed (e.g. sexuality, sexually).
Results: Our sample included 4,513 adolescents, with a mean age of 16.1 years (SD=2.25) at admission and the majority of the sample identifying as White (66.4%). During the initial admission, the proportion of adolescents tested for STIs was low (chlamydia 8.1%, gonorrhea 8.2%), though just over half were tested for pregnancy (56.7%). Following discharge, fewer than 2% of the sample tested positive for STIs or pregnancy (chlamydia 1.8%, gonorrhea, 0.4%, pregnancy 0.9%), though only one-quarter of the sample were tested for STIs and half for pregnancy in follow-up. EHR notes reveal that 51.6% of adolescents had a note documenting the term “sexual*”, suggesting that they may have received SRH history and/or counseling.
Conclusions: Although the inpatient setting could be a natural setting for addressing adolescent SRH, our preliminary findings suggest that only a small proportion of hospitalized adolescents are receiving these important recommended services. Future analyses will: (1) describe the services received in greater detail through manual coding of EHR notes in a random sub-sample of 10% of patients, (2) corroborate key search terms through manual coding of this subsample, and (3) examine how missed opportunities to provide SRH services relate to long-term sexual health outcomes using multivariable logistic regression, to be completed by December 2020. Additional research is needed to support hospitalists caring for adolescents regarding best practice for the provision of adolescent SRH services in the inpatient setting.
Sources of Support: JRGO’s work was supported through the Leadership Education in Adolescent Health Training Program, funded through the Maternal Child Health Bureau (#T71MC00006; PI: Sieving).
#22. Examining Disparities in STI/HIV Testing and Contraception Care Receipt among Sexually Active Adolescents Who Are Women of Color Who Have Sex with Women
Jen Makrides, MD, MA, MHS, Pamela Matson, PhD, MPH, Renata Arrington-Sanders, MD, MPH, ScM, Maria Trent, MD, MPH, Arik V. Marcell, MD, MPH
Johns Hopkins University
Purpose: Sexual minority women and women of color in the United States are at increased risk for STIs and unintended pregnancy. However, we know little about the receipt of STI/HIV and contraception care among adolescents at this intersection, who are women of color who have sex with women (WCSW). This study’s goal was to describe adolescent WCSW’s STI/HIV testing and contraceptive care receipt to help identify areas for improvement in equity of care.
Methods: We analyzed three cycles of cross-sectional data from the nationally representative household-based National Survey of Family Growth (2011-13; 2013-15; 2015-17). The analytic sample consisted of 1,637 sexually active 15-19 year old females; this analysis was IRB approved as exempt. We evaluated four care outcomes: receipt of STI testing, HIV testing, birth control counseling, and birth control method/prescription during the last 12 months. Our primary independent variables included sex of sex partner (opposite-sex only, same-sex only, both sexes) and self-reported race/ethnicity (non-Hispanic (NH) White, NH Black, Hispanic, other). We conducted separate Poisson regression models to examine associations between each independent variable and outcome, using opposite-sex only and NH White as references, respectively. We also ran a stratified model to evaluate for antagonism or synergism between the independent variables, with and without adjusting for sociodemographic factors.
Results: 76.5% of the sample reported opposite-sex only partner(s), 4.2% same-sex only partner(s), and 19.4% both; 54.1% identified as NH White, 18.8% NH Black, 22.6% Hispanic, and 4.4% “other”. Examining sex of sex partner, all care receipt was lower among those with same-sex only partners than those with opposite-sex only and both sex partners; HIV test receipt was significantly higher among those with both sex than opposite-sex partners (aRR/95% CI: 1.37/1.04-1.81). Examining race/ethnicity, HIV test receipt was higher among NH Blacks (aRR/95% CI: 2.15/1.55-2.98) than NH Whites. Regarding contraceptive care, NH Blacks (aRR/95% CI: 0.79/0.59-0.94) and Hispanics (aRR/95% CI: 0.64/0.51-0.81) reported lower birth control method/prescription receipt than NH Whites; no significant differences were seen regarding birth control counseling. Stratified analysis demonstrated persistence of race/ethnicity differences among sex of sex partner groups with regard to HIV test and birth control method/prescription receipt. HIV test receipt was higher among NH Blacks whose partners were opposite-sex only (aRR/95% CI: 2.31/1.58-3.39) and both sexes (aRR/95% CI: 2.09/1.23-3.53) than NH Whites. Conversely, birth control method/prescription receipt was lower among Hispanics whose partners were opposite-sex only (aRR/95% CI: 0.66/0.52-0.85) and both sexes (aRR/95% CI: 0.53/0.34-0.82), and among NH Blacks with both sex partners (aRR/95% CI: 0.65/0.44-0.95), than NH Whites, but not for the same-sex only group.
Conclusions: Adolescents who are WCSW reported higher HIV test receipt but lower contraception care receipt than NH Whites and women with opposite-sex only partners. Study findings of disparities in care receipt highlight the need to improve overall care delivery to adolescents who are WCSW. Future research is needed to better understand the factors that contribute to inequities in care receipt.
Sources of Support: National Institute of Child Health and Human Development T32HD052459 (PI: Trent)
Poster Symposia II: Violence Prevention and Juvenile Justice
#23. Violence Perpetration Among Early Adolescents in an International Context
Sam Beckwith, Robert Wm. Blum, MD, MPH, PhD
Johns Hopkins Bloomberg School of Public Health
Purpose: While reduction of adolescent violence is a high domestic and global priority, there are notable gaps in the existing literature that potentially impact violence prevention programming. First, most research is based on data from high income countries. Second, much of the adolescent literature focuses on dating violence excluding those (especially early adolescents) who are not in relationships. In this study, we identify factors associated with violence perpetration among 10-14 year old boys and girls from low, middle, and high income countries and identify common risk and protective factors that cross geography and cultural context.
Methods: The study sample consists of 6,565 young adolescents 10-14 years old from Flanders, Belgium; Semarang and Denpasar, Indonesia; and Kinshasa, Democratic Republic of the Congo who are enrolled in the Global Early Adolescent Study (www.geastudy.org). Using logistic regression, we identify variables that are significantly related to violence perpetration at the first wave of data collection in Belgium and Indonesia and at the second wave in the DRC. All estimations are run separately for boys and girls.
Results: While there are vast wealth, linguistic, and cultural differences between our three national comparisons, we see some remarkable consistencies in both risk and protective factors for both boys and girls with risk factors including: violence victimization (crude odds ratios range from 3.5-11.5; p < 0.01 for all), pornography viewing (ORs from 1.9-5.3; p < 0.05 for all), depressive symptomology (ORs from 1.6-2.6; p < 0.05 except for girls in Belgium and boys in DRC), and high exposures to adverse childhood experiences (ORs from 2.0-19.7; p < 0.01 for all). Meanwhile, those who were less likely to report endorsing a sexual double standard (among country-gender groups with significant associations, crude ORs were 0.5, p < 0.01 for boys in DRC; 0.5, p < 0.05 for boys in Indonesia; and 0.5, p < 0.01 for girls in Indonesia), who lived in communities where people look out for one another (OR of 0.7, p < 0.01 for boys in DRC; 0.7, p < 0.05 for boys in Indonesia; and 0.6, p < 0.05 for girls in Indonesia) and who are comfortable taking with parents about issues and concerns (OR of 0.7, p < 0.01 for boys in DRC; and 0.6, p < 0.01 for girls in Indonesia) were significantly less likely to report violence perpetration.
Conclusions: There is an extensive literature on adolescent violence perpetration, primarily from North America, indicating significant associations between that outcome and exposure to adversity in childhood, low parental education, early school leaving, parental connections, and depression. Many of these factors appear to be similarly associated with violence perpetration in international contexts. Our analyses also point towards additional factors, including gender norms and pornography viewing, that show significant and substantial association with violence perpetration among male and female early adolescents in multiple countries. What we find can serve as important dimensions when considering violence prevention programming.
Sources of Support: This work is supported in part by the Oak Foundation, the David and Lucile Packard Foundation, the Bill & Melinda Gates Foundation, and USAID.
#24. Discordant Substance Use and the Daily Experience of Partner Violence in Adolescent and Emerging Adults with Previous Dating Violence
Tiffany E. Mark, MD1, Sarah J. Flessa, MHS1, Shang-en Chung, BS, ScM2, Maria Trent, MD, MPH1, Megan H. Bair-Merritt, MD, MSCE3, Pamela A. Matson, PhD, MPH1
1Johns Hopkins School of Medicine; 2Johns Hopkins Bloomberg School of Public Health; 3Boston University School of Medicine
Purpose: Teen dating violence (TDV) is a significant public health issue in the United States and can have detrimental effects on adolescent health. Substance use has been identified as both as a risk factor and a consequence of TDV. Research among adults has found that substance use by one or both partners has different impacts on violence within the relationship. Among adults, concordant use has been shown to have a positive impact and improve relationship quality, while discordant use is associated with increased conflict. This study examines the role of substance use discordance on violence within adolescent and young adult (AYA) relationships, who experience a disproportionate burden of TDV.
Methods: This study recruited 16–19-year-old females using a study van situated in public locations in Baltimore, MD. Eligible participants were in a heterosexual dating relationship, with at least one past-month TDV victimization or perpetration. Participants completed a baseline survey followed by four consecutive months of daily surveys via a smartphone. Each day, participants were asked about dating violence perpetration and/or victimization on that day, their alcohol and drug use, and whether they observed their current partner using a substance that same day. Discordant substance use was defined as one individual using a substance, and the other individual in the relationship not using that substance. Concordant substance use was defined as both partners using or both not using alcohol or drugs. Alcohol and drug use were modeled separately. Generalized estimating equations were used to account for within-participant correlation of the repeated measures.
Results: Participants (N= 143 ) were on average 18.2 (SD 1.1) years old, 93% African American, partners were on average 20.1 (SD 4.4) years old. Overall participants reported 1,020 drinking events (17.6% of days), and 1,274 drug use events (22% of days). Of the 6,935 completed daily surveys, discordant alcohol use was 12%, discordant drug use was 15%, and discordant substance use (alcohol and/or drugs use) was 22% of days. For both alcohol and drug use, discordant use was associated with an increased odds of same day violence victimization [OR: 1.55, 95%CI:1.24,1.95, OR: 1.79 95%CI:1.24,2.58, respectively]. Similarly, both discordant alcohol and drug use resulted in an increased odds of same day violence perpetration [OR: 1.74, 95%CI:1.39,2.17, OR: 1.59, 95%CI:1.16,2.20, respectively]. Days with discordant alcohol and drug use were also associated with an increased odds of mutual violence (both perpetration and victimization experienced) [OR 1.63, 95%CI: 1.30,2.05, OR: 1.43, 95%CI:1.05,1.94, respectively].
Conclusions: This is the first study to use daily data to illustrate that dyadic patterns of substance use uniquely impact relationship functioning. Discordant alcohol and drug use between partners was significantly associated with increased violence victimization and perpetration among this sample of primarily African American AYA women, who are understudied in TDV research. Obtaining this granular understanding of the dyadic context of substance use on TDV has the potential to facilitate the development of effective and developmentally appropriate TDV intervention programs for AYA that integrate strategies to also reduce substance use.
Sources of Support: NIJ 2017-VA-CX-0030, NIH K01DA035387
#25. Juvenile Corrections Officers’ Perceptions of Procedural Justice
Elizabeth Kinsella, MD1, Matthew Aalsma, PhD1, Abby Hunt, MSW2, Carolyn Meagher1,
Monique Hensley2, Mary Ott, MD, MA1
1Indiana University School of Medicine; 2Health Care Education and Training (HCET)
Purpose: Procedural justice is a framework to guide interactions between criminal justice authorities and system-involved individuals. It is built on four pillars: Respect, Fairness, Trust, and Voice. Among adult offenders, experiences of procedural justice are associated with less violence and recidivism, but little is known about procedural justice in the juvenile system. We describe juvenile corrections officers’ views on youth and perceptions of procedural justice.
Methods: Custody staff from three juvenile prisons were interviewed regarding their perceptions of procedural justice. Participants were randomly selected from various shifts and job levels. Interviews were face-to-face, semi-structured, in English, and lasted one hour. Questions focused on youth strengths and challenges as well as perceptions of respect, fairness, and trust among youth and corrections staff. E.g. “What is your perspective on how fairly youth are treated in your facility?” and “How much do staff trust youth? Youth trust staff?” Participants were asked to explain their answers and provide examples. Interviews were then coded for themes related to procedural justice.
Results: Forty-one juvenile corrections staff participated from 3 juvenile facilities located in both urban and rural areas of Indiana. Interviewees represented diversity by race (51% white, 44% African American), gender (63% male, 37% female), and years working in youth facilities (average 8.5 years, range of <1 to 24 years). Key themes included: (1) Youth Strengths & Challenges: Staff recognized many strengths in youth, including intellect, grit, and adaptability. They saw potential in youth but consistently expressed concerns about the negative influence of youths’ home and social environments outside of the facility. Some attributed youths’ future success to an internal “mindset to make it,” while others felt that greater structural supports (mentorship, job training) were necessary to prevent recidivism. (2) Conscious and implicit biases based on race, rural vs. urban status, and moral character of youth (labeling a youth as a “bad kid”) were present. In contrast, many described youth through a trauma-informed lens, identifying problematic behavior not as inherent to the youth but as a learned, maladaptive strategy from past trauma. (3) Respect: “Give respect, get respect” was a persistent theme; staff demonstrated respect by listening to youth and building rapport. (4) Trust: Staff had minimal trust of youth, and when they did it was earned, not given. Staff viewed trust as not consistent with their role of ensuring safety. (5) Fairness: Fairness was defined differently among staff; to some it meant supplying basic needs (food, clothing, shelter) to all youth, while to others it meant taking an equity-based approach in which treatment is tailored to youths’ specific needs based on maturity and mental health.
Conclusions: Juvenile corrections staff recognize the importance of respect, trust, and fairness in their interactions with youth, but their definitions and practice varied. Procedural justice training among juvenile corrections staff should standardize these concepts and provide real-life examples. Youth-staff relations may benefit from a consistent trauma-informed approach, and strengthening community resources for formerly incarcerated youth may prevent recidivism.
Sources of Support: Robert Wood Johnson Foundation #74831.
#26. Exploring Adolescent-adult Connections, Coping, and Safety Among Youths in Neighborhoods Impacted by Community Violence
Maxine Fenner, Alexander T. Riley, Alison Culyba, MD, PhD, MPH
University of Pittsburgh School of Medicine
Purpose: Youths living in neighborhoods impacted by high levels of community violence frequently experience violence exposure and involvement, which negatively affect physical and mental health. Understanding how adult supports help protect youths in communities made vulnerable by structural disadvantage is imperative for designing violence prevention interventions. Our goal was to gain insight into how youths identify adults to help them navigate experiences with violence and explore relationship characteristics, conversations, and strategies that help keep youths safe.
Methods: We conducted semi-structured dyadic interviews with youths ages 13-21 and their self-identified key adult supports recruited through a study of adolescent-adult social networks and violence prevention in neighborhoods impacted by community violence in Pittsburgh, PA in 2019-2020 (n=32 dyads). Interviews focused on adolescent-adult relationships, experiences with violence, and safety strategies. We used an iterative coding process to identify key themes. The lead analyst coded all interviews and met frequently with the research mentor to create the final code book.
Results: Two-thirds (63%) of youth participants were female. 88% of youths self-identified as African American, 3% white, and 9% multiracial. Adult supports commonly included parents (31% mother-son dyads, 31% mother-daughter dyads, and 13% father-daughter dyads) and grandparents (9% maternal grandmother-granddaughter dyads). 3% included coaches and other family members. Youths highlighted the salience of identifying adults who are dependable, nonjudgmental, and available to have frank conversations and real-time cellphone-based contact about navigating experiences with violence and safety. Youths described choosing social interactions carefully, doing their best to avoid high violence areas, and keeping busy with activities (“I try and stay around my house a lot so that if something happens I can just go home”). Many youths discussed the necessity of minimizing contact with peers to avoid violence, resulting in isolation from friends and increased engagement with family at home. Adults shared similar strategies for staying safe, resulting in feelings of isolation from their communities. Adult supports reflected upon intergenerational transfer of violence avoidance, safety planning, and coping strategies through sharing their own experiences with violence; adults specifically noted that they, too, learned about safety in this way from their adult supports (“My mom used to tell me all the time you make sure you be back at this time….There’s a lot of bad things out there nowadays and this is troubling to me. That’s why I’m always concerned about her safety”). Dyads highlighted the need for violence prevention programming to address social isolation and build supportive social networks (“some of the activities should include the parents so that the parents can get to know each other…it’s the fundamentals of social networking with children is that the parents are socializing as well”).
Conclusions: Centering youths’ and adults’ experiences of violence and safety strategies is essential for designing effective violence prevention programming. Findings will inform a community-engaged social network-based violence prevention intervention that recognizes multigenerational experiences of violence, leverages the strengths of shared communication about coping and safety, and creates safe community spaces for engagement.
Sources of Support: University of Pittsburgh Dean’s Summer Research Project, K23HD098277-01(PI:Culyba), UPMC Children’s Hospital Research Advisory Committee Award(PI:Culyba)
#27. Assessing Youth Perceptions of Staff: A Validational Analysis in Adjudicated Youth
Casey A. Pederson, PhD1, Paula J. Fite, PhD2
1Indiana University School of Medicine; 2University of Kansas
Purpose: According to social ecological theory and frameworks of implementation science (Bronfenbrenner, 1977; Damschroder et al., 2009), understanding dynamics that encourage the effective use of evidenced based interventions (EBIs) within juvenile detention centers is important to meeting the current and future demand for adolescent health services. Consistent with research on the therapeutic alliance (Kazdin et al., 2005), developing positive relationships between youth and detention facility staff may enable improvements in youth behavior and allow for the effective implementation of EBIs. Interestingly, research suggests that it is youths’ perceptions of facility staff that are of most importance (e.g., Kupchik & Snyder, 2009). However, no measure has been validated to assess these perceptions, with previous studies relying on self-created measures evaluating a wide variety of staff characteristics. Accordingly, the current study sought to validate a comprehensive measure of youth perceptions of staff characteristics (e.g., Pederson et al., 2020) relevant to youth within detention facilities.
Methods: Youth were recruited from two facilities in the Midwestern United States. Facilities housed both male and female youth age 10 to 17 years old. In facility one, participants included 109 youth (96.7% male), 12 to 17 years in age (M = 15.77, SD = 1.27) who were predominantly white (67.9%). In facility 2, participants included 126 youth (75.4% male), 11 to 17 years in age (M = 15.44, SD = 1.49) who were predominantly white (52.4%). After obtaining consent and assent, youth completed a 15-item self-reported measure regarding their perceptions of staff within the facility. Items reflected constructs of respect, fairness, helpfulness, and appropriate use of force. Facilities provided information regarding youths’ placement in restrictive housing (e.g., placement in a cell away from the general population, such as solitary confinement).
Results: An exploratory factor analysis (EFA) was conducted with youth sampled in one facility, with a confirmatory factor analysis (CFA) conducted with youth sampled from the other. Model fit indices for both the EFA and CFA suggested that a four-factor model best fit the data; however, theoretical considerations, concerns about grouping due to methodological variance, and high (>.80) intercorrelations between factors in CFA procedures resulted in the selection of a one factor model. The resulting internal consistencies were good (α = .85, .90) across both facilities. Further, as expected, the measure was significantly associated with restrictive housing (rs = .23 – .53, ps < .05), with more negative views of staff associated with increases in restrictive housing placement.
Conclusions: A one-factor model best characterized the measure based on both theoretical and statistical considerations. The resulting measure provides detention facility administrators and researchers with an accessible tool to evaluate youth perceptions of staff that may prove to be an important advancement in the literature as facilities look to improve youth outcomes while detained. The current findings, along with future research, can provide guidance on the professional development of staff to provide effective health services for adolescents.
Sources of Support: Support was provided by the Bureau of Justice Statistics and Department of Justice (BJS-2016-9013) and the University of Kansas Clinical Child Psychology Program’s Brown-Kirschman Award.
#28. Future Orientation as a Cross-cutting Protective Factor Against Multiple Forms of Violence
Susheel Kant Khetarpal1, Nicholas Szoko, M.D.2, Maya Ragavan, M.D., M.P.H, M.S.2, Alison Journey Culyba, M.D., PhD, M.P.H2
1University of Pittsburgh School of Medicine; 2UPMC Children’s Hospital of Pittsburgh
Purpose: Future orientation, defined as hopes and plans for the future, is associated with multiple prosocial outcomes, and has been linked to lower levels of youth violence perpetration. Much research to date has used deficit-based measures of future orientation, limited violence outcomes, and focused on youth in suburban settings. Situating our work within the CDC’s “Connecting the Dots” framework of shared violence prevention risk and protective factors, we examined associations between future orientation and multiple violence outcomes among a sample of youth from Pittsburgh, PA.
Methods: Data were drawn from an anonymous school-based survey of health risk and protective behaviors administered to ninth through twelfth graders from 13 high schools within Pittsburgh Public Schools in 2018 modelled on the CDC Youth Risk Behavioral Survey. Future orientation was defined as answering affirmatively to the following: “I am excited about my future” and “if I set goals, I can take action to reach them.” Youth and community violence measures included a past 12-month history of threatening someone (1 item), being threatened (1 item), weapon carrying (1 item), fighting (3 items), and lifetime history of losing a friend or family member to murder (homicide survivorship; 1 item). Sexual/relationship violence measures included a past 12-month history of adolescent relationship abuse (ARA, 2 items), sexual assault (2 items), and lifetime history of transactional sex (1 item). Of the 4207 youths surveyed, those who completed both future orientation items and at least one violence item were included in the analysis. Logistic regression separately examined associations between future orientation and each violence measure (operationalized as any/none). Models were adjusted for age, sex assigned at birth, race/ethnicity, and identification as sexual/gender minority.
Results: There were 2346 participants included in the analysis (57.5% female and 41.7% male), with a mean age of 15.7 years (SD = 1.2 years). 25% of youth identified as Black non-Hispanic, 47% as white non-Hispanic, and 26% as Hispanic/multiracial/other. 82% reported high future orientation. Experiences of violence were common with 3.7% reporting history of threatening someone else to 36% reporting homicide survivorship. Positive future orientation was significantly and inversely associated with all domains of youth and community violence, including weapon carrying (aOR 0.44, CI:0.28-0.70); threatening violence (aOR 0.26, CI:0.16-0.41), being threatened (aOR 0.44, CI:0.30-0.65), fighting (aOR 0.61, CI:0.48-0.77), and homicide survivorship (aOR 0.72, CI:0.57-0.92). Positive future orientation was also associated with significantly lower odds of ARA, sexual assault, and transactional sex (ARA: aOR 0.45, CI:0.32-0.63; sexual assault: aOR 0.65, CI:0.50-0.83; and transactional sex: aOR 0.56, CI:0.37-0.86).
Conclusions: Future orientation was inversely associated with violence exposure and involvement across multiple domains. Providing opportunities for adolescents to envisage their goals and actualize their visions may be an important strategy to prevent multiple forms of violence involvement and exposure. Violence prevention interventions should consider incorporating and evaluating future orientation as a cross-cutting protective factor.
Sources of Support: University of Pittsburgh School of Medicine Clinical Scientist Training Program – NIH UL1TR001857 (Scholar: Khetarpal), The Heinz Endowments, The Grable Foundation, KL2TR001856 (Scholar: Ragavan), K23HD098277-01 (PI:Culyba)
Poster Symposia III: Screening, Measurement, and Consent in Adolescent Behavioral Health
#29. Eating Disorder Screening and Treatment Experiences in Transgender and Gender Diverse Young Adults
Sydney Hartman-Munick, MD1, Scout Silverstein, BS2, Carly Guss, MD, MPH1, Ethan Lopez, BA2, Jerel Calzo, PhD, MPH3, Allegra Gordon, ScD, MPH4
1Boston Children’s Hospital; 2Trans Folx Fighting Eating Disorders; 3San Diego State University School of Public Health; 4Boston University School of Public Health
Purpose: Transgender and gender diverse adolescents and young adults (TGD AYA) are at elevated risk for disordered eating, unhealthy weight control behaviors, and eating disorders (EDs) compared to their cisgender peers. Despite this elevated risk, little is known about TGD AYA experiences with ED screening and treatment. This study aims to better understand TGD AYA experiences with and needs for ED screening and treatment.
Methods: This study uses data from 8 asynchronous online focus groups conducted using the platform Discourse, a dynamic online bulletin board method in which participants posted responses to moderator posed questions at any time over a 4-day period. Participants (N=66) were TGD AYA ages 18-30 years old, recruited using social media and digital outreach to community organizations in collaboration with community partner Trans Folx Fighting Eating Disorders. Focus group topics included positive body image development, the impact of gender affirming care on body image, and ED prevention needs. We conducted inductive thematic analysis of all focus group excerpts that described experiences with ED screening and/or treatment using the software Dedoose.
Results: Participants resided in 25 different US states and reported diverse gender and racial/ethnic identities (29% transgender man, 29% transgender woman, 39% non-binary, 3% another gender identity; 44% individuals of color). Half of participants spontaneously described their experiences with ED screening and/or treatment (N=32). Three major themes emerged from this study: (1) Barriers to ED screening/treatment (e.g., “Eating disorders are often seen as this thing that ‘only affects girls,’ so when they happen to pre-transition trans women and nonbinary people, they’re often ignored or not taken seriously”–age 21, trans woman); (2) Complexity of the relationship between EDs and gender dysphoria (e.g., “My eating disorder started as a way to stop [menstruation] and breast development, so access to binders, hormone blockers/HRT and gender affirming [care] would have helped me more when I was younger than therapy surrounding body image”–age 21, trans man); (3) Need for provider education in gender affirming care practices for ED screening and treatment (e.g., “They need to know that transgender and non-binary young adults can have eating disorders…I can 100% say that as an adolescent and as an adult, I have never been asked my gender or information about my diet/eating history by a healthcare provider”–age 26, non-binary).
Conclusions: Findings from this study identify an ongoing and significant need for gender affirming care for TGD AYA with respect to ED screening and treatment. Health care systems must address barriers to this screening and treatment for TGD AYA, which includes both a better understanding of the intersection of gender dysphoria and EDs as well as an increase in health care provider training.
Sources of Support: LEAH training grant #T71MC00009, HRSA/MCHB Harvard Catalyst | Harvard Clinical and Translational Science Center (National Center for Advancing Translational Sciences, National Institutes of Health Award UL 1TR002541) and financial contributions from Harvard University and affiliated academic healthcare centers.
#30. Impacts of COVID-19 on Health and Health Behaviors of Young Adults
Lauren E. Wisk, PhD, Russell G. Buhr, MD, PhD
David Geffen School of Medicine, University of California, Los Angeles
Purpose: The COVID-19 pandemic caused unprecedented disruption to everyday life across the globe. We sought to characterize COVID-19’s impacts on the health and health behaviors of young adults and middle/older adults in the US by comparing a large, novel sample to matched historical controls from the nation’s premier health monitoring survey.
Methods: Data are from 1109 respondents to an online survey of the impacts of the COVID-19 pandemic on adults (ages 18+), recruited via direct outreach to target populations, social media ads, and word-of-mouth referrals. Each respondent was matched to four historical controls from the 2018 Behavioral Risk Factor Surveillance System based on state, age, sex, race/ethnicity, and survey month. Both respondents and historical controls self-reported information on sociodemographics, health, and health behaviors; survey respondents also provided COVID-19 specific information. Multivariable regression was used to estimate the impact of COVID-19 on health and health behaviors (comparing respondents to matched controls) and to compare the reported impacts of COVID-19 for young adults (ages 18-34) to middle/older adults (ages 35+); all models adjusted for sociodemographics.
Results: Survey respondents were from 42 states (73% from California), 17.1% were young adults, 79.7% female, 75.2% white non-Hispanic, 82.0% had ≥bachelor’s degree, 68.4% were married/partnered, 26.7% had children living with them, 56.6% had a chronic condition, and 96.4% were insured. Compared to historical controls, respondents interviewed during COVID-19 had significantly lower adjusted odds of good general health (OR: 0.87, 95%CI: 0.77-0.98) and reported significantly more poor mental health days in the last month (+2.62 days, 95%CI: 2.10-3.14) though there was not a significant difference in poor physical health days (p=0.8947). Health behaviors in the past month were also significantly different during COVID-19, with significantly higher odds of any alcohol use (OR: 1.24, 95%CI: 1.07-1.44), including significantly more days of alcohol use (+2.01 days, 95%CI: 1.45-2.58) and significantly greater total number of drinks consumed (+6.54 drinks, 95%CI: 3.07-10.00), and significantly lower odds of any exercise (OR: 0.12, 95% CI: 0.10-0.14). Though young adults reported better general health than older adults during COVID-19, they reported significantly more poor mental health days (+2.83 days, 95%CI: 1.62-4.04), including greater anxiety symptoms (+0.67 on GAD-2, 95%CI: 0.38-0.95) and greater depressive symptoms (+0.47 on PHQ-2, 95%CI: 0.22-0.72), and young adults were more likely than older adults to say that their mental health was worse now than it was a year ago (OR: 1.51, 95%CI: 1.03-2.20). Compared to older adults, young adults were more likely to report both drinking more during COVID-19 than usual (OR: 1.58, 95%CI: 1.04-2.40) and exercising more during COVID-19 than usual (OR: 1.60, 95%CI: 1.09-2.37).
Conclusions: Though not nationally representative, this study provides an internally valid estimate of the significant impact of COVID-19 on self-reported mental health, alcohol use, and exercise. In particular, young adults appear especially vulnerable to mental health consequences of current events though demonstrate both positive and negative behavior change; additional socially-distanced yet effective mental/behavioral supports may be needed to mitigate potential adverse effects.
Sources of Support: University of California Office of the President and UCLA Clinical and Translational Science Institute (NIH/NCATS #UL1TR001881)
#31. Public Stigma Towards Adolescents Experiencing Substance Use Disorders: Measurement Development and Preliminary Examination
Annalee Johnson-Kwochka, M.S.1; Michelle P. Salyers, PhD1; Patrick O. Monahan, PhD2; Matthew C. Aalsma, PhD2
1Indiana University – Purdue University Indianapolis; Indianapolis; 2Indiana University School of Medicine
Purpose: Among adolescents experiencing substance use disorders (SUDs), few receive evidence-based treatment, increasing the likelihood of a range of cognitive, physical, and psychosocial problems. Public stigma, or negative attitudes towards people experiencing SUDs, may significantly impact adolescents with SUDs, leading to limited treatment accessibility and utilization. However, few measures have been validated to assess public SUD stigma towards adolescents. In this study we developed such scales by modifying commonly used measures of public mental illness stigma. We examined 1) the psychometric properties of each measure and 2) preliminary data on public stigma toward adolescents with SUDs.
Methods: Each measure (The Attribution Questionnaire, the Level of Contact Report, Social Distance Scale, and a measure of Causal Beliefs about SUDs) was modified via collaborative review from the study authors, who are subject-matter experts in adolescent development, mental illness stigma, SUDs, and measurement development, as well as in consultation with recent literature. Adult participants (n = 304) were recruited from Amazon Mechanical Turk and randomly assigned to one of four vignettes about an adolescent with a specific SUD diagnosis (opioid, marijuana, alcohol, and stimulant use disorders) before completing the measures. We examined psychometric properties of each measure, including factor structures, and used ANCOVAs for differences in stigma on each measure by diagnosis.
Results: The modified 18-item Attribution Questionnaire (AQ-18-SUD) revealed a four-factor structure: negative emotions, assessment of responsibility, social disengagement, and lack of empathy. Factors had good psychometric properties. Additionally, modified versions of the Level of Contact Report (LOR-SUD), the Social Distance Scale (SDS-SUD), and a measure of Causal Beliefs about Substance Use Disorders, demonstrated good psychometrics. Preliminary analysis of public stigma towards adolescents with a SUD suggests that attitudes about marijuana use disorder differ significantly from attitudes about other SUDs; participants who read about an adolescent with marijuana use disorder reported significantly lower negative emotions (p = .022) and greater belief that the adolescent was responsible for his illness (p = .001) when compared to those who read about an adolescent with opioid use disorder. Adolescents with marijuana use disorder also garnered significantly less pity or concern compared to all three other diagnoses (opioids, p < .001, alcohol, p = .001, stimulants, p < .001).
Conclusions: This study is the first to modify and validate measures designed to assess public SUD stigma towards adolescents. The measures we examined all had good factor structure and internal consistency, and correlated in expected ways with other measures. Preliminary analyses suggest that adults view adolescent marijuana use disorders as less severe compared to other SUDs, which may have implications for adults’ motivation to support youth in seeking treatment. Parents or other adults are often essential participants and motivators in substance use treatment for adolescents; if adults do not view a youth’s marijuana use as severe, even when it is negatively affecting the youth’s life, it may be harder for that youth to access and engage in appropriate treatment.
Sources of Support: NIDA UG1050070
#32. An Intersectional Psychometric Evaluation of a Discrimination Scale Among Minority Youth: Is There Measurement Invariance by Gender?
Amber L. Hill, PhD., MSPH; Lynissa R. Stokes, PhD.; Lan Yu, PhD.; Elizabeth Miller, MD., PhD.; Ashley Hill, DrPH, MPH
UPMC Children’s Hospital of Pittsburgh
Purpose: Racism is a public health crisis; researchers have demonstrated racism is strongly associated with poor health and social outcomes among adolescents and young adults. To improve the health and well-being of minority youth, programs must recognize the nuanced intersection between race, gender, and other identities to shift key societal norms and structures. In doing so, it is crucial to be mindful about the ways in which racism is measured at the individual level through experiences of discrimination. Finding valid tools to measure discrimination through an intersectional lens is necessary to accurately assess the effectiveness of programs aimed to reduce those experiences. This study evaluates construct validity of a discrimination scale among minority youth in Pittsburgh, Pennsylvania, and assesses the scale’s measurement invariance by male and female gender.
Methods: Cross-sectional data of 13-19-year-old minority youth were pooled from two gender-transformative programs: Manhood 2.0 and Sisterhood 2.0. Participants completed the Perceptions of Racism in Children and Youth Scale, which includes 10 items on lifetime experiences of discrimination based on skin color, language or accent, or culture/country of origin (“yes”/“no” answer choices for each item). To evaluate construct validity, we conducted a confirmatory factor analysis with the pooled sample (N=749), as well as separately by male (n=560) and female (n=189), using weighted least squared with mean and variance adjusted estimation for ordinal factor indicators. To evaluate convergent validity, we examined the association between participants’ mean discrimination score and mean future orientation score, as well as violence victimization and perpetration outcomes. Finally, we compared goodness-of-fit statistics among increasingly constrained models to evaluate measurement invariance by gender.
Results: Lifetime discriminatory experiences were highly prevalent among male and female participants. Female participants reported higher rates of having “the feeling that someone was afraid of [them]”, “been called an insulting name”, and “someone be rude to [them]” compared to males (p0.04) loaded onto a single construct. The unidimensional structure had strong fit statistics (CFI=0.977; TLI=0.970; RMSEA=0.062; SRMR=0.065). Cronbach’s alpha coefficient for both male and female samples were strong (>0.80). Among males, the mean discrimination score was significantly associated with future orientation (β=0.40; 95%CI: 0.11-0.68). Among females, the mean discrimination score was significantly associated with lifetime non-partner sexual violence victimization (OR=10.80; 95%CI: 2.23-52.33). With regards to measurement invariance, the 10-item discrimination scale showed weak factorial invariance by gender.
Conclusions: The 10-item Perceptions of Racism in Children and Youth Scale showed construct validity among male and female minority youth in Pittsburgh, Pennsylvania, indicating that the intended construct was accurately measured. However, caution must be taken in comparing mean scores between male and female participants as only weak factorial invariance was proven. Further research in scale development and validation should continue to evaluate how the construct of discrimination is similar and different among intersectional identities to ensure measurement tools most accurately reflect the lived experiences of minority youth.
Sources of Support: Manhood 2.0 – Centers for Disease Control and Prevention (U01CE002528; PI: Miller). Sisterhood 2.0 – Department of Human Services (PI: Miller). National Institute of Child Health and Human Development (T32HD087162, Ashley Hill and Lynissa Stokes).
#33. Changes in Markers of Toxic Stress and Resilience Among Youth Participating in an After-School Running and Mentorship Program, and their Association with Adverse Childhood Experiences
Christopher Renjilian, MD, MBE, Kenneth Ginsburg, MD, MSEd, Victoria Miller, PhD
Children’s Hospital of Philadelphia
Purpose: The primary aim of this study was to observe changes in markers of toxic stress and resilience over time in a cohort of youth participating in an after-school distance running and mentorship program. The secondary aim was to evaluate whether observed changes differed between groups of youth with varying levels of exposure to adverse childhood experiences (ACEs).
Methods: A prospective, survey-based, observational cohort study of high school students who voluntarily enrolled in the program was conducted. Anonymous questionnaires were administered during the first and last month of the 8-month program. Demographic characteristics and ACE scores were assessed at baseline. Measures of depression (PHQ8), anxiety (GAD7), and grit (Grit-S) were obtained at baseline and follow-up. Baseline and follow-up surveys were linked by unique identifiers. For the primary aim, paired-samples t-tests were performed to evaluate whether PHQ8, GAD7 and Grit-S scores differed at baseline and follow up. For the secondary aim, the difference in PHQ8, GAD7 and Grit-S from baseline to follow-up was calculated for each subject. Subjects were stratified into four adversity exposure severity groups based on their ACE scores: none (ACE Score = 0), low (ACE Score = 1), moderate (ACE score = 2-3) and high (ACE score = 4-10). One-way ANOVA tests with post-hoc analyses were performed to evaluate whether changes in PHQ8, GAD7 and Grit-S differed across ACE severity groups.
Results: 213 youth enrolled at baseline. 151 completed surveys at follow-up. The mean ACE score was 1.98, and subjects were evenly distributed across ACE severity groups. Primary aim: There was a significant difference in PHQ8 at baseline (mean = 6.63, SD = 4.712 ) and follow-up (mean = 5.61, SD = 4.838), t(146) = 2.612, p = 0.010), as well as GAD7 at baseline (mean = 6.24, SD = 4.842 ) and follow-up (mean = 5.37, SD = 4.795 ), t(143) = 2.360, p = 0.020), and Grit-S at baseline (mean = 3.46441, SD = 0.562265) and follow-up (mean = 3.56601, SD = 0.538501 ), t(143 ) = – 2.44, p = 0.016). Secondary Aim: One-way ANOVA with post-hoc analyses showed no significant differences in the change of in PHQ8, GAD7 or Grit-S scores across ACE severity groups.
Conclusions: A modest but significant decrease in scores for depression and anxiety and a significant increase in grit over the study period was observed. These findings are consistent with the proposal that youth development programming that combines adult mentorship and exercise may help young people to mitigate effects of toxic stress and cultivate resilience. Youth with higher levels ACEs exposure have been viewed as “at risk” and “harder to reach” through programmatic efforts. However, this study found no significant differences between groups of students with varying levels of ACE exposure in changes in depression, anxiety and grit over the study period. This finding suggests that all youth, including those who have survived higher levels of adversity, may be poised to benefit from combinedmentorship and exercise interventions.
Sources of Support: Children’s Hospital of Philadelphia CARES award, American Medical Society for Sports Medicine Young Investigator Award
#34. Mapping the Consent Process for Transgender Youth: A Content Analysis of Consent Forms for Gender-Related Care
Samhita Lakshmi Nelamangala, Katherine E. Boguszewski, MA, Julia Taylor, MD, MA
University of Virginia
Purpose: Recent clinical guidelines emphasize protection against harm, the involvement of mental health professionals, youth assent, and parental permission for transgender (TG) adolescents considering pubertal suppression (PS) and gender-affirming hormones (GAHs). The guidelines do not, however, address the process of obtaining minor assent and parental permission or issues that increase the complexity of consenting to PS and GAHs. This study aims to describe and compare informed consent processes across clinical sites providing PS and GAHs. This study is the first to look at variations in consent processes as a step towards refining decision support and informed consent processes that address the specific needs of TG youth and their families.
Methods: As part of a larger, IRB-approved survey about informed consent processes, providers of gender-related care to adolescents uploaded informed consent forms for PS and GAHs. Publicly available consent forms were also found through a web search. We conducted content analysis on all consent forms using quantitative and qualitative methods. Published clinical guidelines and ethical norms from the Endocrine Society and the World Professional Association for Transgender Health (WPATH) for obtaining minor assent and parental permission were used to develop a coding instrument to evaluate form content, tone, and style. Eleven core elements of informed consent were identified and analyzed across all forms. Four additional elements were identified and analyzed specifically for GAH consent forms.
Results: 28 informed consent forms were analyzed (eight for pubertal suppression, ten for testosterone and ten for estrogen). Percentage agreement (87.5%) and kappa score (0.71) measuring inter-rater reliability were calculated and suggested substantial agreement. 96% (n=27) of consent forms utilized short phrases or bullet points and 71% (n=20) did not use jargon. Only 50% (n=5) of the PS consent forms had all 11 core elements, and one included less than half. 80% (n=16) of GAH consent forms contained between 10 to 15 core elements and 20% (n=4) had less than 10 of the core elements. Mental health provider involvement was mentioned in 87.5% (n=7) of PS forms, but was only present in 50% (n=10) of GAH forms. Risks of treatment were included in 100% of forms and explicitly named in 93% (n=26). However, only 29% (n=8) of forms explicitly identified impacts of PS or GAHs as benefits. 82% (n=23) of all forms included a signature line for minor assent, while 50% (n=14) explicitly confirmed the minor’s understanding and documented agreement with the intended treatment.
Conclusions: There was substantial variability in consent forms in regards to their content, style, and inclusion of basic elements of informed consent. While the risks of treatment were well categorized, there was little consistency in the way that benefits were portrayed or defined. A robust discussion or documentation of assent was not uniformly present across the analyzed consent forms. The role of consent forms in fostering minor participation and assent when initiating PS and GAHs needs further clarification and development. Future research should focus on ways to encourage and prioritize active minor assent thereby improving the health and experience of TG adolescents.
Sources of Support: UVA Department of Pediatrics
