1. Health Education & Behavior Change Mary Jane Rotheram-Borus, Ph.D.

2. Sequential Intervention Strategies Causal Agent Identified National Campaign Targeted Social Marketing Providers High-Risk Person Treatment

3. % People Changing Actions 0 100 Causal Agent Identified National Campaign Targeted Social Marketing ProvidersHigh-Risk Group Treatment Time % People Changing Actions

4. Interpersonal Levels Organizations Families Couples Persons

5. Multiple Problem Behavior Sex Drugs School Trouble Delinquency/ Juvenile Justice Emotional Distress

6. Social Cost of Runaways Requiring Social Services * Social cost/month - NYC cost/child x N of runaways who have received service (e.g., for foster care, n = 91)

7. Institutional Placements: % Lifetime

8. Interventions Universal Selected Indicated

9. Condoms Higher nationally over time (46%  53%) Consistent use (10% - 20%) Anglo & African American > Latino Males > Females Relationship status influences > if perceived peer use > if physician discusses

10. School-based Programs 78% of states mandate 37% include use of condoms Unsuccessful = general, unspecific No successful abstinence programs

11. Interventions Universal Selected Indicated

12. Vulnerable Subgroups –Gay/Bisexual –African American Women in Inner Cities –East Coast Latino Adolescents –Homeless –Youth in Jail –Severely Mentally Ill –Abused Youth

13. Problem Populations Intervention Program parameters Strategies Techniques Reinforcement Participation in Intervention Behavior Change Maintenance of Behavior Change PopulationsDomains of ChangeInterventionsOutcomes Figure 1. Integrated Framework for Preventive and Treatment Interventions Relationships Interventionist - Consumer relationship Social relationships Intentions/Motivations Emotional reactions Perceived consequences Normative beliefs Self-standards Self-efficacy Attitudes Learned Competencies Framing the problem Problem-solving skills Regulation of affect Interpersonal skills Environment Barriers Facilitators Behavior Predispositions Temperament Serotonin Regulation

14. n = 307 25 to 70 years old Participation criteria:  Not institutionalized  At least one adolescent, aged 11 to 18 years old 77% recruited; 84% traceable Parents with HIV

15. Model Underlying the Program Parent Health Lifestyle: Substance Use Sex Adolescent Ethnicity Age Gender Parent Disclosure Custody Parenting Illness-Related Tasks Adolescent Family Relations Grief Custody Adolescent Behavioral Social Mental Health Intermediate Primary Outcomes Outcomes Background Intervention Intervention Roles Rules Routines

16. Project TALC: PLWA Assessment Months 0 6 12 18 24 36 42 48 54 60 Enhanced CareStandard Care PLWA dies PLWA dies Module 3: Bereavement Module 3: Bereavement Module 2: Custody Module 2: Custody Module 1: Disclosure Module 1: Disclosure A Coping Skills Intervention for Parents with HIV & their Adolescent Children

17. Module I: Preparation Adapting to AIDS Disclosure Parenting

18. Custody Planning Daily Routines Saying Goodbye Module II: Pre-Death

19. New Families Healthy Daily Routines Future Goals Module III: New Caregivers

20. BSI Overall Intervention Control

21. Multiple Problem Behaviors Intervention Control

22. Adolescent Family Events

23. Adolescent Self Esteem

24. Emotional Distress Multiple Problem Behaviors Family Stressful Events Self Esteem Effectiveness – 2 Years

25. Impact of Intervention: 4 Year Outcomes

26. Intervention Outcome 4 Year Data: Parents - Multiple Problem Behaviors InterventionControl

27. 4 Year: Parents - Emotional Distress

28. 6 Year Outcome: Youth Quality of Romantic Relationships

29. 6 Year Outcome: Youth In School/Employed

30. 6 Year Outcome: Youth Receiving Public Assistance

31. 6 Year Outcome: Youth Alcohol, Last 30 Days

32. First Childbearing in Adolescent Females

33. Baby CBCL Intervention Outcomes Across Three Generations Youth's Babies: Adjustment Problems

34. Baby MDI

35. Survival of parent was associated with disorganized child attachment Typical Disorganized Attachments proportion

36. Intergenerational impact for parents, adolescents, & babies Long-term benefits of intervention Ongoing maintenance needed due to relapse at 4 years Methods to scale-up Project TALC Families:

37. 4-5% of adolescents have lost a parent 5-15% have a parent with a chronic illness Bereavement

38. 1 1.0 0.8 0.6 0.4 0.2 0.0 BSI Total Depression Somatization Bereaved-Nonbereaved Parent Death (years) Parental Death and Emotional Distress

39. At least 1 disorder 45% Depressive disorders20% Anxiety disorders 39% Post traumatic stress disorder24% Psychiatric Diagnosis n= 339

40. Bereavement and Mental Health Outcomes Longitudinal analysis of emotional distress highlight important period for intervention delivery High PTSD prevalence suggests enhanced intervention needs

41. Cumulative having plan (%)Age category Custody Plans Over Time

42. 15% Always; 37% Never 54% Change plans; 12% Siblings 4.9 Changes per child 81% Other Family Members 93% Guardians Agreed Stability of Custody Plans

43. Problem Populations Intervention Program parameters Strategies Techniques Reinforcement Participation in Intervention Behavior Change Maintenance of Behavior Change PopulationsDomains of ChangeInterventionsOutcomes Figure 1. Integrated Framework for Preventive and Treatment Interventions Relationships Interventionist - Consumer relationship Social relationships Intentions/Motivations Emotional reactions Perceived consequences Normative beliefs Self-standards Self-efficacy Attitudes Learned Competencies Framing the problem Problem-solving skills Regulation of affect Interpersonal skills Environment Barriers Faciliators Behavior Predispositions Temperament Serotonin Regulation

44. Summary Health Education = Information Behavior Change = Skills Perceptions Environment Predispositions Emotions