There has been a surge in the rates of adolescents who are becoming infected with HIV. This study of 214 'at risk' clients being treated on an inpatient psychiatric hospitalization basis examines why such clients continue to engage in high-risk behaviors. Results and suggestions for a psychoeducational curriculum for professionals are included in this article.
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The rate of adolescents living with HIV infection has increased during the past 10 years. Although most junior and senior high schools currently provide education on HIV and AIDS, such information is typically presented in the context of sex education/health classes and family life courses. Teens are also regularly exposed to HIV and AIDS information in public service announcements on television and radio spots. Magazine articles about teen heroes and their HIV/AIDS status (basketball great Magic Johnson and rapper Eazy-E, in particular) have also played a role in educating teens about HIV and AIDS (Stephenson & Walsh-Childers, 1993). Health departments and many school health clinics provide free counseling and literature regarding HIV and AIDS, as well as other sexually transmitted diseases, to any students requesting such services.
Given that teens receive education, counseling, and literature on a regular basis from a variety of sources, why does the rate of HIV infection continue to rise? Epidemiologists at the Centers for Disease Control and Prevention announced on February 27, 1997, that the incidence of HIV infections for heterosexuals continues to grow ('We're Finally Making Strides,' 1997). Studies have indicated that knowledge and changes in behavior do not always have a direct correlational relationship. Rotheram-Borus and Koopman (1991) studied a group of adolescents and found that, although the youth had general knowledge about HIV risks, the knowledge did not influence their reported sexual risk behaviors. Other studies have also reflected this same lack of influence on sexual behavior, whether the knowledge involved HIV transmission (Berger & Levin, 1993; Keller et al., 1991; Segest, Mygind, Harris, & Bay, 1991) or was general knowledge about HIV and sexually transmitted diseases (STDs; Donnmeyer, Marquard, Gibson, & Taylor, 1989; Edgar, Freimuth, & Hammond, 1988; Geringer, Marks, Allen, & Armstrong, 1993; Linden, Kegeles, Hearst, Grant, & Johnson, 1990; Rotheram-Borus & Koopman, 1991; Stevens-Smith & Remley, 1994; Winkelstein, Wiley, & Padian, 1988).
During the teen years, individuals experience a false sense of invulnerability, and many place themselves in high-risk situations as a result of sexual and emotional exploration (Fisher, 1988; Handler, Lampman, Levy & Weeks, 1994; Hackerman & King, 1998; Hayes, 1987; Hofferth, Kahn, & Baldwin, 1987; Keeling, 1988; King, 1988b; Melton, 1988; Slater, 1989). Many youth are strongly influenced by their peers and by their lack of sufficient impulse control (Howard & Zibert, 1994; King, 1988a, 1988b; Slater, 1989). Such impulsivity is particularly a factor in sexual activity (Berger & Levin, 1993; Hirschorn, 1986; Roscoe & Kruger, 1990; Stephenson & Walsh-Childers, 1993; Tonks, 1993). Of the general population of teens, 50% to 70% report sexual activity by the age of 19 (Stevens-Smith & Remley, 1994). When it comes to HIV and STDs, Segest et al. (1991) found that, because of their incorrectly perceived invincibility, many teens continue to believe that they are not at risk for HIV and that AIDS may not affect them in general.
Adolescents' abuse of alcohol and chemicals compounds the issue even further, because these substances lower the user's inhibitions. An adolescent who uses condoms consistently may not use protection while under the influence of alcohol or drugs (Berger & Levin, 1993; Hackerman & King, 1998; Harvey & Spigner, 1995; Johnson, 1990; Pennbridge, Freese, & MacKenzie, 1992). Koopman, Rosario, and Rotheram-Borus's (1989) study of 302 adolescents found that 'substance use was significantly related to reporting more sexual partners and to less frequent condom use' (p. 95).
Youth with psychiatric and emotional disturbances are particularly at risk for HIV infection because of their impaired and skewed social judgments, poor impulse controls, and ineffective coping skills. Stiffman, Dore, Earls, and Cunningham (1992) found that youth with behavioral health issues were more at risk for HIV infection, but they also observed that a reduction in the mental health symptomatology of these youth lowered their AIDS-related risk behaviors over time. A review of the literature also yields studies that show that the homeless and runaway adolescents who place themselves in dangerous situations (such as those that are depicted in this study) tend to do so because of ineffective coping skills, poor social judgment, poor impulse control, and other issues that bring them into behavioral health treatment and also because of reckless behaviors (Bond, Mazin, & Jiminez, 1992; Rotheram-Borus, Koopman, & Bradley, 1989; Rotheram-Borus, Koopman, Haignere, & Davies; 1991; Shaffer & Caton, 1984). Such behavior includes, but is not limited to, promiscuous sexual behavior with multiple partners of the same or opposite sex; inconsistent or no use of latex condoms; and regular use of alcohol, marijuana, cocaine, inhalants, intravenous drugs, and a multitude of pills of various sorts (Bond et al., 1992; Centers for Disease Control, 1990; Cohen, MacKenzie, & Yates, 1991; Hackerman & King, 1998; Stricof, Kennedy, Nattell, Weifuse, & Novick, 1991; Yates, MacKenzie, Pennbridge, & Cohen, 1988). Many homeless and runaway adolescents left their homes and families due to abuse and neglect, and sexual abuse in particular places such youngsters at risk for HIV infection (Bond et al., 1992).
A specific population within the emotionally impaired population of youth who need behavioral health services includes homeless teens, and this group must be recognized in this study. Also, because of the negative connotations and stigma that society attributes to homosexuality, gay male, lesbian, and transgendered adolescents attempting to come to terms with their sexual orientation form another group that is at risk for alcohol and drug abuse, depression, running away, and suicide (Cranston, 1991; Gonsiorek, 1984; Hippler, 1986; Ramafedi, 1985; Russell, 1989). The National Gay and Lesbian Task Force estimates that one in four families has a homosexual member, and over 16 million Americans are estimated to be gay or lesbian in sexual orientation (Jones, Shainberg, & Byer, 1985; Russell, 1989).
Given this extensive knowledge that adolescents with emotional and psychiatric treatment issues are particularly at risk for HIV infection, this study of 214 behavioral health adolescent clients being treated in an inpatient psychiatric hospital examined their knowledge of HIV and AIDS and why such clients continue to engage in high-risk behaviors. A discussion of the results and suggestions for an effective psychoeducational curriculum for behavioral health professionals are also included in this article.
METHOD
The population involved in the study, which took place from 1992 to 1996, was 148 adolescent girls and 66 adolescent boys who were treated at free-standing, inpatient, behavioral health facilities in the Memphis, Tennessee, area. (Reader's note. Free-standing indicates that only psychiatric services are offered, not medical or surgical services. It is the facility preferred by most insurance companies to treat adolescents in the area described for this study.) All participants were from Memphis or from rural towns throughout northern Mississippi, western Tennessee, or southeastern Arkansas (approximately a 200-mile radius of Memphis). The predominance of female participants was directly correlated to the youths' behaviors in the open psychiatric units. Teens who were overtly acting out on the units (through aggression), who were disrupting activities (by distracting and threatening), who had therapeutic assignments that were incomplete due to refusal to accept the assignments, or who were showing general noncompliance with the unit milieus were not permitted to attend this particular educational group and were provided with the educational information on a one-to-one basis by me in individual sessions. More boys than girls were in this category.
The actual diagnoses of the participants were varied and abundant, yet all participants had to meet some level of acuity that precipitated grounds for admission to the psychiatric hospitals. Examples of such critical behaviors are provided in Appendix A.
Many of the youths (both male and female) had histories of ongoing, chronic physical or sexual abuse, or both, and the teens were more at risk of HIV infection than the general adolescent population because of sexually acting out with no use of latex condoms (or sporadic latex condom use with multiple partners), polysubstance abuse, running away/homelessness (with related exchange of sexual favors for drugs, money, shelter), and general prostitution for drugs and money. Most of the participants had very poor or ineffective coping skills (which ultimately led to their hospital admission), and their social judgments were highly impaired. Support systems for many ranged from poor to nonexistent--often no adult to rely on other than one parent or a child protective services social worker. Quite a few lived in impoverished communities with limited financial and community resources. Others lived in group homes or would later be placed at various residential treatment facilities because of the continued need for close supervision and treatment. Again, such stress factors in the lives of these youth precipitated behavioral and emotional symptoms requiring inpatient hospitalization for stabilization and to avert the risk for harm to themselves, others, or property.
Based on the American National Red Cross's (1995) HIV/AIDS Instructor's Manual, I devised a brief questionnaire containing several questions regarding basic facts about HIV/AIDS that the Red Cross believes are pertinent for all adolescents. The questionnaire (see Appendix B) was approved by the nursing directors at the psychiatric hospitals involved.
The same questions were provided on both a pretest and a posttest during the same single 2-hour educational group session. The 214 participants completed the pretest in small groups of the same gender (ranging in size from 4 to 14 members). Answers to the pretests were discussed in group fashion, along with many other questions the teens were allowed to ask. The discussions were immediately followed by the posttest. Finally, pamphlets written at a 3rd grade reading level were provided to group members for their private use, and they were encouraged to ask more questions after the groups were dismissed. A breakdown of participant ages, academic grade levels, races, and genders are shown in Table 1.
To encourage frank and open discussion, the groups were held separately by gender. Participants' comments reflected their preference for this arrangement. Girls said they did not feel 'dumb' and were glad not to be laughed at by the boys; boys gave similar verbal responses.
RESULTS
A comparison of the pretest and the posttest answers showed improvement in correct responses on the posttest (results for all questions are shown in Table 2). For Question 1, 'What is HIV?' 90 of the 214 adolescents answered correctly on the pretest. At the end of the group session, 198 of the 214 were able to state what HIV was. The 12 incorrect replies from the pretest section were 'HIV is AIDS' (9 responses) and 'HIV is a bad disease' (3 responses). On the posttest, the 2 incorrect responses were 'HIV is AIDS.'
Incorrect answers to Question 2 (see Table 2), 'How does HIV weaken the body's immune system,' were varied and included 'Eats your germs,' 'Makes you little,' and 'Kills body fluids.' The three incorrect answers at the posttest were 'Messes you up real bad,' 'Makes you shake and sweat,' and 'Kills red blood cells.'
Question 3 was 'There are four body fluids (secretions) that carry higher concentrations of HIV infection than others. What are the four?' Individuals were to write in their own responses. The four acceptable answers were semen, vaginal secretions, blood, and breast milk (see Table 2). Incorrect responses at pretest included urine (13), saliva (10), mucus (1), tears (1), and t-cells (3). Although the posttest showed improvement (from 56 blank pretests to 9 blank posttests, along with multiple correct responses) in the responses to this body fluid question, there were various incorrect replies including urine (8), sweat (1), tears, (2), pus (1), diarrhea (2), and saliva (4).
Question 4 of the study examined knowledge of a false-negative HIV serum test and asked 'How soon can HIV antigens be detected before a person can have a positive HIV test? If a person tests negatively, can he or she still have HIV?' Because of the numerous incorrect responses on both the pretest and posttest, I deduced that the participants just wrote in numbers to prevent turning in blank responses (see Table 2). The guesses ranged from 1 day to 12 years. However, only 6 participants answered correctly for the pretest, and 187 were correct for the posttest.
When asked Question 5, 'Why are teenagers with HIV growing in number?' the participants were allowed to put any response they chose and as many responses as they could. A list of the responses for the pre- and posttest are given in Table 3. This particular question prompted lengthy discussion in each focus group. The boys talked about intravenous drug use and the many people they knew who mainlined and 'skin-popped' drugs, and a few admitted that they had shared needles prior to beginning treatment. Regarding 'ignorance' as an answer, many explained that they felt invincible and that they could not be at risk simply because they were 'too young to get in serious trouble.' That response prompted debates among members of the groups, including arguments such as 'If you're so hot and can't get in trouble, then why are you in treatment?' Others discussed how lowering inhibitions by getting drunk or high put them at risk. Many acknowledged having unprotected sex while high, and many also admitted they knew better at the time but said '(We) were high and having fun.'
The last question of the study asked the participants 'How can we protect ourselves from HIV infection?' Again, they were permitted to list as many protective measures as they could. This question also prompted heated discussions and debates within the groups. Many girls who were sexually active stated they were embarrassed to purchase condoms, whereas others argued, 'No glove, no love, baby.' Some stated they believed their boyfriends would leave them if they requested that they use latex condoms with Nonoxynl-9, and they were countered by other girls saying, 'Then let him go. If he ain't got no respect for you, he ain't worth it.' The boys had similar discussions, stating they did not like condoms because 'They just don't feel right.' They were met with group member comments such as 'Well, it's not gonna feel right when you're in the hospital with tubes and stuff in you either, if you get sick.' Boys, especially those who were street gang members, boasted more than girls did regarding multiple sex partners.
During the discussion of the questions that took place between administration of the pretest and posttest, the participants were asked where they had learned what they did know about HIV and AIDS. They reported classroom discussions regarding HIV and AIDS, seeing and hearing public service announcements on television and radio, and hearing the topic discussed among peers, yet many admitted they truly did not know what it all meant. This gives rise to the question 'Why are these adolescents, particularly behavioral health clients, not internalizing what they are learning from school and elsewhere?' The adolescents supplied the answers. Most reported hearing their teachers and school nurses discuss HIV and AIDS. They also stated that most of the professionals spoke in a language 'above their heads' and presented the material in a matter-of-fact, dry fashion that did not hold their interest. Many of the participants wanted open discussions in the classrooms yet feared asking questions because they thought they would be perceived as 'dumb' by the educators and 'punks' by their peers.
The improvement in the answers from pretest to posttest indicated that most of the teens were captivated enough to pay attention and join in the discussions. Most commented that such discussion was not allowed in classes at the home schools when there were guest presenters. They added that they typically 'tuned out' the guest speakers and focused on passing notes, drawing, or daydreaming. I allowed the participants to use any vocabulary they chose and to debate among themselves with the rule that I could intervene if someone yelled out incorrect or misleading answers. I kept in mind that each of the participants had behavioral health treatment issues (such as poor anger management, anxiety, and depressive symptomatology) acute enough to require hospitalization and that this might need to be addressed during the group sessions. However, the groups never got out of hand, and focus was maintained. At the conclusion of each group session, it was not uncommon for several participants to go to the nursing station to sign a release/request for HIV screening, because they realized they had placed themselves at risk through their acting-out behavior and poor social judgment. The ones who chose not to request testing denied risk-taking behaviors or had previously been tested by their physicians or health departments. At least 10 adolescents who chose to be tested for HIV tested positive with the ELISA, and 8 tested positive with the follow-up/retest of the Western Blot.
Focusing on an important comment from the group discussion, I asked the adolescents what they meant by professionals speaking 'above their heads,' and they stated that language was used that they did not understand. I have used a case study to explain how a professional might communicate at a level that is beyond the comprehension of an adolescent with behavioral health issues who might not have the courage to speak up and say he or she did not understand. When the information is lost, the youngster remains at risk for infection.
CASE STUDY
Lisa (name changed for anonymity), a 15-year-old, African American, heterosexual girl, was admitted to an inpatient behavioral health facility in 1995. She had been diagnosed seropositive for HIV a week prior to hospitalization by her local health department after being evaluated at her local rape crisis center She had been allegedly raped by her biological father and was seen at the rape crisis center the next morning. In discussing her social history with Lisa, I learned that Lisa's mother had died when Lisa was in preschool and that she had been raised by her extended maternal family in an impoverished area of one of the largest U.S. cities in a coastal state. Lisa had only recently learned about her father's whereabouts, although she had met him in the past. Her extended family allowed her to visit with him in a rural town in a bordering state of Tennessee for a few weeks during the summer of 1995. Lisa had a history of depression relating to 'The hole in my heart where my mama should be,' family discord, poor academic performance, poor social judgment, polysubstance abuse (primarily marijuana, alcohol, and cocaine), being a runaway, and street gang involvement for the previous 2 years. She had been sexually active for 2 years prior to her admission to the inpatient behavioral health facility. Previous treatment included a residential placement for 30 days 1 year prior to her current admission. During that 30-day placement, she had eloped from the residential facility. One week into the visit with her father and paternal siblings, her father allegedly became drunk and beat and raped her in his truck. Lisa threatened suicide to the child protective services social worker assigned to her case after the alleged rape. It was at this point that Lisa was admitted to the behavioral health hospital for crisis intervention and stabilization services that I was to provide.
When Lisa spoke with me, she reported knowing what HIV was. She said she had received quite a lot of counseling the previous week through her social worker at the health department. Lisa's admission laboratory work showed a T-4 count of 340, but she could not explain what a T-4 count was, what '340' meant, what HIV was, or how the virus was known to be spread. When she was told by the professionals that she was HIV positive, she assumed that her father had infected her a week earlier when he allegedly raped her. She also assumed that her T-4 count had substantially dropped to 340 during this 1-week time frame.
In processing with Lisa her risk factors (sexual activity since the age of 13, with two partners, with condoms rarely used, and with partners who had multiple sexual partners themselves, and her alcohol and drug use), she began to internalize that unprotected sex, possibly as early as the age of 13, might have been the source of her infection. She felt somewhat relieved that her father had not infected her, yet hoped she had infected him. During this process time, Lisa's behavioral health treatment issues were addressed; as she became more emotionally stable, she was more willing to consider the acting-out behaviors that had placed her at risk.
Lisa was given AZT and other medications and was able to articulate the purpose of the medication. She was able to look at how polysubstance abuse while she was in the street gang had lowered her inhibitions, skewing her judgment. As her therapy progressed, she began to recognize how her sexual behavior was, for her, a way to have men care for her and show her 'love'; she had never had a male role model in her life. Because Lisa could not depend on family members for proper care once she returned home to her extended family, she was educated about changes needed in her diet (such as eating only fully-cooked meat) and how certain pets could cause her to become ill through their feces (i.e., histoplasmosis from bird droppings and toxoplasmosis through cat feces).
While she was an inpatient, Lisa developed her first opportunistic infection, characterized by spiked fever and fluid retention in her lungs. Her internal medicine physician and her psychiatric nurse spoke with her about the need to transfer to a medical hospital for stabilization. I met with her prior to transfer, and Lisa reported that she did not understand what her doctor and nurse had told her, because, she said, they 'spoke above my head.' I answered her questions regarding intravenous antibiotics, bed rest, laboratory work, the goal of medical stabilization, and the need to follow the physician directives for her prescribed medications after discharge, especially once she began treatment at a nearby adolescent residential treatment facility.
I walked Lisa to the ambulance waiting to transport her to the hospital. Lisa became tearful as she entered the back of the vehicle, stating that she was afraid because she did not know what was going to happen and that she believed I was the only adult who had been 'straight' with her regarding HIV, AIDS, and her behavioral health issues.
STRATEGIES AND RECOMMENDATIONS FOR DEVELOPING PSYCHOEDUCATIONAL MATERIAL
The Youth Health Report Card of 1993 (which summarizes trends in various health indicators regarding the health status of youth in the United States) reflected high incidences of gonorrhea, syphilis, AIDS, and suicides (Wynder, 1994). These findings resulted in the following recommendations of the School Health Education Task Force:
Establish a qualified comprehensive school health education coordinator in each state department of education, each school district, and each school to help implement and integrate programs that can be effective in reducing various categorical health risk behaviors ... Develop and implement a national strategy to involve relevant public and private sector agencies and families in each community to help schools implement comprehensive school health education programs. (p. 115)
This national strategy could include community mental health centers in addressing the educational needs of their adolescent clients.
The principal purpose of HIV/AIDS education is to prevent HIV infection. However, the method of providing the information can make a significant difference to the youngsters. I learned from the participants that this education should include discussion regarding behaviors exhibited by adolescents that place them at risk for HIV infection and other STDs. It is imperative that the youth acquire the knowledge and skills they will need to internalize and maintain a change of behavior that will eliminate their risks for future infection. It is also crucial that educators be realistic and recognize that sexual and drug-related behaviors are a part of many youths' lives.
On the basis of this study and the direct work I have done with teens who have psychiatric illnesses, I suggest that the education be provided within groups of the same gender when it is possible. Questions flow more easily from the teens without the pressure to look 'cool' in front of their peers of the opposite sex. I did not find any issues regarding being a woman who was leading all-male groups; the boys were as open with me as were the young women. Examples of questions asked during the discussion sessions of the study included, 'If two condoms are worn, will that provide better protection' (asked by a 17-year-old); 'If someone has HIV, why can't they live in a bubble' (asked by a 13-year-old); and 'What's oral sex' (asked by a 14-year-old). Other questions asked anonymously (participants placed written questions in a box that was passed around during the discussion) included 'Can you die from syphilis?' 'Can you get pregnant from masturbating?' 'What are the symptoms of chlamydia?' and 'How long does it take for a guy to ejaculate?' The youth want these answers, but many are too embarrassed to ask their parents, and they know their friends probably do not know the correct answers.
To speak the language of these adolescents, it is best to talk with them instead of at them or to them. Listen to them and their concerns without bias. Sit with them in the midst of the group instead of in the front of the group, as if presenting a lecture. Get a volunteer to write information on a chalkboard or dry-erase board to help debates flow. Encourage group discussions and debates. If the participants seem shy or fearful of speaking up, offer a few questions and encourage a few of them to try to answer. This method has never failed me, and the questions, along with discussions and laughter, always followed. It is crucial for the facts to be presented and internalized. Many youngsters believe that they are invincible 'fun-machines' and that nothing can or will harm them. This myth must be shattered if internalization is to occur.
The adolescents must know the basic concepts about sex and sexually transmitted diseases before they learn more advanced information (Joseph, 1991). Lisa was not able to learn from her health department, physicians, or nurses because they assumed she already knew the basics about HIV. The resulting confusion spinning within her head contributed to her suicidal ideation. There was no way she could comprehend the material of these professionals the way they presented it. She feared telling them she did not understand, 'Because they seemed busy and had other things to do.'
When developing psychoeducational intervention programs, assume nothing. Present the information as though the youngsters have never heard of HIV. When preparing the curriculum, base it on community and parental values. For instance, if presenting to a group of teens receiving behavioral health services in residential programs for Catholic Charities, abstinence should be encouraged. Those participants who are already sexually active should be encouraged to cease sexual activity until marriage, with a commitment to monogamy. These recommendations reflect the values of Catholic Charities and many other residential programs run by religious organizations throughout the South, and these values should be respected. In speaking of abstinence, however, the subject of relationships can be addressed. The teens can learn that with courage, assertiveness, and social skills, they do not have to be sexually involved with someone in order to gain esteem and a sense of belonging. In my experience, adolescents between the ages of 13 and 18 feel a higher degree of pressure to be accepted by peers than at any other time in their young lives. This need for acceptance and intimacy may become the central focus of their actions. Many teens will challenge the abstinence viewpoint with statements such as 'But that's not reality. We're doing it, and we're gonna keep doing it.'
Once they are already sexually active, abstinence may be an unrealistic expectation for many teens; therefore, education regarding protection is crucial. If appropriate for the population, the curriculum needs to cover birth control, especially the use of latex condoms versus lambskin condoms (many teens do not know the difference except for price). The fact that Nonoxynl-9, which is a term that appears on condom wrappers and boxes, does not protect against any STDs must be discussed. When addressing contraception, all methods must be outlined, with a discussion of the pros and cons of each. Encourage the adolescents to talk with their parents, doctors, or nurse practitioners at the health departments in order to choose the appropriate birth control for their needs.
When developing material to be presented, many details need to be taken into consideration:
1. What issues will be covered?
2. Who will present the information, and how are they qualified to do so?
3. What ages will be involved?
4. What is the cognitive level of the participants (i.e., Will clients with full scale IQs under 70 participate? How will they be taught)?
5. What restrictions will the community and the parents require?
6. Will a peer counselor be involved?
7. Who will distribute releases/permission slips to parents/guardians for adolescents' participation?
Peers can have a significant impact on one another, especially among adolescents. When it comes to teenagers, research has shown that peer counselors and peer role models are quite effective in encouraging behavioral changes in other teens (Effickson & Bell, 1990; Kelly et al., 1991; Perry, Killen, Telch, Slinkard, & Danaher, 1980; Stevens, 1990; Stevens-Smith & Remley, 1994; Telch, Killen, McAlister, Perry, & Maccoby, 1982). With this in mind, consider involving an appropriate peer in the educational groups to aid in discussion participation.
Above all, psychoeducational intervention programs for behavioral health clients should stress what HIV and AIDS are and how they are spread. What behaviors place adolescents at risk for transmission of sexual diseases, what can be done for prevention, and what myths need to be dispelled? These are the basic facts that must be known before more advanced information is to be covered (American National Red Cross, 1995). Clarify that HIV is transmitted almost exclusively by actions that can be altered to prevent risk. In 1989, Feldman concluded that many U.S. school districts were not prepared to teach teens how to have safer sex, which seems to hold true to this day. However, this is where community health and mental health centers can assist. Anderson (1992) stressed that the clinician should be nonjudgmental and respond therapeutically to those adolescents who are living with HIV and are seeking behavioral health services.
Professionals need to be aware of the kinds of questions these clients are asking and should respond in a professional manner that provides the kind of information that will allow these adolescents to apply preventive measures in a practical way. Many youth want to know, for example, 'If blood carries HIV, why doesn't urine?' It is recommended that they be taught that HIV is blood borne, not airborne, and it lives in all internal body fluids, yet the virus has been found to be extremely fragile and dies when exposed to air. They should know that any body fluid can be considered infected until it is completely dry, and the thicker and more condensed the fluid, the greater the probability that the contagion is present.
Other adolescents want to know why there are more males than females with HIV. To dispel the 'It's only homosexual men who get it from sex' myth, they must learn that both genders and all sexual orientations are equally at risk, depending on what preventive measures are taken. They learn that sodomy, for instance, is behavior that involves more of a risk because of the possibility of microscopic anal tearing occurring at penetration, allowing for the exchange of body fluids (blood and semen). Most youth do not know this information, and it can be presented in a very nonbiased and nonjudgmental manner. Depending on the length of the educational program, once the critical information is learned, other topics can be addressed and explored.
CONCLUSION
Adolescents who seek behavioral health services come with diverse symptoms, including depression and substance abuse. It is believed that addressing the mental health symptoms may have a preventative effect regarding the risk for contagion with HIV because acting-out behaviors (such as intravenous drug use and sexual promiscuity with multiple partners) tend to diminish with behavioral health treatment. Behavioral health programs and facilities that serve youth and use psychoeducational materials for education about HIV prevention can play a significant role in protecting these at-risk adolescents from HIV infection.
APPENDIX A
Examples of Critical Behaviors Providing a Basis for Admission to Psychiatric Hospitals
Examples of critical behaviors that provide a basis for admission to psychiatric hopsitals are alcohol/chemical abuse and addiction, running away, school expulsion, starving or binging severely enough to require 24-hour nursing supervision, severe conduct/behavioral problems, suicide attempts, hallucinations, severe manic episodes (such as racing thoughts with rapid speech, acute insomnia, lack of inhibitions, psychosis), severe depressive symptomatology (such as active suicidal ideation with plan and intent, feelings of hopelessness with the risk of suicide, lengthy hypersomnia or insomnia, lengthy crying spells, self-mutilation), and severe emotional 'breakdown' (lack of emotional strength to respond to external stimuli, including catatonia).
Common Axis I diagnoses found in the 'acting in' track (for which I was the primary therapist) included, but were not limited to, the following: major depressive disorder, dysthymia, posttraumatic stress disorder, generalized anxiety disorder, attention deficit hyperactivity disorder, atypical impulse control, bipolar disorder, cyclothymia, anorexia nervosa and bulimia nervosa, obsessive compulsive disorder, Tourette's disorder, adjustment disorder, schizophreniform disorder, organic personality disorder, and schizoaffective disorder.
Also present and treated in another track were the 'acting out' youth with a variety of Axis I diagnoses including, but not limited to, intermittent explosive disorder, conduct disorder, polysubstance dependence, pyromania, and pedophilia. Common Axis II diagnoses included borderline personality disorder, histrionic personality disorder, and antisocial personality disorder.
APPENDIX B
HIV/AIDS Questionnaire
Name:-- Age:-- Grade:-- Gender:--
1. What is HIV?
2. How does HIV weaken the body's immune system?
3. There are four body fluids (secretions) that carry higher concentrations of HIV infection than others.
What are the four?
1.
2.
3.
4.
4. How soon can HIV antigens be detected before a person can have a positive HIV blood test? If a person tests negatively, can he or she still have HIV?
5. Why are teenagers with HIV growing in number?
6. How can we protect ourselves from HIV?
TABLE 1 Participant Demographics Number of Female Participants (n = 148) (a) Grade Level (Age in Years) Grade Level Age 5th (10) 0 0 6th (11) 4 0 7th (12) 6 4 8th (13) 19 13 9th (14) 52 27 10th (15) 24 36 11th (16) 25 45 12th (17) 11 20 Graduate (18) 0 1 Drop-out (19) 0 0 Unknown (unknown) 7 2 Number of Male Participants (n = 66) (b) Grade Level (Age in Years) Grade Level Age 5th (10) 1 1 6th (11) 2 0 7th (12) 7 2 8th (13) 5 4 9th (14) 10 11 10th (15) 20 13 11th (16) 6 19 12th (17) 7 12 Graduate (18) 2 2 Drop-out (19) 1 1 Unknown (unknown) 5 1 (a) 118 girls were Caucasian and 30 girls were African American. (b) 50 boys were Caucasian and 16 boys were African American. TABLE 2 Comparison of Pretest and Posttest Answers to the HIV/AIDS Questionnaire Correct Question Pretest Posttest What is HIV? Girls 43 135 Boys 47 63 How does HIV weaken the body's immune system? Girls 53 136 Boys 35 65 There are four body fluids (secretions) that carry higher concen- trations of HIV infection than others. What are the four? Girls Semen 59 127 Vaginal secretions 27 117 Breast milk 17 113 Blood 71 130 Boys Semen 45 57 Vaginal secretions 15 47 Breast milk 0 37 Blood 46 54 How soon can HIV antigens be detected before a person can have a positive HIV test? If a person tests negatively, can he or she still have HIV? Girls 4 131 Boys 2 56 Incorrect Question Pretest Posttest What is HIV? Girls 9 2 Boys 3 0 How does HIV weaken the body's immune system? Girls 77 3 Boys 28 0 There are four body fluids (secretions) that carry higher concen- trations of HIV infection than others. What are the four? Girls Semen 19 12 Vaginal secretions Breast milk Blood Boys Semen 9 6 Vaginal secretions Breast milk Blood How soon can HIV antigens be detected before a person can have a positive HIV test? If a person tests negatively, can he or she still have HIV? Girls 24 11 Boys 1 3 Left Blank Question Pretest Posttest What is HIV? Girls 96 11 Boys 21 3 How does HIV weaken the body's immune system? Girls 18 9 Boys 3 1 There are four body fluids (secretions) that carry higher concen- trations of HIV infection than others. What are the four? Girls Semen 56 9 Vaginal secretions Breast milk Blood Boys Semen 14 2 Vaginal secretions Breast milk Blood How soon can HIV antigens be detected before a person can have a positive HIV test? If a person tests negatively, can he or she still have HIV? Girls 120 6 Boys 63 7 TABLE 3 Pretest and Posttest Responses to the Question 'Why Are Teenagers With HIV Growing in Number?' Pretest Posttest Response Female Male Female Male Unprotected sex 100 48 101 62 Multiple sex partners 6 0 7 0 Dirty/shared needles 39 27 35 33 Drug use (IV and other) 9 0 17 4 Contact with infected blood 14 0 3 0 Ignorance 0 1 15 1 Left blank 26 14 6 0
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Adversity has the effect of eliciting talents, which, in prosperous circumstances, would have lain dormant.
--Horace, Poet and satirist
