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Try out PMC Labs and tell us what you think. Learn More. This study examined individual and social factors associated with sexual risk behavior among African American girls seeking outpatient mental health services across two years and key developmental transitions. Findings support a social-personal framework of sexual risk for African American girls seeking mental health care, underscoring the potential benefits of early intervention to reduce externalizing problems while strengthening mother-daughter communication and relationships to prevent subsequent sexual risk and associated negative outcomes.
African Americans comprise only Likewise, over 6. The SPF also offers a heuristic guideline of the pathways to sexual risk explored in this study. Figure 1 illustrates the theoretical model with the hypothesized relationships based on the SPF. Adolescents with mental health problems engage in the same risk behaviors as their peers but at higher rates Brown et al.
Externalizing problems aggression, delinquency, conduct disorders Donenberg et al. Mental health problems may exacerbate sexual risk taking directly as a result of impulsive decision-making, Black girl seeks Stewart thinking, and poor affect regulation Brown et al. Sexual exploration is normative during the teen years and increases with age National Research Council and Institute of Medicine, but can lead to negative consequences e. Family context, therefore, can shape how girls interact with peers and partners, including sexual-decision making and behavior see Figure 1.
Positive mother-daughter relationships can mitigate the influence of negative peers Emerson et al. Adolescent substance use and risky sexual behavior are associated with peer attitudes about alcohol and drug use and sexual activity Bachanas et al. For youth with mental health problems specifically, the tendency for strained family, peer, and partner relationships may exacerbate the need for peer acceptance and willingness to compromise healthy behavior i.
Research suggests that rejection sensitivity can emerge as a self-protective response to rejection, but later prompt behaviors that undermine healthy relationships. Rejection sensitive individuals may avoid assertive behavior e. Additionally, African American girls are more likely to be raised in single working female-headed households, challenging parental efforts at monitoring and placing greater responsibility for sexual Black girl seeks Stewart on female caregivers.
Similarly, male peers and partners may have undue influence on girls in the absence of a strong male role model in the family. The study builds on research in several ways. First, few studies have examined sexual risk among African American girls across two years during a period representing key developmental transitions, including the initiation of sexual activity for many. Second, we are not aware of any studies targeting African American girls living in a large urban area seeking mental health services, a highly vulnerable population with documented health disparities. Third, most studies report cross-sectional relationships and have not evaluated the unique direct and indirect contributions and combined effects of mental health problems with individual, family, peer, and partner factors on sexual risk taking over time.
Understanding the broader context of African American girls seeking mental health care is imperative to de and implement effective HIV prevention programs for young women and sustain positive outcomes. In addition to these scientific advancements, there are three methodological strengths of the study: the inclusion of a population underrepresented in longitudinal research, the use of a composite indicator of well-known risk behaviors as a more robust variable to evaluate sexual activity, and including data for participants with at least one follow up time point, maximizing power to detect small effects.
Consistent with Figure 1 and research reviewed above, we hypothesized that externalizing symptoms would predict sexual behavior over time, but their impact would be mitigated in part by maternal acceptance-rejection and mother-daughter risk communication.
We did not make predictions about internalizing symptoms given inconsistencies in prior research. We expected more maternal acceptance and better more open, helpful, comfortable mother-daughter risk communication about sex during early adolescence at baseline to predict less sexual risk among girls two years later.
We hypothesized that peer support of substance use, girlfriend dating behavior, rejection sensitivity, and partner risk communication frequency and openness at months would mediate the associations between sexual risk at months and maternal acceptance-rejection and mother-daughter risk communication at baseline. Specifically, we expected more baseline maternal acceptance and open and frequent mother-daughter communication to protect against having peers who support substance use, girlfriends who engage in dating behavior, and sensitivity to rejection one year later.
Lastly, we expected better mother-daughter risk communication at baseline to predict more frequent and open partner risk communication at months, and less risky sex at months. These included biological fathers Mothers and daughters were recruited from eight mental health clinics in urban Chicago. Clinic staff contacted eligible families 12—16 years-old, self-identified as Black or African American and requested permission to forward their contact information to the research team. The project recruiter explained the study in detail and scheduled Black girl seeks Stewart appointment.
Girls identified as wards of the state or with ificant cognitive impairment interfering with their ability to understand the assent process were excluded from the study. At baseline and month follow-up, mothers reported on mental health services received. For families who declined research participation, only data on child age was retained due to IRB restrictions. There were no age differences between girls whose families consented and refused. Using the methods of Brown et al.
Caregivers and daughters separately provided informed consent and assent. Family members were interviewed at baseline,and months using a structured protocol that included interviewer-administered and computer-assisted measures. We adapted five measures for use in this study see below. CAB members reviewed each measure and deleted, added, or reworded items to increase clarity and relevance to the study population.
Next, we conducted one-on-one interviews with African American girls and their mothers asking if they understood the items, whether the items applied to them, if they made sense, and if there was anything we should change. Structural equation modeling SEM was conducted using Mplus v. The latent variable score used in the analyses was determined by the factor loadings and variable thresholds determined by the model. The Youth Self-Report YSR is a widely-used, standardized measure of self-reported emotional and behavior problems normed for 11—18 year olds Achenbach, b.
Symptom counts from the YSR were examined instead of symptom counts from the diagnostic interview, because the former is specifically normed for the population and has been widely used facilitating comparisons to other research. Higher scores indicate greater problems. We used baseline YSR internalizing and externalizing raw scores in the data analyses. Girls rated maternal i. Five subscales comprised of eight items each were used in this study: acceptance e. High scores indicated greater acceptance, positive involvement, and acceptance of individuation, and less rejection and hostile detachment.
Girls reported their sexual communication with mothers using an expanded and adapted version of Miller et al. We used Miller et al. The rest of the items i. We calculated scores on three constructs: helpfulnessopenness Black girl seeks Stewart, and comfort. An average score was computed across the five topics for helpfulnesswith higher scores indicating more helpful discussions.
Girls who did not discuss any of the five topics did not receive a score on this variable. A total openness score was calculated with higher scores indicating more open and receptive communication. The eight topics include the five referenced above plus three additional ones: handling sexual pressures, how to be close with a partner without having sex, and how to talk to a partner about using condoms. An average comfort score was derived separately for self and perceived mother comfort. Higher scores reflected less comfort, and girls who did not discuss any of the eight topics did not receive comfort scores.
Twelve-month follow-up data were used in the analyses. Based on modification indices in confirmatory factor analysis, we included a residual correlation between approval of alcohol use and approval of marijuana use. Girls provided feedback on the items during testing. Similar to peer support of substance use, month follow up reports were used in the data analyses. Items were created using Miller et al.
The investigative team and CAB chose four topic discussion items from Miller et al. These topics were then queried for frequency of communication. Items were tested in interviews with girls. In confirmatory factor analysis, the of strongly disagree and somewhat disagree were collapsed due to low frequency of endorsement for these .
Data analyses used month follow-up reports. Minor wording changes were made to make items more relevant to girls the scale had been developed for women ; CAB and girls provided feedback on adapted items. The Rejection Sensitivity Questionnaire depicts 13 hypothetical situations where girls make a request to a parent, peer, or romantic partner. Final scores were based on the product of the two ratings for each situation with higher scores indicating greater rejection sensitivity. How concerned or anxious would you be over whether or not the person would want to be only with you? In order to improve the reliability Black girl seeks Stewart the measure and to reduce the of observed variables in the model, we created four random parcels of items to use as indicators of the latent variable in SEM analyses.
We estimated measurement models for each of the latent constructs using maximum likelihood estimation for continuous measures and mean and variance-adjusted weighted least squares WLSMV for categorical measures. We estimated bivariate associations between the outcome latent variable of sexual risk behavior measured at month follow-up, and baseline covariates including adolescent age, internalizing symptoms, and externalizing symptoms. Black girl seeks Stewart, we estimated Black girl seeks Stewart associations between the outcome and baseline measures of maternal acceptance-rejection and mother-daughter risk communication, and each theorized mediating variable at month follow up — peer support of substance use, girlfriend dating behavior, rejection sensitivity, and partner risk communication frequency and openness.
We also estimated associations between theorized mediating variables and baseline predictors. We estimated the theoretical model Figure 1 with some adjustments based on the of the bivariate analysis. We included adolescent baseline age, externalizing symptoms, and internalizing symptoms as covariates.
A correlation term was included between peer support of substance use and girlfriend dating behavior, as these measures were closely related, with items drawn from the same instrument. We then modified the model adding paths based on modification indices. The average age of sexual debut was 13 years. Measures of fit for the measurement models are shown in Table 1. Modification indices supported the inclusion of correlated errors for certain pairs of items or subscales indicating shared method variance.
For mother-daughter risk communication, we included correlated errors for the two comfort subscales. For peer support of substance use, we included correlated errors for the two approval items. For girlfriend dating behavior, we included correlated errors for the two sexual activity items. The regression coefficients and standard errors for the bivariate models are presented in Table 2. Adjusting for adolescent age, and externalizing and internalizing symptoms, several bivariate relationships emerged consistent with the proposed theoretical framework.
Specifically, maternal acceptance-rejection at baseline was negatively associated with peer support of substance use at months and positively associated with partner risk communication openness at months. Mother-daughter risk communication at baseline was positively associated with partner risk communication openness at months and negatively associated with rejection sensitivity at months. Based on the of the bivariate analyses, paths regressing peer support of substance use on mother-daughter risk communication, girlfriend dating behavior on maternal acceptance-rejection and mother-daughter risk communication, and partner risk communication frequency on mother-daughter risk communication were omitted from the model, while a path regressing partner risk communication frequency on maternal acceptance-rejection was added.
In the initial estimation of the theoretical model, only direct effects of baseline internalizing and externalizing symptoms on later sexual risk behavior were included. However, modification indices revealed ificant unexplained common variance for several variables. Thus, we added paths from externalizing symptoms to maternal acceptance-rejection, mother-daughter risk communication, peer support of substance use, and girlfriend dating behavior; from girlfriend dating behavior and rejection sensitivity to partner risk communication frequency; from peer support of substance use to partner risk communication openness; and from adolescent age to peer support of substance use and girlfriend dating behavior.
Due to a negative residual variance, we dropped one indicator from the measure of partner risk communication openness. Next, we removed paths with p-values greater than. Model fit and structural coefficients for the initial hypothesized model Model 1 and the final best-fitting model Model 2 are shown in Table 3. Figure 2 shows a diagram of the final model. Indirect effects are shown in Table 4. In Model 1, the total indirect effect for maternal acceptance-rejection was ificant, although no single pathway was ificant. Higher levels of maternal acceptance at baseline were associated with less frequent partner risk communication and less involvement with peers who support substance use at 12 months, and consequently less sexual risk behavior at months.
Model 2 also revealed a ificant indirect effect of mother-daughter risk communication via rejection sensitivity and partner risk communication frequency. Mother-daughter risk communication at baseline was associated with lower levels of rejection sensitivity at months, which predicted more frequent partner risk communication at months, and more sexual risk behavior at months. The indirect effect of rejection sensitivity via partner risk communication frequency was ificant, as was the indirect effect of girlfriend dating behavior via partner risk communication frequency.
Interestingly, the effect was spread among several variable pathways; the only specific pathway to reach statistical ificance was that via peer support of substance use.
In some cases, these links were mediated by peer support of substance use, girlfriend dating behavior, and frequency of partner risk communication. Taken together, the unique study population of African American girls seeking outpatient mental health care, longitudinal data covering two years of adolescent development, and a test of the differential contributions of individual and social predictors of sexual risk represent ificant advances over research.
underscore the potential benefits of addressing mental health and family context early in adolescence to mitigate subsequent sexual risk among African American girls. In line with our hypothesis and the SPF, individual attributes, namely externalizing but not internalizing mental health symptoms, were directly and indirectly related to risky sexual behavior Brown et al. This study extends findings to African American girls seeking outpatient mental health services and clarifies longitudinal associations across important developmental transitions.
were unique to externalizing problems, which supports research Donenberg et al. Heightened sexual risk taking in relation to externalizing symptoms may reflect the inherent nature of these problems. For example, impulsivity may interfere with accurate risk assessment and willingness to refuse sex without a condom Donenberg et al. Similarly, the tendency toward rule breaking combined with poor affect regulation may explain higher rates of alcohol and drug use before sex, a component of the composite score used in this study.
Building on the SPF and consistent with the hypotheses, higher rates of externalizing symptoms predicted risky sex through several pathways, including lower maternal acceptance and greater peer support of Black girl seeks Stewart use. However, these data extend research by controlling for multiple relationships simultaneously to determine the most predictive pathway, and by testing longitudinal associations among African American girls. At least two explanations for these are possible. These peer associations may result in high-risk sex that reinforces intimacy and a feeling of belonging.
In either case, these data suggest that reducing externalizing problems during early adolescence may reduce a cascade of negative factors that culminate in early sexual risk taking. As predicted from the SPF and prior research Donenberg et al.Black girl seeks Stewart
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