Psychological Adjustment, Substance Use, HIV Knowledge, and Risky

Journal of Pediatric Psychology, Vol. 27, No. 4, 2002, pp. 373–384

Psychological Adjustment, Substance Use, HIV Knowledge, and Risky Sexual Behavior in At-Risk Minority Females: Developmental Differences During Adolescence Pamela J. Bachanas,1 PhD, Mary K. Morris,2 PhD, Jennifer K. Lewis-Gess,2 PhD, Eileen J. Sarett-Cuasay,1 PhD, Adriana L. Flores,1 PhD, Kimberly S. Sirl,3 PhD, and Mary K. Sawyer,1 MD 1

Emory University School of Medicine, 2 Georgia State University, and 3 St. Louis Children’s Hospital

Objective: To assess developmental differences in the psychological functioning, substance use, coping style, social support, HIV knowledge, and risky sexual behavior of at-risk, minority adolescent girls; to assess developmental differences in psychosocial correlates of risky sexual behavior in older and younger adolescents. Method: Participants included 164 minority teens, ages 12–19, who were receiving medical care in an adolescent primary care clinic. Teens completed measures of psychological adjustment, substance use, coping style, social support, religious involvement, and HIV knowledge and attitudes. In addition, they answered questions regarding their sexual history, family situation, school status, and psychiatric and legal history. Results: Younger teens (ages 12–15) reported more symptoms of depression and earlier sexual debuts than older teens (ages 16–19). However, older teens reported significantly more substance use and were more likely to have been pregnant and to have contracted a sexually transmitted disease (STD) than younger teens. Older teens also reported more religious involvement and using more adaptive coping strategies than younger teens. Developmental differences in the correlates of risky behaviors were also found between younger and older teens. Specifically, conduct problems and substance use were significantly associated with risky sexual behavior for younger teens, but not for older teens. Similarly, younger teens whose peers were engaging in risky behaviors reported engaging in more risky sexual behaviors; however, these same relations were not found for older teens. Conclusions: Young minority adolescents exhibiting conduct problems and using substances seem to be at highest risk for contracting HIV and STDs as a result of risky sexual behavior. Prevention interventions should target teens in high-risk environments during late elementary school or early middle school to encourage teens to delay intercourse, practice safer sex, and avoid drug and alcohol use. An interdisciplinary model of care in primary care settings is clearly indicated to provide these services to at-risk youths. Key words: minority youth; HIV; STDs; risky behavior; prevention.

䉷 2002 Society of Pediatric Psychology

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Sexually transmitted diseases (STDs) have become a serious health problem among our nation’s teens. It is currently estimated that 3 million adolescents are infected with a sexually transmitted disease each year and approximately one fourth of all new STD cases are diagnosed among 15- to 19-year-olds (Centers for Disease Control and Prevention [CDC], 1998). African American adolescents from impoverished, inner-city environments have among the highest rates of STDs (CDC, 1998). HIV has also become a significant health concern for adolescents. Approximately 3,865 teens (ages 13–19) in the United States are living with AIDS, and over 294,000 young adults (ages 20–34) are living with AIDS (CDC, 1999). Given the long incubation period of HIV, it is highly likely that a large number of these adults contracted HIV during adolescence. Young women of color are disproportionately affected, as 73% of 13- to 19-year-olds with HIV and 66% of 13- to 19-year-olds with AIDS are African American (CDC, 1999). The average age of sexual debut for teens in the United States is currently 16; however, the mean age for sexual debut among inner-city youths is 13 (CDC, 2000). African American adolescent girls tend to initiate sex earlier than Caucasian or Latina teens, and they are more likely to initiate sexual activity prior to age 13 than Caucasian teens (CDC, 2000). Early sexual activity (i.e., sexual intercourse prior to age 16) appears to be problematic, as emotional readiness for sexual activity and cognitive readiness, necessary for responsible sexual decision making, are less likely to have been attained at these earlier ages than in later adolescence (i.e., ages 16– 19) (Belgrave, Marin, & Chambers, 2000). Consequently, younger adolescents are more likely to engage in impulsive sexual behavior, are less likely to use contraception, and are at higher risk for pregnancy and STDs than older adolescents. In addition, teens who initiate sexual activity at younger ages are significantly increasing their lifetime risk for STDs and HIV, as they are likely to have more sexual partners and more unprotected sexual contacts than teens who delay sexual activity (Coker et al., 1994; Orr, Beiter, & Ingersoll, 1991; Smith, 1997). Previous research has shown that family, environmental, and interpersonal factors are associated with early sexual activity in teens (Smith, 1997). Adolescents from low-income families and from

All correspondence should be sent to Pamela Bachanas, Emory University School of Medicine, Pediatric Infectious Disease Program, 341 Ponce de Leon Ave., Atlanta, Georgia 30308. E-mail: [email protected].

Bachanas et al.

mother-alone or mother-absent families tend to become sexually active at younger ages (Murray, 1992). Adolescents with emotional or behavioral problems are also more likely to engage in early sexual activity (Keller et al., 1991). For example, African American girls who report high levels of depression and hopelessness are more likely to begin having sex early, more likely to engage in unprotected sex, and more likely to become pregnant (Durant, Jay, Linder, Shoffitt, & Litt, 1984; MillerJohnson et al., 1999; Smith, 1997). In addition, several studies have shown that African American youths who report engaging in antisocial or delinquent behavior also report engaging in risky sexual behavior (Doljanac & Zimmerman, 1998; Santelli & Beilenson, 1992). Teens who use drugs or alcohol are also more likely to be sexually active at earlier ages, possibly due to the disinhibiting effects of these substances on adolescents’ decisions to delay intercourse (Fortenberry, 1995; Millstein & Moscicki, 1995). Many researchers have reported that alcohol use, marijuana use, delinquency, and precocious sexual activity tend to co-occur in teens as problem behaviors (e.g., Doljanac & Zimmerman, 1998; Donovan, Jessor, & Costa, 1991). Other factors identified in the literature have been associated with teens engaging in fewer risky behaviors and may play a protective role in teens’ choices. Adolescents who report having more social support are less likely to engage in risky behaviors. For example, St. Lawrence and colleagues found that African American teens who reported high levels of peer social support were less likely to engage in casual sex, had more positive attitudes about using condoms, and reported fewer STDs and fewer nonmonogamous partners than African American teens who reported less social support (St. Lawrence, Brasfield, Jefferson, & Alleyene, 1994). An individual’s coping style may also serve a protective role in coping with the stresses of adolescence. Specifically, individuals who employ more adaptive coping strategies such as cognitive restructuring and problem solving are likely to engage in fewer risky behaviors than those who use more palliative coping methods (e.g., wishful thinking, problem avoidance; Laurent, Catanzaro, & Callan, 1997). The relationship between adolescents’ coping style and engaging in risky behaviors has not previously been assessed with minority adolescents. Other factors associated with reduced sexual risk taking in teens include school attendance and religious involvement. Youths who are striving to accomplish long-term goals (e.g., high school graduation)

Risky Behavior in Minority Female Adolescents

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are more motivated to avoid the negative side effects of sexual risk taking such as unwanted pregnancy (Belgrave et. al., 2000). In addition, teens who attend religious services more often are more likely to delay sexual activity, as religion may provide moral restraint against sexual activity for adolescents (Belgrave et al., 2000; Leigh, Weddle, & Lowen, 1998). A significant amount of attention has been paid over the past decade to educating youths about HIV. While these intervention efforts have been successful at increasing teens’ knowledge of HIV transmission, they have not resulted in reductions in teens’ risky sexual behaviors (Kirby & DiClemente, 1994). Further research has shown that in addition to knowledge of HIV, risky behavior among peers, sexual self-efficacy, and perceived risk of contracting HIV are important factors in determining whether teens engage in risky sexual behaviors. Specifically, teens who associate with peers who are engaging in risky behaviors are more likely to engage in risky sexual behaviors (Millstein & Moscicki, 1995). Adolescents who do not see themselves as being at risk for contracting HIV are also more likely to engage in risky sexual behaviors (Stevenson, Davis, Weber, Weiman, & Abdul-Kabir, 1995). In addition, teens’ sexual self-efficacy (e.g., their confidence in their ability to communicate with their partners and actually practice safer sex) has been linked to increased condom use by teens (Jemmott, Jemmott, Spears, Hewitt, & Cruz-Collins, 1992). Models of risk-taking behavior in adolescents have identified a developmental trajectory for teens engaging in risky behaviors. For example, rates of sexual activity, substance use, reckless vehicle use, and delinquency have been shown to increase with age during adolescence (Igra & Irwin, 1996). However, previous studies have not examined developmental or age differences in the relationships between psychosocial factors and risky sexual behavior. The majority of studies cited above identifying psychosocial factors and HIV knowledge and attitudes as predictors of risky sexual behavior in teens included a broad age range of adolescents (e.g., 12–19 years old). However, none of these studies assessed developmental differences between younger and older adolescents. Some researchers have focused on a narrow age range of teens (e.g., ages 11–14) and have assessed these relationships only with younger adolescents (e.g., Black, Ricardo, & Stanton, 1997). To date, it is not known if the relationships reported above between family, environmental, and interpersonal factors and risky

sexual behavior apply to both younger and older teens. These findings would have significant implications for prevention interventions with at-risk youths. The purpose of this study was to explore developmental differences in psychosocial correlates of risky sexual behavior in a sample of minority, innercity girls known to be at high risk for STDs and HIV. Specifically, this study assessed risk factors (psychological adjustment, substance use), resilience factors (coping style, social support, religious involvement, living with parents), HIV knowledge and attitudes, and risky sexual behavior in a sample of urban, minority adolescent girls. Differences in these factors between younger adolescents (ages 12–15) and older adolescents (ages 16–19) were examined. Risk factors, resilience factors, and HIV knowledge and attitudes were also examined as correlates of risky sexual behavior, and developmental differences in these relationships were investigated. We hypothesized that the majority of teens in this sample would be engaging in high rates of risky behaviors; however, we expected older teens to be engaging in more risky sexual behavior than younger teens, given developmental norms. Similarly, we expected older teens to report more substance use than younger teens. We also predicted that older teens would report more knowledge of HIV, more confidence in their ability to practice safer sex, and more perceived risk of contracting HIV, given that they have likely had more experience and exposure than younger teens. Younger teens who were engaging in other risky behaviors (e.g., substance use, delinquent behaviors) were also predicted to be engaging in risky sexual behaviors. We did not predict this same relationship for older teens, given that sexual activity, substance use, and delinquent behaviors increase normatively during adolescence. In contrast, we expected that for both older and younger teens, living with their parents, attending school, and involvement with a church would be associated with engaging in fewer risky sexual behaviors. Last, we explored developmental differences in teens’ coping style, social support, and religious involvement.

Method Participants and Setting Participants. One hundred sixty-four female adolescents, ranging in age from 12 to 19 (M ⫽ 15.7 years,

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SD ⫽ 1.8 years) served as participants in this study. African Americans comprised 96% of the sample, 3% self-identified as from mixed race backgrounds, and 1% were Latina. Sixty-four percent of teens (104 of 164) lived with one or both of their parents, and 29% (47 of 164) lived with a grandparent or other relative. The remainder of the sample lived on their own (5%; 8 of 164) or in residential facilities (1%; 1 of 164). All participants were from low-income families and lived in inner-city neighborhoods of the metropolitan Atlanta area. Twenty-four percent of teens (39 of 164) reported that they had been arrested in the past, and 7% (11 of 164) were reportedly on probation at the time of this study. Four percent of adolescents in this study (7 of 164) reported a prior psychiatric hospitalization, and 26% (43 of 164) reported receiving outpatient counseling in the past. To be eligible for participation, teens had to be patients of the Adolescent Primary Care Clinic at Hughes Spalding Children’s Hospital. Additionally, they had to be able to speak and understand English and to complete the battery of questionnaires. All participants were recruited and enrolled in the study at the Adolescent Primary Care Clinic, which provides comprehensive medical care and psychosocial services to youths ages 10 to 19. The clinic is part of a university-affiliated indigent care hospital. Measures A demographic questionnaire was completed that included the following variables: age, ethnicity, living situation, number of children, family income, legal history, psychiatric history, and current mental health involvement. Risky Sexual Behavior. Participants were asked about their current sexual behaviors and sexual histories. Specifically, teens were asked to indicate the age at which they first willingly had vaginal intercourse. Additionally, participants were asked about the number of sexual partners they have had in the last 60 days and their frequency of condom use. In order to calculate frequency of condom use, we asked teens how many times they had sex with each partner reported and how many times they used a condom. Last, participants were asked about their STD and pregnancy history. Psychological Adjustment was assessed with the Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983), which is a global measure of psychological adjustment. This 53-item scale asks re-

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spondents to report symptoms they have experienced in the previous week and to rate the severity of symptoms on a 5-point scale. The BSI yields an overall global severity score (GSI), which has been shown to be a valid assessment of adolescent psychological adjustment (Handal, Gist, Gilner, & Searight, 1993). In addition, participants completed the Beck Depression Inventory (BDI; Beck & Beamesderfer, 1974), which consists of 21 items and yields scores of cognitive, behavioral, affective, and somatic depressive symptomatology. State and traitrelated anxiety were measured with the State-Trait Anxiety Inventory (STAI; Speilberger, Gorusch, & Lushene, 1970). Participants also completed the Conduct Disorder Subscale of the Adolescent Symptom Inventory–4 (Gadow & Sprafkin, 1997) to assess conduct problems and delinquency. Substance Use was measured with a 5-item scale that asks teens how often in the past 3 months they drank alcohol, got drunk from alcohol, or used marijuana, crack, or IV drugs. Items are scored along a 4-point Likert scale from none/never to several times a week (DiIorio, Parsons, Lehr, Adame, & Carlone, 1993). Total scores were used in the analyses that follow, and higher scores indicated more substance use. In addition, teens were asked if they ever had a drink or tried marijuana, cocaine, amphetamines, or IV drugs. If so, participants were asked how many days in the past month they had used the substance and how much they used. These questions were used for descriptive purposes only and were not used in the correlational analyses. Resilience Factors. These included coping style, social support, religious involvement, and school attendance. Participants completed the Coping Strategies Inventory (CSI; Tobin, Holroyd, & Reynolds, 1983) to assess coping thoughts and behaviors in response to a specific stressor. This scale consists of 36 items and yields assessments of palliative coping (e.g., problem avoidance, wishful thinking) and adaptive coping (e.g., problem solving, cognitive restructuring). A palliative coping ratio score was derived to reflect the relative use of palliative to adaptive coping strategies. Participants also completed the 20-item Medical Outcomes Study (MOS) Social Support Survey (Sherbourne & Stewart, 1991), which assesses perceived availability of social support. This measure assesses emotional and physical support, tangible support, and affectionate support and yields an overall score of social support. Teens were also asked to describe how religious they are on a 4-point Likert scale ranging from “not at


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all religious” to “very religious.” In addition, they were asked to report the average number of times they attended church services in a month. Last, teens reported whether they were currently attending school. HIV Knowledge and Attitudes. Teens completed questionnaires assessing their knowledge of HIV, sexual self-efficacy, perceptions of their own personal risk for contracting HIV, and perceptions of risky behaviors engaged in by their peers. These questionnaires have all been used in previous studies with African American adolescents and young adults and have demonstrated internal consistency, reliability, and construct validity (DiIorio, 1997). HIV-related knowledge was measured by the 15item Knowing About HIV and AIDS scale (Popham et al., 1995), which measures functional knowledge about HIV/AIDS in a true/false format. The Safer Sex Practice Self-Efficacy Scale (Soet, Dudley, & DiIorio, 1999) was used to measure self-efficacy related to condom use and discussion about safer sex. This is a 12-item scale that contains three factors: refusing to have sex, properly applying a condom, and negotiating for condom use. Total scores have been shown to be valid assessments of adolescents and young adults’ confidence in their ability to practice safer sex (Soet et al., 1999). Personal risk of contracting HIV was measured by a single item asking teens to rate their perceived level of risk of contracting HIV in their lifetime on a 4-point scale ranging from none to high. Peer norms were measured by a 7-item scale (DiIorio et al., 1993) assessing one’s perception of his or her peers’ involvement in risky practices such as having sex without a condom, having multiple sex partners, and using illicit substances. Participants evaluated how many of their close friends practice each behavior (1 ⫽ none to 5 ⫽ all), resulting in a total score reflecting teens’ perceptions of their peers’ risky practices.

pate. If the adolescent was under age 18, the signature of a parent or legal guardian was obtained. If the teen was 18 or older, the study requirements were explained and the teen was asked to sign a consent form. All data collection took place in an exam room or staff offices of the clinic. A trained research assistant verbally administered the battery of questionnaires to participants, in order to control for differences in reading ability. The research assistants were graduate student volunteers who were not associated with the clinic in any capacity. The questionnaire battery took approximately 60 to 90 minutes to complete. Participants were paid $10.00 for their participation. Approximately 10% of teens who were approached and asked to participate declined to take part in the study. Potential subjects who declined participation reportedly did so due to lack of interest or belief that the procedure would take too long to complete.

Procedure The Human Investigations Committee of Emory University School of Medicine approved this study prior to its initiation. Adolescents attending clinic appointments or being seen on a walk-in basis in the Adolescent Primary Care Clinic were approached in the clinic waiting area by the study coordinator. The purpose and requirements of the study were explained to those teens who met the eligibility criteria and they were invited to partici-

Results Risky Sexual Behavior. Means, standard deviations, and ranges of all measures are presented in Table I. Seventy-seven percent of teens in this sample (127 of 164) had been sexually active at least once in the past. The average age for sexual debut for this sample was 14.2 years (SD ⫽ 1.4), and 57% of sexually active teens (72 of 127) had their first sexual experience at age 14 or younger. Of those sexually active teens, 81% (103 of 127) reported having been sexually active in the last 60 days and 19% of the sample (24 of 127) reported having had more than one sexual partner in the last 60 days. Twenty-four percent of sexually active teens (30 of 127) had been pregnant at least once and 8% (10 of 127) had been pregnant two or more times. Thirty-nine percent of sexually active teens (49 of 127) reported that they had previously been diagnosed with at least one STD. In addition, 26% (26 of 99) of sexually active teens who responded reported that they used condoms less than half of the times they engaged in sexual activity, and 14% (14 of 99) reported never using condoms. Psychological Adjustment. Eighteen percent of adolescents (29 of 164) reported psychological distress in the borderline or clinical ranges (T-score ⱖ 90th percentile) on the Global Severity Index of the BSI. On the BDI, 27% of participants (44 of 164) endorsed depressive symptoms in the moderate range

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Table I. Means, Standard Deviations, and Ranges for All Measures Ages 12–15 (n ⫽ 72) M

SD

Ages 16–19 (n ⫽ 92) Range

M

SD

Range

Risky sexual behavior Age of sexual debut No. recent sexual partners

13.3

1.2

9–15

14.8

1.4

11–18*

1.0

1.6

0–8

1.1

1.1

0–7

% sexual encounters w/ condoms

.35

.00–1.0

History of pregnancy (no/yes)

1.0

.81

.21

1–2

1.3

.70

.39 .46

.00–1.0 1–2*

History of STD (no/yes)

1.2

.37

1–2

1.4

.50

1–2*

Psychological adjustment BSI–Global Severity Index

51.9

9.3

26–78

52.1

12.1

Beck Depression Inventory

16.7

10.6

0–45

13.7

9.6

STAI-State

45.3

8.6

20–67

45.5

10.4

20–73

ASI–Conduct Disorder

10.8

11.0

0–58

12.7

8.6

0–44

5.7

1.6

4–13

7.2

2.6

5–15**

.24

.77–2.0*

Substance use

29–80 0–39*

Resilience factors Coping style ratio MOS social support

1.44 77.5

Religious involvement

2.5

Church attendance

2.9

.27 15.7

.83–2.2

1.36

24–95

79.8

1–4

2.8

3.9

0–10

2.6

.95

14 .84

39–95 1–4*

2.4

0–12

HIV knowledge and attitudes HIV knowledge

55.4

7.9

31–72

59.4

9.2

34–75**

Sexual self-efficacy

96.3

22.5

30–120

103.2

23.2

21–120

Peer norms

16.9

5.5

7–28

22.2

5.4

9–35**

1.7

0.9

1–4

1.7

0.7

1–4

HIV risk perception

BSI ⫽ Brief Symptom Inventory–Global Severity Index; STAI ⫽ State-Trait Anxiety Index–State Scale; ASI ⫽ Adolescent Symptom Inventory– Conduct Disorder Subscale. *p ⬍ .05. **p ⬍ .01.

and 12% (20 of 164) endorsed symptoms in the severe range. Eighteen percent of teens (30 of 164) endorsed anxiety symptoms greater than a standard deviation above the adolescent normative mean on the STAI-State Scale, and 2% of participants (3 of 164) reported symptoms greater than two standard deviations above the normative mean. Substance Use History. Sixty-seven percent of teens (109 of 164) reported having used alcohol in the past, and 38% (63 of 164) reported drinking alcohol one or more times in the past month. Fortythree percent of adolescents (70 of 164) endorsed at least one instance of marijuana use in the past, and 25% (41 of 164) reported using marijuana one or more times in the past month. Only alcohol and marijuana use were reported by the adolescents in this study, with the exception of two teens who admitted to heroin and PCP use. Resilience Factors. At the time of the study, 84% of participants (137 of 164) were attending school , and all teens in the 12- to 15-year-old group were attending school. Only 9% (14 of 164) of teens in

this sample had children of their own. The vast majority of teens’ parents were still living; only 6% (10 of 164) of teens’ mothers were deceased and 9% (15 of 164) of teens’ fathers were deceased. Regarding religious involvement, on average, adolescents in this sample reported attending church three times a month and described themselves as “somewhat” religious. No appropriate norms were available for comparison of teens’ self-reported coping style or perceived level of social support. Differences Between Younger (Ages 12–15) and Older (Ages 16–19) Teens’ Risky Sexual Behavior, Psychological Adjustment, Substance Use, and HIV Knowledge and Attitudes. There were significant differences between older and younger teens’ self-reported risky sexual behaviors. The age of sexual debut differed between the younger and older teens, with the younger teens engaging in sexual intercourse significantly earlier (M ⫽ 13.2) than the older teens (M ⫽ 14.8, t ⫽ 5.61, p ⬍ .001). However, older teens were more likely to have been pregnant (t ⫽ 4.26, p ⬍ .001) and to have been diagnosed with an STD


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Table II. Correlations Between Psychological Adjustment, Substance Use, Resilience Factors, HIV Knowledge and Attitudes, and Sexual Behavior for Younger Teens (Ages 12–15) Sexual debut

# partners last 60 days

STD history

Pregnancy history

Condom frequency

Psychological adjustment BSI–GSI

⫺.30*

.16

.13

.11

BDI

⫺.29

.07

.06

.07

.12

STAI-State

⫺.28

.13

⫺.12

⫺.24*

.29


⫺.33*

.19

.25*

.07

⫺.34*

⫺.22

.34**

.66**

.41**

⫺.39*

Substance use

⫺.07

Resilience factors ⫺.13

.22

.10

⫺.02

.05

.08

.08

⫺.13

.10


⫺.13

⫺.07

⫺.02

⫺.04

⫺.28

Church attendance

⫺.18

.05

⫺.01

⫺.08

⫺.09

.05

.08

⫺.10

.05

.16

⫺.09

⫺.03

⫺.17

⫺.17

⫺.10

.05

.21

⫺.33

⫺.18

.03

.05

.34**

.04

⫺.07

.08

.14

.16

Coping style ratio MOS social support

Mother living Father living

.17

HIV knowledge and attitudes HIV knowledge

.03


.31**

Peer norms

.09

HIV risk perception

.13

.04 ⫺.25* .27* ⫺.13

BSI ⫽ Brief Symptom Inventory–Global Severity Index; BDI ⫽ Beck Depression Inventory; STAI ⫽ State-Trait Anxiety Index–State Scale; ASI ⫽ Adolescent Symptom Inventory–Conduct Disorder Subscale. *p ⬍ .05. **p ⬍ .01.

(t ⫽ 3.63, p ⬍ .001) than younger teens. The two age groups did not significantly differ on number of recent sexual partners or frequency of condom use. With regard to adolescents’ psychological functioning, younger teens reported significantly more depressive symptoms than older teens (t ⫽ ⫺2.1, p ⬍ .04); however, older and younger teens did not differ on self-reported psychological distress, anxiety, or conduct problems. As predicted, older teens reported significantly more drug and alcohol use than younger teens (t ⫽ 4.7, p ⬍ .001). Older and younger teens also differed on several resilience factors. Older teens described themselves as more religious than younger teens (t ⫽ 2.06, p ⬍ .04); however, the two groups did not differ on how often they reported attending church each month. Older teens also reported using more adaptive coping strategies than younger teens (t ⫽ ⫺2.0, p ⬍ .05). The two age groups did not differ on their perceived level of social support. Older teens reported more knowledge of HIV transmission than younger teens, as predicted (t ⫽ 2.89, p ⬍ .01). In addition, older teens reported having more peers who were engaging in risky behaviors than younger teens (t ⫽ 6.03, p ⬍ .001).

Contrary to expectations, the two age groups did not significantly differ on their perceived confidence in their ability to practice safer sex or on their perceived risk of contracting HIV. Correlates of Sexual Behavior in Younger Teens (Ages 12–15). We examined the relationships between psychological adjustment, substance use, resilience factors, HIV knowledge and attitudes, and risky sexual behavior for teens ages 12–15 (see Table II). As hypothesized, younger adolescents who reported conduct problems also reported earlier sexual debuts (r ⫽ ⫺.33, p ⬍ .03), histories of STDs (r ⫽ .25, p ⬍ .04), and less frequent condom use (r ⫽ ⫺.34, p ⬍ .05) than teens who did not report conduct problems. Similarly, as predicted, drug and alcohol use was significantly associated with number of recent sexual partners (r ⫽ .34, p ⬍ .01), history of STDs (r ⫽ .66, p ⬍ .001), pregnancy history (r ⫽ .41, p ⬍ .001), and frequency of condom use (r ⫽ ⫺.39, p ⬍ .03) in younger teens. Specifically, teens who reported more substance use also reported more sexual partners, STDs, and pregnancies, as well as less frequent condom use, than teens who did not report using drugs or alcohol. Younger teens who reported high levels of psychological distress also

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Bachanas et al.

reported initiating sexual activity at earlier ages (r ⫽ ⫺.30, p ⬍ .05). In addition, there was a trend for younger teens who reported more symptoms of depression (r ⫽ ⫺.29, p ⬍ .06) and anxiety (r ⫽ ⫺.28, p ⬍ .06) to also report initiating sexual activity at younger ages. Younger teens who reported high levels of anxiety also reported histories of becoming pregnant (r ⫽ ⫺.24, p ⬍ .05). Younger teens who reported more confidence in their ability to negotiate and practice safer sex tended to engage in sexual activity later (r ⫽ .31, p ⬍ .01) and reported fewer sexual partners in the past 2 months (r ⫽ ⫺.25, p ⬍ .04). In addition, teens who reported that their peers were engaging in fewer risky behaviors also reported fewer sexual partners (r ⫽ .27, p ⬍ .03) and fewer STD diagnoses (r ⫽ .34, p ⬍ .01). Younger adolescents’ perception of their personal risk for contracting HIV and their knowledge of HIV transmission and progression were not significantly correlated with their sexual behavior. Contrary to expectations, religious involvement, church attendance, and whether their parents were living were not significantly associated with younger teens’ risky sexual behavior. Similarly,

younger adolescents’ coping style and perceived level of social support were not correlated with their risky sexual practices. Finally, all of the younger teens were attending school, so this factor was not included as a correlate of risky sexual behavior for this group. Correlates of Sexual Behavior in Older Teens (Ages 16–19). In contrast to younger teens, older teens’ sexual behaviors were not significantly associated with their current psychological functioning or substance use (see Table III). Similarly, HIV knowledge, sexual self-efficacy, and perceived risk of contracting HIV were not correlated with older teens’ sexual behavior. However, older teens who reported that their peers were engaging in risky behaviors tended to report less frequent condom use (r ⫽ ⫺.34, p ⬍ .01). For older adolescents, several psychosocial factors were significantly correlated with their sexual behavior. Specifically, older teens whose mothers had died tended to engage in sexual activity at younger ages (r ⫽ ⫺.22, p ⬍ .04). In addition, teens who initiated sex at younger ages were also more likely to have a child (r ⫽ ⫺.23, p ⬍ .04) than teens who delayed sexual activity. Older teens who had become pregnant were less likely to be at-

Table III. Correlations Between Psychological Adjustment, Substance Use, Resilience Factors, HIV Knowledge and Attitudes, and Sexual Behavior for Older Teens (Ages 16–19) Sexual debut

# partners last 60 days

STD history

Pregnancy history

Condom frequency

Psychological functioning BSI–GSI

.08

⫺.13

.15

.05

⫺.09

BDI

.11

⫺.07

.08

.14

⫺.07

STAI-State

.08

⫺.08

⫺.04

.14

⫺.09


.08

⫺.04

.00

⫺.11

⫺.14

⫺.07

.01

.09

.10

⫺.16 ⫺.03

Substance use Resilience factors

⫺.03

⫺.09

.15

⫺.02

MOS social support

.09

.09

.18

⫺.05

.01


.10

⫺.08

⫺.14

⫺.07

.03

Coping style ratio

.08

⫺.23*

⫺.03

⫺.09

⫺.08

Mother living

⫺.22*

.12

⫺.19

⫺.02

.22

Father living

.01

.08

.06

.08

.02

Attending school

.01

.02

⫺.06

⫺.24*

.06

HIV knowledge

⫺.13

.09

⫺.05

.14


⫺.02

.08

.01

⫺.06

Peer norms

⫺.14

.08

.18

.13

⫺.34**

.08

.11

.14

.01

⫺.08

Church attendance

HIV knowledge and attitudes

HIV risk perception

⫺.06 .07

BSI–GSI ⫽ Brief Symptom Inventory–Global Severity Index; BDI ⫽ Beck Depression Inventory; STAI ⫽ State-Trait Anxiety Index–State Scale; ASI ⫽ Adolescent Symptom Inventory–Conduct Disorder Subscale. *p ⬍ .05. **p ⬍ .01.


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tending school (r ⫽ ⫺.24, p ⬍ .05) than teens who had never been pregnant. With regard to resilience factors, older teens who attended religious services more often reported fewer sexual partners in the past two months (r ⫽ ⫺.23, p ⬍ .03) than teens who were less involved with a church. However, older teens’ coping style and perceived level of social support were not significantly associated with their risky sexual behavior.

ing assertiveness and communication/negotiation skills around delaying intercourse and condom use. Perhaps the most striking differences between older and younger teens were the different patterns of relationships identified between risky sexual behavior and psychological adjustment, substance use, and resilience factors. Specifically, consistent with previous studies, younger teens who reported high levels of conduct problems and substance use also reported engaging in more risky sexual behaviors. This pattern is consistent with Jessor and Jessor’s theory of problem behavior (1977), which suggests that problem behaviors such as alcohol use, marijuana use, delinquency, and precocious sexual activity tend to be associated with each other in teens (Donovan, Jessor, & Costa, 1991). However, significant relationships between substance use, delinquency, and risky sexual behavior were not found for older adolescents. These findings suggest that problem behavior theories may be more applicable to younger adolescents than to older adolescents, as sexual activity, substance use, and conduct problems become normative by middle to late adolescence. Externalizing behavior problems were significantly associated with a range of risky sexual behaviors in younger teens. However, internalizing behaviors (e.g., psychological distress, depression, anxiety) were associated only with early sexual debuts and not with more direct measures of risky sexual behavior (e.g., number of recent sexual partners, frequency of condom use). This finding suggests that younger adolescent girls who reported experiencing more psychological distress may seek emotional support or acceptance by engaging in sexual activity at younger ages. In contrast, risky sexual behaviors in older teens were not significantly associated with internalizing or externalizing behavior problems. Instead, environmental factors seemed to be more important for older teens. Specifically, indices of environmental support (e.g., whether their mother was living, involvement in a church, and peers’ level of involvement in risky behaviors) were significantly associated with older teens’ risky sexual activities. Taken together, these findings seem to suggest that individual characteristics (e.g., psychological functioning) seem more important for younger teens engaging in risky sexual practices, and environmental support seems more important for older teens as these behaviors become more normative. For younger teens, peers engaging in risky be-

Discussion Young women of color from impoverished, urban environments are at high risk for contracting HIV and other STDs. This study assessed developmental differences in the psychological adjustment, substance use, coping style, social support, HIV knowledge and attitudes, and risky sexual behavior of atrisk minority, adolescent girls attending a primary care clinic. In addition, developmental differences between younger and older teens were explored in psychosocial correlates of risky sexual behavior. As predicted, older teens reported engaging in more risky sexual behaviors and more substance use than younger teens. This is likely due to differences in developmental norms, which indicate that sexual activity and substance use increase with age during adolescence (CDC, 2000; Johnston, O’Malley, & Bachman, 1995). Older and younger teens significantly differed in their reported histories of pregnancy and STDs; however, they did not significantly differ in their report of number of recent sexual partners or frequency of condom use. This may reflect a difference in exposure time, as older teens have had a longer period of time to become pregnant or contract an STD than younger teens. As hypothesized, older teens reported more knowledge of HIV transmission and progression than younger teens; however, they did not endorse more confidence in their ability to practice safer sex or more perceived risk of contracting HIV than younger teens. Despite increased experience with sexual encounters as they get older, teens do not necessarily increase their confidence or skills in communicating about or negotiating safer sex practices. Given that adolescents’ risk of pregnancy, STDs, and HIV increases over the course of adolescence as they increase their number of partners and number of sexual encounters, these findings highlight the importance of providing teens with skillbased prevention interventions that target enhanc-

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haviors was associated with teens’ reports of number of recent sexual partners and histories of STDs. For older teens, perceptions of their peers engaging in risky behaviors was associated with teens’ report of less frequent condom use. These findings were consistent with previous studies in the literature, which have shown that peer influence seems to be particularly important for teens with regard to sexual activity (Millstein & Moscicki, 1995). It is not clear from these findings if adolescents initiate risky behaviors to conform to an existing peer group or if those teens inclined to engage in risky behaviors are drawn to those peers who are similarly inclined (Igra & Irwin, 1996). The findings from this study indicate that the pattern of risk factors for risky sexual behavior does seem to differ for older and younger teens. Teens between the ages of 12 and 15 who are engaging in delinquent behavior, using substances, and associating with peers who are engaging in risky behaviors seem to be at greater risk for HIV and STDs, given that they are more likely to initiate sexual activity earlier, have more sexual partners, and practice safer sex less often. Clearly, these teens should be targeted for mental health intervention and prevention interventions implemented early (i.e., late elementary and middle school), given that many teens will initiate sexual activity at these younger ages. In addition, prevention interventions should target groups of peers rather than individuals to have the broadest impact. Contrary to our expectations, most of the resilience factors identified in previous studies as being associated with fewer risky sexual practices in teens (e.g., coping style, social support) were not associated with teens’ sexual practices in this study. The exception was church participation, which was associated with fewer sexual partners in older teens, suggesting that religious involvement may serve a protective role for older teens, but not for younger teens. The lack of findings in this study may be due to weaknesses in the measures used to assess coping style and social support. While these measures have documented reliability and validity with other samples, they may not have captured the experiences of African American adolescents coping with the stresses associated with living in impoverished, inner-city environments. Other factors that may serve as sources of strength or support (e.g., family relationships) were not assessed in this study. For both older and younger teens, knowledge of HIV transmission and perceived risk of contracting

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HIV were not significantly associated with teens’ risky sexual behavior. Furthermore, both groups of teens demonstrated high levels of HIV knowledge, but perceived themselves to be at low risk for contracting HIV despite engaging in behaviors that placed them at high risk. Consistent with previous studies, these findings suggest that despite accurate knowledge, teens do not perceive their behaviors as placing them at risk for contracting HIV (Overby & Kegeles, 1994). Consequently, HIV prevention strategies should target decreasing feelings of invincibility characteristic of adolescence and increasing risk perception based on teens’ behaviors. Several limitations to this study warrant noting. Although we actively recruited male participants, only a few were enrolled. The adolescent clinic primarily serves girls, so over 95% of subjects enrolled were female. Therefore, we decided to focus on minority females; however, data on young males would be important to obtain for comparison. Similarly, the adolescent clinic serves mostly African American teens, so there are also no comparison data for Latina, Caucasian, or higher SES teens. Consequently, these findings may have limited generalizability to other groups; however, they likely represent low-income, minority youths presenting to clinics in urban settings. Given the nature of the clinic, the sample in this study is also potentially biased in that most of the teens were sexually active. Therefore, the risk factors for teens in this sample may not be representative of teens from different environments. In addition, although we tried to choose measures that had been used with African American adolescents, most of the measures used in this study do not have norms for urban youths of color. Consequently, we cannot be certain that the measures used in this study adequately represented the experiences of African American girls in an urban environment. We did not obtain information on teens’ sexual abuse history. Given that sexual abuse histories have consistently been associated with early sexual activity in teens, this lack of data represents a weakness of this study. In addition, we relied on teens’ self-report for the majority of the data. Teens may have underreported some illegal behaviors (e.g., substance use) or sexual behaviors that they were uncomfortable discussing with an interviewer. However, we also recorded STD and pregnancy history from the teens’ medical charts and obtained high concordance rates between the girls’ report and their medical records, suggesting that their re-


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sponses were valid. Finally, the focus of this study was exploratory. We chose a broad approach to assessing developmental differences in a large number of factors, which only allowed for correlational analyses. Consequently, the conclusions that can be drawn from this study are limited, and identifying developmental trends will require future longitudinal studies. Future research should attempt to develop models that can be tested through regression analysis to obtain more information on predictors of risky sexual behavior in older and younger teens. In addition, future research should target male adolescents, other minority and nonminority teens, and higher SES groups for comparison. Finally, developing and evaluating prevention interventions with at-risk youths should be a priority. In conclusion, the findings from this study support the need for providing multidisciplinary services to at-risk youths who present for care in medical clinics. These findings also reflect the importance of the psychologist’s role in primary care settings and the need to develop preventionoriented approaches to mental health intervention. The Adolescent Primary Care Clinic offers on-site mental health services for teens presenting with

emotional or behavioral problems and provides prevention-focused intervention to teens engaging in risky behaviors. Clinic-based mental health services have allowed providers to directly target those teens for intervention who are at highest risk. Identifying and intervening with teens early may result in reducing the numbers of adolescents who develop psychiatric and substance abuse problems, teen pregnancy, and HIV.

Acknowledgments Portions of these data were previously presented at the CDC/NIMH HIV Prevention Conference, Atlanta, Georgia, 1999, at the 107th Annual Convention of the American Psychological Association, Boston, Massachusetts, 1999, and at the 7th Florida Conference on Child Health Psychology in Gainesville, Florida, 1999. This study was supported by a grant from the National Institute of Mental Health (NIMH MH 51761–04S1) to Pamela Bachanas, PhD, and Mary Morris, PhD. Received March 8, 2001; accepted September 19, 2001

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