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Successful family-based weight loss interventions for African American adolescents are rare. Parent-adolescent interactions supporting adoption of healthier nutrition and physical activity practices are not well understood. African American caregivers' and adolescents' perspectives on how they worked together to achieve weight loss need further exploration. This study describes the relationships experienced by adolescents and caregivers during the 6-month, evidence-based FIT Families weight loss trial and explores differences between families whose adolescents were successful and unsuccessful with weight loss. Exit interviews conducted with 136 adolescents (age 12–16 years; BMI percentile ≥95) and their caregivers (primarily mothers) were taped and transcribed verbatim. Content and thematic analysis was conducted to explore differences between groups stratified by weight loss. Five adolescent-caregiver relationship patterns emerged which describe dyads working together, working alone, working against each other; caregiver support and caregiver working on self. When relationship patterns were compared between groups stratified by weight loss, three themes emerged: motivation, support, and persistence. Families that achieved the greatest weight loss referred more often to working together to reach weight loss goals, attributed their success to adolescent self-motivation, with engaged caregiver support which allowed families to persist in change efforts. Family relationships involving adolescent autonomy, engaged parental support, and persistence despite challenges, clustered differently among adolescents who were successful at weight loss compared to those who were not. Interventionists trained to reinforce effective adolescent-parent interactions will advance behavioral interventions for families who have typically benefited least in prior interventions.

African American adolescents with type 1 diabetes (T1D) are at elevated risk for poor diabetes management and metabolic control. Parental supervision and monitoring of adolescent diabetes management have been shown to promote better diabetes management among adolescents, but parents typically decrease their oversight during the transition to independent diabetes care.The purpose of the study was to conduct a randomized clinical trial to test the feasibility and efficacy of a three-session, computer-delivered motivational intervention (The 3Ms) to promote increased parental monitoring among primary caregivers of young African American adolescents with T1D. The intervention was brief and optimized for delivery during routine diabetes clinic visits.Sixty-seven adolescents with T1D aged 11-14 and their primary caregiver were randomly assigned to one of three arms: adolescent and parent motivational intervention (Arm 1), adolescent control and parent motivational intervention (Arm 2), or adolescent and parent control (Arm 3). Intervention effects were assessed 1 month after intervention completion.Parents in Arm 1 and Arm 2 had significant increases in knowledge of the importance of monitoring adolescents' diabetes care. Parents in Arm 2 also had trend to significant increases in direct observation and monitoring of adolescent diabetes care, and adolescents in Arm 2 had significant improvements in glycemic control.Findings from the present study provide preliminary support for the efficacy of a brief, computer-delivered parenting intervention for improving family management practices and adolescent health outcomes among African American adolescents with T1D and their caregivers.

The purpose of this study was to predict low, moderate, hard and very hard physical activity (PA) and walking/biking/jogging based PA. One-hundred and fifty-nine severe to morbid obese African-American adolescents participated. We predicted 8% of the variance in hard PA largely due to family support and 10% of the variance in very hard PA due to other support (e.g. counselor) and having home PA equipment. We also predicted 10% of the variance in walking/biking/jogging due to the walkability of the neighborhood. Our findings support the value of social support and environmental supports in helping obese African American adolescents increase PA.

Background/objective The negative effects of stress on persons with type 1 diabetes (T1D) are well-established, but effective interventions to reduce stress among emerging adults with T1D are limited. The study objective was to conduct a pilot randomized controlled trial (RCT) to obtain preliminary data on the efficacy of mindfulness-based stress reduction (MBSR) to reduce stress and improve diabetes health outcomes in a population of high-risk, urban emerging adults with poorly controlled diabetes. Methods Forty-eight participants aged 16 to 20 years of age with T1D (mean duration = 8 years) were randomly assigned to one of three conditions: MSBR, cognitive-behavioral stress management (CBSM), or a diabetes support group. Data were collected at baseline, end of treatment, and 3 months after treatment completion. Measures of self-reported stress and depressive symptoms, diabetes management, and glycemic control were obtained. Results MBSR was found to reduce self-reported stress at end of treatment (P = 0.03, d = -0.49) and 3-month follow-up (P = 0.01, d = -0.67), but no effects on diabetes management or glycemic control were found. Diabetes support group participants had improved glycemic control at the end of treatment (P = 0.01, d = -0.62) as well as reduced depressive symptoms at 3-month follow-up (P = 0.01, d = -0.71). Conclusions Results provide preliminary support for the efficacy of MBSR to improve psychosocial adjustment in emerging adults with poorly controlled T1D but require replication in adequately powered studies. Findings also support the value of peer support in improving health outcomes in this age group.

Objective Determine whether Multisystemic Therapy-Health Care (MST-HC) improved asthma knowledge and controller device use skills among African-American youth with poorly controlled asthma and whether any improvements mediated changes in illness management. Methods A randomized controlled trial was conducted with 170 adolescents with moderate to severe asthma. Families were randomized to MST-HC or attention control. Data were collected at baseline and 6 and 12 months after intervention completion. Results In linear mixed models, adolescents in the MST-HC group had increases in asthma knowledge; asthma knowledge was unchanged for attention control. Controller device use skills increased for adolescents in the MST-HC group, while skills declined for attention control. Both knowledge and skills mediated the relationship between intervention condition and changes in illness management. Conclusions Tailored, home-based interventions that include knowledge and skills building components are one means by which illness management in African-American youth with poorly controlled asthma can be improved.

OBJECTIVE: The goal of the current study was to determine how a set of social cognitive factors predict antiretroviral therapy (ART) medication adherence in youth living with HIV in an era of newer highly active ART medications using a conceptual model. METHODS: Behaviorally infected youth living with HIV ages 13–24 (N = 822) from 14 sites within the Adolescent Medicine Trials Unit (AMTU) were included in the study. Structural equation modeling was used to explore predictors of ART medication adherence. RESULTS: Results found that motivational readiness for ART was related to higher ART medication adherence, which was associated with lower viral load. Higher social support and higher self-efficacy had an indirect relationship with higher adherence through increased motivational readiness. Fewer psychological symptoms were associated with higher social support and higher self-efficacy. Lower substance use was directly associated with lower adherence. CONCLUSIONS: The results provide insight into factors that may be related to adherence in youth living with HIV. Findings suggest focusing on motivational readiness to increase adherence. Improving the patients’ ART self-efficacy and strengthening their social support networks during treatment can increase motivational readiness for ART treatment. Furthermore, programs maybe more effective with the inclusion of risk reduction components especially those related to substance use.

Multiple factors in family environment have been known to exacerbate childhood asthma morbidity, such as psychological stress (Marin, Chen, Munch, & Miller, 2009), marital conflict (Northey, Griffin, & Krainz, 1998), parental stress (Shalowitz, Berry, Quinn, & Wolf, 2001), and family conflict (Anda et al., 2006). Additional family characteristics, such as poor caregiver or youth mental health (Ortega, Goodwin, McQuaid, & Canino, 2004; Wood et al., 2007), family disorganization (Kaugars, Klinnert, & Bender, 2004), and minority ethnicity (Bauman et al., 2002) all are contributing components through which the family environment and stress can negatively impact the asthma symptom profile. Research also has demonstrated that increased exposure to stress in adolescents with asthma is associated with greater eosinophil counts, increased lymphocyte proliferation, and increased production of pro-inflammatory cytokines, which may contribute to increased asthma symptom expression (Chen et al., 2006; Kang et al., 1997). Given the accumulating evidence for a biopsychosocial model of asthma, it is important for researchers to identify aspects of relationships that can contribute to the exacerbation and persistence of asthma symptoms. Furthermore, the research to date has largely focused on the extent to which very general family characteristics, such as family-related stress, impact asthma morbidity during youth using parent and youth accounts of the family environment. No investigations to our knowledge have examined the direct effect of daily conflict in everyday life on youth health. Frequent conflict in the home has been theorized to create vulnerabilities in youth by disrupting biological and psychological processes through interactions with genetic and environmental factors (Repetti, Taylor, & Seeman, 2002). Family conflict has been associated with a variety of poor health outcomes, including lower weight attainment in infancy (Stein, Woolley, Cooper, & Fairburn, 1994), slower growth in childhood (Montgomery, Bartley, & Wilkinson, 1997), and greater psychological distress during adolescence (Gunnlaugsson , Kristjansson, Einarsdottir, & Sigfusdottir, 2011). Research also has demonstrated that youth growing up in environments with increased conflict and anger have amplified emotional responses to stressors and more often use maladaptive coping strategies, which negatively impact physical health (Cummings, Zahn-Waxler, & Radke-Yarrow, 1981; Repetti, Robles, & Reynolds, 2011; Valiente, Fabes, Eisenberg, & Spinrad, 2004). Surprisingly, very little is known about the direct impact of conflict at home on serious physical health problems, such as asthma during childhood and adolescence. Moreover, there has been a recent call for research focusing on the adversities youth face on a routine basis, such as family conflict, to clarify links between stress during development and chronic illness (Miller, Chen, & Parker, 2011). Family conflict is a construct that typically is measured via brief questionnaire reports or laboratory interactions. However, questionnaire reports of family conflict include potential sources of bias, aspects of social desirability, and shared method variance (Campbell & Fiske, 1959; Mehl, Robbins, & Deters, 2012). Additionally, assessing family conflict from short laboratory interactions can raise questions regarding generalizability of these interactions, as research has long documented variations in parental behaviors due to changes in the context in which they are measured (Belsky, 1980). Research suggests that data should be collected from multiple informants (e.g., from both parents and children) due to contextual elements and situational determinants that may influence an individual's perceptions (Achenbach, McConaughy, & Howell, 1987; Kerr, Lunkenheimer, & Olson, 2007). Collecting questionnaire data from multiple informants can sometimes pose a challenge in family research. Alternatively, naturalistic observation can provide reasonably objective and detailed accounts of daily interactions in the home. The Electronically Activated Recorder (EAR; Mehl, Pennebaker, Crow, Dabbs, & Price, 2001) is a relatively new naturalistic observation method used to capture participant behaviors and interactions as they occur in daily life. The EAR unobtrusively takes brief recordings of ambient sounds and interactions as they occur in a participant's environment. By taking an observational approach, the EAR helps to address the potential issues of bias, shared method variance, and generalizability that can sometimes hinder questionnaire and laboratory measures of conflict. Previous studies of families have documented the usefulness of the EAR in assessing everyday behaviors in the home. For example, parental negative emotionality (Slatcher & Trentacosta, 2012) and parental depressive symptoms (Slatcher & Trentacosta, 2011) have been linked with increased problem behaviors in young children. Increased observed-conflict in the home of young children (aged 3-5) was associated with an altered diurnal cortisol profile, including flatter (less “healthy”) cortisol slopes and lowered waking cortisol levels, whereas maternal questionnaire reports of daily parent-child conflict were unrelated to cortisol patterns (Slatcher & Robles, 2012). To our knowledge, no studies to date have addressed how naturalistically-observed everyday family interactions are associated with youth asthma symptoms. This study addresses that gap by using the EAR to assess the links between observed conflict in the home and the health of youth with asthma.

Parental monitoring of adolescent diabetes care is an important predictor of adolescent regimen adherence. To date, no studies have investigated whether socio-demographic factors are associated with low levels of parental monitoring or differences in parental monitoring styles, and their moderating effects in families of adolescents with type 1 diabetes. The purpose of this cross-sectional study was to determine whether youth and family socio-demographic factors moderated the relationship between monitoring and youth regimen adherence (i.e., mean frequency of blood glucose testing [BGT]). Data were collected from 267 adolescents with type 1 diabetes and their parents. Hierarchical multiple regression analyses were employed. Socio-demographic factors accounted for 17.1% of the variance in adherence. After parental monitoring scales were entered, R2 in all eight equations increased and R2 change score in six of eight equations were significant. All models were significant after the interaction terms were entered. In the adolescent report models, parent age and family structure were both independently associated with adherence and also moderated the association between adolescent-report parental monitoring and adherence to diabetes care, in particular, adolescent report of parental direct observation/presence during diabetes care. In the parent report models, income was moderated the association between parent-report youth disclosure and adherence. Research should focus on identifying additional modifiable factors that place families at risk for low levels of parental monitoring of diabetes care. Future clinical research is needed to help identify risk factors for low levels of parental monitoring and develop interventions to promote optimal parenting skills that can support youth diabetes care.

Purpose: The purpose of this study was to assess the feasibility of a three-session computer intervention to improve diabetes management among African-American youth with type 1 diabetes. Methods: The 3 Ms (Medication, Meter, and Meals) intervention was based on the Information-Motivation-Behavioral Skills model of health behavior change and Motivational Interviewing approaches. Feasibility was assessed based on rates of intervention participation and intervention satisfaction using a mixed-methods approach. Participants included 23 youths aged 10–13. Results: Mean satisfaction rates from questionnaires were high across ratings for both general satisfaction and helpfulness of the intervention for improving diabetes care. Intervention participation rates were also high, with 87% completing all three sessions. Thematic analyses suggests that adolescents found the intervention helpful for changing their diabetes management behaviors, their thoughts about the importance of diabetes care, reminding them to com...

This study included African Americans with asthma in emerging adulthood, a developmental period largely neglected in the research literature but known to be a time of great risk asthma morbidity and mortality. We conducted thematic analysis of semi-structured interviews ( N = 19) to explore barriers to adherence in the context of the transition into adulthood. Key themes for non-adherence emerged after careful follow-up prompting by the interviewer: forgetting to take medications, deciding not to take medications as prescribed, and systemic barriers. Clinicians and researchers interested in improving adherence should carefully assess barriers to adherence when working with this population. Effective adherence interventions should target both intentional and unintentional reasons for non-adherence behavior and take into account the unique developmental needs of emerging adults.

Objective To adapt an evidence-based intervention targeting diabetes management in adolescents with poorly controlled type 1 diabetes for use in a community setting by community health workers (CHWs) and to conduct pilot testing of the new intervention, REACH for Control (RFC). The study was conducted as a collaboration between university researchers and a federally qualified health center. Methods In a pilot effectiveness trial, feasibility and acceptability of RFC were evaluated based on participant enrollment, treatment dose, and consumer satisfaction. RFC effects on adolescent adherence, health outcomes, and quality of life were also assessed. The trial used a parallel group design. Families were randomized to 6 months of RFC plus standard medical care (n = 26) or standard care (SC) only (n = 24). Data were collected at baseline and 7-month posttest. A mixed-methods approach was used to analyze data. Results Qualitative analyses suggested that caregivers viewed RFC and delivery of a home-based intervention by CHWs positively. Furthermore, adolescents who received RFC had statistically significant (p = .05) and clinically meaningful improvements in hemoglobin A1c (HbA1c) (0.7%) and reported significant improvements in quality of life from baseline to follow-up (p = .001). No significant changes were found for adolescents in standard medical care. However, while dose of primary intervention session delivered was acceptable, dose of follow-up sessions used for skills practice was low. Conclusions Results provide preliminary support for RFC's acceptability and effectiveness to improve health status and quality of life when used in community settings serving high-risk, low-income families. Additional testing in a full-scale effectiveness trial appears warranted.

Objective The primary purpose of the study was to determine whether Multisystemic Therapy adapted for health care settings (MST-HC) improved asthma management and health outcomes in high-risk African American adolescents with asthma. Method Eligibility included self-reported African American ethnicity, ages 12 to 16, moderate to severe asthma, and an inpatient hospitalization or at least 2 emergency department visits for asthma in the last 12 months. Adolescents and their families (N = 170) were randomized to MST-HC or in-home family support. Data were collected at baseline and posttreatment (7 months) based on an asthma management interview, medication adherence phone diary, and lung function biomarker (forced expiratory volume in 1 s [FEV1]). Analyses were conducted using linear mixed modeling for continuous outcomes and generalized linear mixed modeling for binary outcomes. Results In intent-to-treat analyses, adolescents randomized to MST-HC were more likely to improve on 2 of the measures of medication adherence and FEV1. Per-protocol analysis demonstrated that MST-HC had a medium effect on adherence measures and had a small to medium effect on lung function and the adolescent's response to asthma exacerbations. Conclusion There are few interventions that have been shown to successfully improve asthma management in minority youth at highest risk for poor morbidity and mortality. MST, a home-based psychotherapy originally developed to target behavior problems in youth, improved asthma management and lung function compared to a strong comparison condition. Further follow-up is necessary to determine whether MST-HC reduces health care utilization accounting for seasonal variability. A limitation to the study is that a greater number of participants in the control group came from single-parent families than in the MST group.

Objective: Asthma medication adherence is low, particularly among African American adolescents, a high-risk group with respect to asthma prevalence, morbidity, and mortality. This study tested the utility of self-determination theory (SDT), a theory of motivation, to explain adherence to asthma medication regimens in African American adolescents. Method: We used baseline data from 168 urban African American adolescents (Mage 13.94 years; 61% male) with poorly controlled asthma who were part of a trial testing the efficacy of interventions to improve adherence. Participants and their caregivers were interviewed using the Family Asthma Management System Scale; this study used the Asthma Medication Adherence subscale. Adolescents completed four asthma-specific scales representing the SDT constructs of autonomous motivation (one importance scale), competence (one confidence scale), and relatedness (two scales—family routines and parental support). Using multiple linear regression, we tested the hypothesis that SDT variables would predict adherence. Results: Adherence was significantly correlated with three SDT variables—importance, confidence, and family routines. In multivariate analysis, family routines was the only significant predictor of asthma adherence (p .001). Asthma management behaviors integrated into and shared among family members was associated with better adherence. Greater confidence was marginally associated with increased adherence (p .07). Conclusion: Though several variables representing SDT constructs were correlated with adherence, results demonstrate that family routines may be more relevant for African American adolescents’ adherence than other SDT constructs. Thus, helping families to share and better integrate asthma care into daily schedules may be an important intervention strategy to improve medication adherence among high-risk African American adolescents.

Motivational interviewing (MI) has been shown to reduce sexual risks among HIV-positive men who have sex with men (HMSM) in the U.S. We conducted a randomized trial of Healthy Choices, a 4-session MI intervention, targeting sexual risks among 110 HIV-positive youth ages 16–25 years in Thailand. Risk assessments were conducted at baseline, 1 month, and 6 months post-intervention. This report presents the analysis of 74 HMSM in the study. There were 37 HMSM in the Intervention group and 37 in the control group. The proportions of participants having anal sex and having sex with either HIV-uninfected or unknown partners in past 30 days were significantly lower in Intervention group than in control group at 6 months post-intervention (38% vs. 65%, p = .04; and 27% vs. 62%, p < .01, respectively). There were no significant differences in general mental health scores and HIV stigma scores between the two groups at any study visit. Thirty-five (95%) HMSM in the Intervention group vs. 31 (84%) in control group attended ≥3 sessions. Loss to follow-up was 8% and 30%, respectively (p = .04). Healthy Choices for young Thai HMSM was associated with sexual risk reduction. Improvements in mental health and HIV stigma were noted in Intervention group. Healthy Choices is a promising behavioral intervention and should be further developed to serve the needs of young HMSM in resource-limited countries.

hailandisamongthefewless-developedcountrieswith successful HIV prevention among segments ofthe population (National AIDS Prevention andAlleviation Committee, 2010). However, the successof HIV prevention among Thai adolescents andyoung adults has been questionable. The highestpercentage of Thai persons with AIDS remain inthe age group of 25–34 years, indicating that thetime of greatest HIV acquisition has occurred inadolescence and young adulthood (Thai WorkingGroup on HIV/AIDS, 2010). Most Thai youth livingwith HIV (TYLH) acquire HIV through sexualcontact (National AIDS Prevention and AlleviationCommittee, 2010). In a study of TYLH, only half re-ported consistent condom use in the previous 30 days(Rongkavilit et al., 2007); therefore, secondaryprevention targeting sexual risk behaviors in TYLHare needed.Behavioral intervention research targeting youthwith HIV in less-developed countries remains non-existent. An intervention that is brief, culturallyacceptable, and can increase young people’s intrinsicmotivation to reduce risk behaviors and maintainthese changes over time is critically neededfor this setting. Motivational interviewing (MI),an empirically supported behavioral counselingapproach, targets an individual’s intrinsic motivationfor change by exploring and resolving ambivalenceabout behavior change while supporting theindividual’s self-efficacy and autonomy for makingchanges. The MI approach can impact the informa-tion, motivation, and behavioral skills necessary toachieve a behavior change according to theInformation-Motivation-Behavioral Skills model(Fisher & Fisher, 1992). MI has been successfully

Young people represent the largest number of new HIV infections, thus youth living with HIV (YLH) are likely to be the largest group to initiate antiretroviral treatment (ART). Adherence patterns for behaviorally infected YLH are not adequate to effectively manage the disease; therefore, novel interventions are needed to improve medication adherence. The purpose of the current study, which will precede a randomized controlled trial, was to assess the initial feasibility of an individually tailored computer-based two-session interactive motivational interviewing (MI) intervention for YLH newly recommended to start ART. Intervention development occurred in collaboration with three youth advisory groups. Ten youth (ages 18–24) were recruited to participate in this study. Participants completed the intervention online. Intervention components focused on medication adherence (rating perceived importance and confidence, and goal setting). Retention was 100% for both intervention sessions. All participants (n = 10) felt medication adherence was important, but 80% felt confident they could manage their adherence to HIV medications. Ninety percent of participants set the goal of taking their HIV medications exactly as prescribed and reported success achieving this goal at follow-up. Additionally, participants were satisfied with the quality of the sessions and the amount of assistance they received for managing their adherence to HIV medications (90% participants for Session 1; 89% for Session 2). Per exit interview responses, participants felt that the intervention made them think more about their health and was a motivator for them to take better care of their health. In conclusion, the intervention was feasible for YLH enrolled in the study.

To describe the asthma medication device skills of high-risk African American adolescents and associations between skills and other components of illness management,170 African American adolescents, with at least one hospitalization or two emergency department visits in the last year, demonstrated how they use their asthma quick-relief and controller medication devices. Observations were scored using an in vivo observation asthma skills checklist. To assess other areas of asthma management, adolescents and their primary caregiver were interviewed using the Family Asthma Management System Scales,Only 5% of adolescents correctly demonstrated all controller skills, and none of the adolescents correctly showed all quick-relief inhaler skills (5% showed between 90 and 95% of skills). Several components of asthma management predicting controller medication skills were attendance at an asthma specialty clinic, collaboration with provider, medication adherence, and quick-relief medication skills. These variables accounted for a total of 24% of the variance in controller medication skills,Results indicate the need for interventions directly targeting observed asthma management skills and the importance of relationship with providers.

Objective To apply a social ecological model to explore the psychosocial factors prospectively associated with longitudinal adherence to antiretroviral treatment in youth perinatally infected with HIV. Methods Randomly selected youth, age 8 to

Improvements in behavior following active interventions diminish over time across a broad spectrum of behaviors. Motivational interviewing (MI) has been found to increase intrinsic motivation forinitialbehavior change, but there has been little discussion on how to integrate MI and the cognitive-behavioral treatments (CBTs) commonly used tomaintainchange. A prominent CBT approach to relapse prevention that has been tested in multiple behavioral domains includes the following maintenance strategies: managing the goal violation effect, flexible goal setting, identifying triggers and developing coping skills, and increasing self-efficacy and social support. Using a model of integration where MI is the foundation for CBT delivery, the integration of specific relational and technical components of MI and CBT strategies for maintenance of change are described. A universal maintenance intervention that uses MI as an integrative framework to deliver CBT may address maintenance of behavior change across multiple behavioral domains. Further research is necessary to confirm whether delivering MI with fidelity adds to the effectiveness of CBT maintenance interventions.

Individuals with HIV disease often evidence deficits in prospective memory (PM), which interfere with daily functioning and increase the risk of suboptimal health behaviours. This study examined the benefits of simple encoding and cueing supports on naturalistic time-based PM in 47 HIV-positive young adults. All participants completed a naturalistic time-based PM task in which they were instructed to text the examiner once per day for seven days at a specified time. Participants were randomised into (1) a Calendaring condition in which they created a calendar event in their mobile telephone for the specified texting time; (2) an Alarm condition in which they programmed an alarm into their mobile telephone for the specified texting time; (3) a Combined calendaring and alarm condition; and (4) a Control condition. Participants in the Combined condition demonstrated significantly better naturalistic PM performance than participants in the Control and Calendaring conditions. Findings indicate that HIV-positive young people may benefit from a combined calendaring and alarm supportive strategy for successful execution of future intentions in daily life.

Adherence to antiretroviral medication for the treatment of HIV is a significant predictor of virologic suppression and is associated with dramatic reductions in mortality and morbidity and other improved clinical outcomes for pediatric patient populations. Effective strategies for addressing adherence problems in youth infected with HIV are needed and require significant attention to the complex interplay of multiple, interacting causal risk factors that lead to poor self-care. Within the context of a pilot randomized trial, we evaluated the feasibility and initial efficacy of a multisystemic therapy (MST) intervention adapted to address HIV medication adherence problems against a usual care condition that was bolstered with a single session of motivational interviewing (MI). For 34 participating youth, health outcomes (viral load [VL] and CD4 count) were obtained from approximately 10 months pre-baseline through approximately 6 months post-baseline and self-reported medication adherence outcomes were obtained quarterly from baseline through 9 months post-baseline. Using mixed-effects regression models we examined within- and between-groups differences in the slopes of these outcomes. Feasibility was supported, with a 77% recruitment rate and near-maximal treatment and research retention and completion rates. Initial efficacy also was supported, with the MST condition but not the MI condition demonstrating statistically and clinically significant VL reductions following the start of treatment. There was also some support for improved CD4 count and self-reported medication adherence for the MST but not the MI condition. MST was successfully adapted to improve the health outcomes of youth poorly adherent to antiretroviral medications. Replication trials and studies designed to identify the mechanisms of action are important next steps.

Few interventions have effectively improved health outcomes among youth with diabetes in chronic poor metabolic control.This study aims to determine whether multisystemic therapy (MST), an intensive, home-based, tailored family treatment, was superior to weekly telephone support for improving regimen adherence and metabolic control among adolescents with chronic poor metabolic control.A randomized controlled trial was conducted with 146 adolescents with types 1 or 2 diabetes. Data were collected at baseline, 7 months (treatment termination), and 12 months (6 months follow-up).Adolescents receiving MST had significantly improved metabolic control at 7 (1.01 % decrease) and 12 months (0.74 % decrease) compared to adolescents in telephone support. Parents of adolescents receiving MST reported significant improvements in adolescent adherence. However, adolescent-reported adherence was unchanged.MST improved health outcomes among adolescents with chronic poor metabolic control when compared to telephone support. Home-based approaches may provide a viable means to improve access to behavioral interventions for such youth.

This study used a descriptive, cross-sectional analysis to examine a social ecological model of obesity among African-American female adolescents residing in obesogenic environments. The goal was to identify factors that promote weight resilience, defined as maintaining a healthy body weight despite living in an environment that encourages inactivity and undermines healthy weight behaviors. During 2005 to 2008, weight-resilient (n=32) and obese (n=35) African-American female adolescents (12 to 17 years) living in Detroit, MI, and their caregivers completed measures of individual, family, and extrafamilial weight-resilience factors. Variables related to weight resilience in bivariate analyses were subjected to multivariate analysis using logistic regression to test the hypothesis that these factors independently predicted adolescent membership into the weight-resilient or obese group. As hypothesized, the odds of an adolescent being weight resilient were predicted by lower caregiver body mass index (calculated as kg/m 2 ) (odds ratio [OR]=0.790; 95% confidence interval [CI]: 0.642 to 0.973), lower caregiver distress (OR=0.796; 95% CI: 0.635 to 0.998), higher caregiver monitoring and supervision of exercise (OR=5.746; 95% CI: 1.435 to 23.004), more frequent full-service grocery store shopping (OR=5.147; 95% CI: 1.137 to 23.298), and more peer support for eating (OR=0.656; 95% CI: 0.445 to 0.969). Contrary to prediction, lower eating self-efficacy (OR=0.597; 95% CI: 0.369 to 0.965) also predicted weight resilience. The model correctly classified 92.5% of all cases. Findings suggest that increasing psychosocial weight-resilience factors across multiple systems might be an important intervention strategy for obese African-American female adolescents residing in obesogenic environments.

We evaluated the psychometric properties of a revised version of the Parental Monitoring of Diabetes Care questionnaire (PMDC-R) designed to evaluate parental supervision and monitoring of adolescent diabetes care behaviors. The revised measure was intended to capture a broad range of ways used by parents to gather information about youth adherence to diabetes care.Two hundred sixty-seven caregivers of 12-18-year-old adolescents with type 1 diabetes completed the PMDC-R. Measures of parental knowledge of youth illness management, illness management behavior, and metabolic control were also obtained.The PMDC-R demonstrated good internal consistency (alpha coefficient = .91) and test-retest reliability (r = .79, p.001). Supporting the instrument's construct validity, a bifactor model with one primary factor and three secondary factors had an acceptable fit to the data (comparative fit index = .92, root mean square error of approximation = .06). Concurrent validity was also supported. In structural equation models, parental monitoring, as assessed by the PMDC-R, had a significant direct effect on parental knowledge of adolescent diabetes management and, through knowledge, an indirect effect on adolescent diabetes management and metabolic control.The PMDC-R displayed strong psychometric properties and represents an important next step in refining the measurement of parental monitoring for youth with chronic illnesses.

The provision of culturally relevant yet evidence-based interventions has become crucial to global HIV prevention and treatment efforts. In Thailand, where treatment for HIV has become widely available, medication adherence and risk behaviors remain an issue for Thai youth living with HIV. Previous research on motivational interviewing (MI) has proven effective in promoting medication adherence and HIV risk reduction in the United States. However, to test the efficacy of MI in the Thai context a feasible method for monitoring treatment fidelity must be implemented. This article describes a collaborative three-step process model for implementing the MI Treatment Integrity (MITI) across cultures while identifying linguistic issues that the English-originated MITI was not designed to detect as part of a larger intervention for Thai youth living with HIV. Step 1 describes the training of the Thai MITI coder, Step 2 describes identifying cultural and linguistic issues unique to the Thai context, and Step 3 describes an MITI booster training and incorporation of the MITI feedback into supervision and team discussion. Throughout the process the research team collaborated to implement the MITI while creating additional ways to evaluate in-session processes that the MITI is not designed to detect. The feasibility of using the MITI as a measure of treatment fidelity for MI delivered in the Thai linguistic and cultural context is discussed.

Human immunodeficiency virus (HIV) disease is commonly associated with deficits in prospective memory (PM), which increase the risk of suboptimal health behaviours, like medication non-adherence. This study examined the potential benefits of a brief future visualisation exercise during the encoding stage of a naturalistic PM task in 60 young adults (aged 19-24 years) with HIV disease. Participants were administered a brief clinical neuropsychological assessment, which included a standardised performance-based measure of time- and event-based PM. All participants were also given a naturalistic PM task in which they were asked to complete a mock medication management task when the examiner showed them the Grooved Pegboard Test during their neuropsychological evaluation. Participants were randomised into: (1) a visualisation condition in which they spent 30 sec imagining successfully completing the naturalistic PM task; or (2) a control condition in which they repeated the task instructions. Logistic regression analyses revealed significant interactions between clinical neurocognitive functions and visualisation. HIV positive (HIV+) participants with intact retrospective learning and/or low time-based PM demonstrated observable gains from the visualisation technique, while HIV+ participants with impaired learning and/or intact time-based PM did not evidence gains. Findings indicate that individual differences in neurocognitive ability moderate the response to visualisation in HIV+ young adults. The extent to which such cognitive supports improve health-related PM outcomes (e.g., medication adherence) remains to be determined.

This paper briefly reviews the research literature on motivational interviewing (MI) and behaviour change in adolescents and then discusses the implications of adolescent cognitive and social–emotional developmental processes for the relational and technical components of MI. Research suggests that MI is efficacious in improving substance use in adolescents. Research has been slower to emerge in other behaviours, but available randomized controlled trials suggest that MI has great promise for improving mental and physical health outcomes in this developmental period. The relational and technical components of MI are highly relevant for the adolescent developmental period, and studies have shown that these components are related to outcomes in this population. There are several ways to include MI in clinical interventions for adolescents, ranging from MI in brief settings to using MI as a platform from which all other treatments are offered. Future research is necessary to test the effects of MI in adolescent group settings and the full integration of MI into other adolescent treatment approaches.

The aim of this research study was to examine the relationship between 4 sources of social support (support for the adolescent from family, support for the adolescent from friends, support for the caregiver from another adult, and support to the family from the health care provider) and adolescents' diabetes outcomes (illness management behavior and health status) using a diverse sample of urban adolescents.One hundred forty-one adolescents with insulin-managed diabetes and their primary caregivers completed questionnaires assessing social support and illness management behavior. Glucose meters were downloaded and hemoglobin A1c assays were obtained. Structural equation modeling was used to test a model social support informed by social ecological theory.The results of the structural equation modeling indicated that support for the caregiver from another adult was directly and positively related to support for the adolescent from family and indirectly related to better illness management. Support for the adolescent from family was directly related to better diabetes management and, through better management, to better diabetes health. Support to the family from the health care provider was not related to support for the adolescent and support to the adolescent from friends was not related to illness management, as hypothesized.This study identifies a novel target for social support intervention to improve adolescents' illness management behavior-the caregivers of adolescents with diabetes. By enhancing the social support caregivers receive from other adults in their lives, caregivers' ability to support their adolescent children with diabetes might also be improved which, in turn, improves adolescents' illness outcomes.

Objectives Investigate effect of baseline motivation for change on treatment fidelity, therapeutic alliance, treatment dose, and treatment outcome in a randomized controlled trial of family therapy for youth with poorly controlled diabetes. Methods Seventy-four adolescents and caregivers completed measures of motivation for change. Measures of fidelity, alliance, dose, and youth health status were collected. Structural equation modeling was used to test the direct and indirect effects of motivation on treatment outcomes. Results Parent motivation was significantly related to alliance and fidelity. Only alliance was significantly related to posttreatment metabolic control. In adolescent models, only motivation was significantly related to alliance. In both models, motivation had a significant indirect effect on metabolic control through alliance. Conclusions Findings demonstrate the importance of parent and youth initial motivational status and treatment alliance to treatment outcome among youth with poorly controlled diabetes. Additional research on treatment techniques that promote motivation for change is needed.

Purpose More than 50% of youth living with HIV (YLH) have unprotected sex. In previous studies, we reported effects of a motivational interviewing-based multirisk reduction intervention, "Healthy Choices" in improving motivation, depression, and viral load in YLH. In this study, we report the effect of the intervention on increasing condom use. Methods Six waves of longitudinal data (n = 142) across a period from baseline through 15 months postintervention were analyzed. The developmental trajectory modeling method was used for program effect evaluation. Results The three groups detected with distinct sexual risks were: Persistent low sexual risk (PLSR), delayed high sexual risk, and high and growing sexual risk with regard to levels and time trajectories of condom use throughout the trial. Receiving Healthy Choices increased the likelihood to be in the PLSR group (63% vs. 32%, p p β = −.325, p β = −.364, p Conclusion The motivational interviewing-based program Healthy Choices, when delivered in clinic settings, can prevent unprotected sex in subgroups of YLH, although more intensive interventions may be needed to change risk trajectories among those at highest risk of transmitting the AIDS virus. Developmental trajectory analysis provides an alternative approach to evaluate program effects for study samples that contain distinct subgroups.

African American adolescents are disproportionately affected by obesity. Few interventions target this group, produce sustainable results, and retain participants. Phenomenology was used to compare the treatment experiences of African American families in multisystemic therapy for weight loss. Families that discontinued treatment described life problems and negative experiences with interventions as barriers. Therapeutic time was spent building confidence and motivation for treatment. Although successful families struggled with intrafamilial relationships, they were more engaged in treatment and experienced greater weight loss. Instilling hope is one strategy proposed to increase treatment engagement in families dealing with serious life problems.

With disproportionately higher rates of HIV/AIDS among youth and increasing access to antiretroviral therapy (ART) in Thailand, there is a growing urgency in understanding the challenges to medication adherence confronting this population and in developing theory-based interventions to address these challenges. One potentially relevant model, the information-motivation-behavioral skills (IMB) model of adherence, was developed in Western settings characterized by a more individualistic culture in contrast to the more collectivistic culture of Thailand. We explored the application and adaptability of IMB on ART adherence among HIV-positive Thai youth through the analysis of qualitative data from a pilot motivational interviewing study. Twenty-two interview sessions from 10 HIV-positive Thai youth (17–24 years) were analyzed; 6 youth were on ART. Data support the utility of IMB as a potential framework for understanding ART adherence in this population. However, data indicate a consideration to expand the motivation construct of IMB to incorporate youths' perceived familial and social responsibilities and the need to adhere to medications for short- and long-term well-being of self, family, and society in a context of Buddhist values. These modifications to IMB could be relevant in other cultural settings with more collectivistic worldviews.

Objective To determine whether multisystemic therapy, an intensive, home- and community-based intervention, could increase family support for healthy eating and exercise in obese African-American adolescents. Relationships between changes in family support, weight status, and body fat composition at the end of the trial were also evaluated. Method A pilot randomized clinical trial was conducted with 49 obese adolescents (body mass index > or = 95th %ile). Participants were randomized to receive multisystemic therapy or Shapedown, a group weight loss intervention. Participants received treatment for 6 months. Data were collected at baseline and 7-month posttest (i.e., treatment termination). Changes in family support for healthy eating and exercise were assessed by self-report questionnaire. Bivariate analyses were used to assess the relationship between change in family support during the trial and youth body mass index, percent overweight, and body fat composition at follow-up. Results Participation in multisystemic therapy was associated with significantly greater improvements in family encouragement for healthy eating and family participation in exercise and greater decreases in discouraging behavior from family members than Shapedown participation. Increases in family participation in exercise were significantly related to lower youth body mass index, percent overweight, and body fat composition at follow-up. Conclusions Intensive, home- and community-based treatment increased family support for health behavior changes among obese minority adolescents, and these changes were directly related to weight status. Such health improvements are important for the well-being of a subset of youth who are at high risk for future health complications.

This study investigates HIV positive adolescents' health literacy and whether factors associated with health literacy in HIV-positive adults are associated with health literacy among HIV-positive adolescents.Adolescents in this study were behaviorally and perinatally HIV-infected youth (n=186) from five U.S. cities. Participants had a mean age of 20.5, and 49.5% were male.Contrary to findings for adult HIV-positive patients, among adolescents health literacy was not significantly associated with: medication adherence adjusting for age and education level; viral load; or self-efficacy to adhere to medication regimens. The only significant association was of health literacy with medical care received.Practice implications are discussed.

Objectives. We sought to determine whether field outreach with motivational interviewing, as compared with traditional field outreach, leads to increases in HIV counseling and testing and rates of return for test results among young African American men who have sex with men (MSM). Methods. In a randomized, 2-group, repeated-measures design, 96 young African American MSM completed a motivational interviewing—based field outreach session and 92 young African American MSM completed a traditional field outreach session. The percentages of participants agreeing to traditional HIV counseling and testing (an oral swab of the cheek) and returning for test results were the primary outcome measures. Results. More of the participants in the motivational interviewing condition than the control condition received HIV counseling and testing (49% versus 20%; χ21 = 17.94; P = .000) and returned for test results (98% versus 72%; χ21 = 10.22; P = .001). Conclusions. The addition of motivational interviewing to field outreach is effective in encouraging high-risk young African American MSM to learn their HIV status. Also, peer outreach workers can be effectively trained to reduce health disparities by providing evidence-based brief counseling approaches targeting high-risk minority populations.

Purpose To describe multiple risk behaviors (substance use, sexual risk, and medication adherence) in a multi-site sample of youth living with human immunodeficiency virus (HIV) in five U.S. cites. Methods Youth (N=352) were recruited from four Adolescent Trials Network (ATN) sites (Philadelphia, Fort Lauderdale, Baltimore, and Los Angeles) and one non-ATN site in Detroit and screened for multiple problem behaviors for an intervention study. A substance abuse problem was determined with the CRAFFT, a six-item adolescent screener. Single items were used to screen for current sexual risk and for an HIV medication adherence problem. Of the youth, 239 (68%) had at least one of the three risk behavior problems based on the screener. A total of 186 (52.8%) completed longer, in-depth questionnaires for each problem behavior. Results Of the 352 youth screened, 60% had problem level substance use and 42% had a sexual risk problem. Of the 165 (47%) who were prescribed medications, 91 (55%) reported an adherence problem. A total of 112 (32%) reported no problem behavior, 123 (35%) reported 1 problem behavior, 95 (27%) reported 2 problem behaviors, and 20 (6%) reported 3 problem behaviors. Males were more likely to have a substance use problem. Younger youth living with HIV and those perinatally infected were more likely to have an adherence problem. Among the 186 (52.8%) completing longer measures, those with a substance abuse problem had higher substance use on a timeline follow-back procedure than those without. Participants who screened positive for a sexual risk problem reported more unprotected sex on an in-depth interview than those without. Those who screened positive for an adherence problem had higher viral loads than those without an adherence problem. Conclusions Results suggest high rates of problem behaviors among youth living with HIV, particularly in older youth. Younger and perinatally infected youth may require specialized adherence interventions. Associations between the screener and more in-depth assessment measures suggest potential clinical utility of screening youth for high-risk behaviors.

Overweight and obesity are increasing dramatically in the United States of America, especially among children. Effective treatment of the multiple risk factors that promote youth obesity requires treatment approaches that are flexible and comprehensive enough to address each of these factors. One such treatment approach is Multisystemic Therapy (MST), an empirically supported, intensive home-based treatment approach that has been proven effective with other childhood chronic illnesses and which has recently been adapted to treat youth with obesity. This case report describes the use of MST to treat an obese 15-year-old African American boy during the course of a pilot study designed to determine the feasibility of MST for African American youth.

Objective To present a case study using multisystemic therapy (MST), an intensive family focused psychotherapy. For the clinical trial from which this case was drawn, MST was adapted to address multiple human immunodeficiency virus (HIV) transmission risk behaviors in HIV-infected youth. Targeted behaviors included medication nonadherence, risky sexual behaviors, and substance use. Method One young woman's transmission risk behaviors are described, followed by a description of the MST procedures used to identify and treat the primary drivers of these risk behaviors. Outcome measures were self-report, urine screens, and blood draws. Results At discharge, the young woman showed significant improvements in medication adherence and related health status (e.g., reduced HIV viral load), healthier sexual behaviors, and reduced substance use. Importantly, neither her boyfriend nor her newborn tested positive for HIV. Conclusions Findings from this case study suggest that MST has the potential to reduce transmission risk behaviors among teens with HIV.

To test whether self-report data agree with medical record data in marginalized, HIV-infected populations, we collected information about HIV primary care visits over a 6-month period from both sources. Patients were drawn from a large study of engagement and retention in care conducted between 2003 and 2005. Self-report data were collected in face-to-face interviews and medical records were extracted using a rigorous, standardized protocol with multiple quality checks. We found poor overall agreement (weighted kappa = 0.36, 95% confidence interval = 0.28, 0.43). Factors associated with disagreement included younger age (adjusted odds ratio for 20 versus 40 years = 1.25, 95% confidence interval = 0.98, 1.60), non-Hispanic black race/ethnicity (adjusted odds ratio for non-Hispanic blacks versus non-Hispanic whites = 1.48, 95% confidence interval = 1.03, 2.13), lower education (adjusted odds ratio for high school education, GED, or less versus some college or college graduate = 1.43, 95% confidence interval = 0.96, 2.13), and substance use (adjusted odds ratio for any illicit drug/heavy alcohol use in the past 6 months versus no use = 1.39, 95% confidence interval = 1.02, 1.90). These findings do not support a conclusion that unconfirmed self-report data of HIV primary care visits are a sufficient substitute for rigorously collected medical record data in studies focusing on marginalized populations. Use of other data sources (e.g., administrative data), use of other self-reported outcome measures that have better concordance with medical records/administrative data (e.g., CD4 counts), or incorporation of rigorous measures to increase reliability of self-report data may be needed. Limitations of this study include the lack of a true gold standard with which to compare self-report data.

Objective To test predictors of medication adherence in high-risk racial or ethnic minority youth living with HIV (YLH) using a conceptual model of social cognitive predictors including a continuous measure of motivational readiness. Methods Youth were participants in a multi-site clinical trial examining the efficacy of a motivational intervention. Racial-minority YLH (primarily African American) who were prescribed antiretroviral medication were included (N = 104). Data were collected using computer-assisted personal interviewing method via an Internet-based application and questionnaires. Results Using path analysis with bootstrapping, most youth reported suboptimal adherence, which predicted higher viral load. Higher motivational readiness predicted optimal adherence, and higher social support predicted readiness. Decisional balance was indirectly related to adherence. Conclusions The model provided a plausible framework for understanding adherence in this population. Culturally competent interventions focused on readiness and social support may be helpful for improving adherence in YLH.

Cross-sectional data were gathered from 1,625 children (M age = 12.85, SD = 2.21) which included 755 AIDS orphans, 466 vulnerable children, and 404 comparison children. Participants completed self-report measures of exposure to traumatic events, and psychosocial adjustment including behavior problems, depression, self-esteem, and future orientation. AIDS orphans and vulnerable children reported experiencing a higher total occurrence, density, duration, initial impact and lasting impact of traumatic events compared to comparison children. Scores reflecting adjustment were lower among orphans and vulnerable children than among comparison children. Both orphan status and traumatic events contributed unique variance in the expected direction to the prediction of psychosocial adjustment. The data in the current study suggested that children affected by HIV/AIDS in China are exposed to more trauma and suffer more adjustment problems than children who do not experience HIV/AIDS in their families.

Youth living with HIV (YLH) are at particularly high risk for poor retention in HIV primary care. This study utilized Motivational Interviewing (MI) to improve youth retention in primary care and compared the fidelity and outcomes of peer outreach workers (POW) to masters level staff (MLS). Eighty-seven YLH were randomized to receive two MI sessions from POW or MLS. YLH were aged 16-29 and 92% were African American. Thirty-seven audiotaped sessions were coded with the Motivational Interviewing Treatment Integrity (MITI) coding system. Retention in care was assessed by review of medical records. POW had higher fidelity on two MITI scales, and did not differ from MLS on remaining three scales. While both groups improved the regularity of primary care appointments, the effect size for POW on retention in care and intervention dose was larger than that of MLS. The results suggest that POW can provide MI with quality comparable to MLS with adequate training and supervision. MI provided by POW to improve retention in health care services may increase the cost-effectiveness of evidence-based practices in urban settings.

African-American adolescents have the highest rates of asthma morbidity and mortality, yet there are few successful behavioral interventions to improve illness management for this group. Mental health providers have an opportunity to expand their services and impact by targeting adolescents with poor asthma management. We describe the adaptation of Multisystemic Therapy (MST), an intensive, home and community-based treatment originally used with antisocial youth, for improving asthma management. We present a case study to illustrate the treatment model. Feasibility was demonstrated with eight African American adolescents with chronic, persistent asthma, suggesting that further evaluation of MST for youth with asthma and poor illness management is warranted.

BACKGROUND: Parent/caregiver or child/youth self-report and pill counts are commonly used methods for assessing adherence to antiretroviral therapy (ART) among children and youth with HIV. The purpose of this study was to compare these different methods with one another and with viral load. METHODS: Randomly selected parent/caregiver and child/youth dyads were interviewed using several adherence self-report measures and an announced pill count was performed. Adherence assessment methods were compared with one another and their relative validity was assessed by comparison with the child’s viral load close to the time of the interview or pill count, adjusting for primary caregiver, child age, and child disclosure of the diagnosis. RESULTS: There were 151 evaluable participants. Adherence rate by pill count was ≥ 90% in 52% of participants, was significantly associated with log(RNA) viral load (p=0.032), and had significant agreement with viral load < 400 copies/mL. However, pill count data were incomplete for 26% of participants. With similar proportions considered adherent, a variety of self-report adherence assessment methods also were associated with log(RNA) viral load including: “no dose missed within the past one month” (p=0.054 child/youth interview, p=0.004 parent/caregiver interview), and no barrier to adherence identified (p=0.085 child/youth interview, p=0.015 parent/caregiver interview). Within-rater and inter-rater agreement was high among self-report methods. Three day recall of missed doses was not associated with viral load. CONCLUSION: Findings demonstrate the validity of adherence assessment strategies that allow the parent/caregiver or child/youth to report on adherence over a longer period of time and to identify adherence barriers. Adherence assessed by announced pill count was robustly associated with viral load, but there was incomplete data for many participants.

Parental monitoring has been defined as “a set of correlated parenting behaviors involving attention to and tracking of the child's whereabouts, activities, and adaptations.” This construct is of significant interest due to its relatedness to a broad range of youth risk behaviors, including risky sexual behavior, substance abuse, and poor adherence. However, to date, measures of parental monitoring are largely absent from the chronic illness literature. The present article focuses upon two key problems in the operationalization of the monitoring construct to date: (a) poor conceptual specificity in parenting constructs such as monitoring, overprotection, and over-involvement when used to date among youth with chronic conditions and (b) the confounding of existing measures of parental monitoring with items evaluating parental knowledge of youth activities, which has resulted in a lack of data regarding the mechanisms by which parents obtain their information. Recommendations for the future development of monitoring measures are discussed.