ARA - California School

Report
EVIDENCE-INFORMED
INTERVENTIONS FOR
ADDRESSING
ADOLESCENT
RELATIONSHIP ABUSE
(ARA) IN SBHC’S
Sandi Goldstein, MPH
California Adolescent Health Collaborative
Lisa James, MA
Futures Without Violence
OBJECTIVES
At the end of this session, participants will
be better able to:
 demonstrate a greater understanding of
the prevalence and impact of ARA.
 implement new strategies for integrating
ARA into clinical encounters.
 formulate a multidisciplinary approach.
DEFINITIONS: WHY LANGUAGE
MATTERS
Reframing the
conversation from
Teen Dating Violence to
Adolescent Relationship
Abuse:
“Are you hanging out
with anyone?”
“Are you seeing anyone
right now?”
WHAT IS ADOLESCENT
RELATIONSHIP ABUSE?
 ARA refers to an escalating pattern of repeated acts that physically,
sexually, or emotionally abuse a member of a heterosexual or
homosexual couple in in the context of a dating or similarly defined
relationship which one or both partners is a minor.
 Range of controlling behaviors: monitoring cell phone usage, telling
a partner what s/he can wear, controlling where s/he goes, and
manipulating contraceptive use.
 The defining characteristic is a repetitive pattern of behaviors
aiming to maintain power and control in a relationship.
ARA AND
TECHNOLOGY
One in four teens in a
relationship report being
called names, harassed, or
put down by their partner via
cell phone/texting
One in five teen girls
have electronically sent
or posted nude/seminude photos or videos
of themselves (12% of
these girls say they felt
‘pressured’ to do so)
HEALTH
CONSEQUENCES OF
ARA
1 in 5
(20%) U.S. teen
girls report ever experiencing
physical and/or sexual violence in
an intimate relationship.
(CDC Morbidity and Mortality Weekly Report.
February 2008. ;Silverman et al, 2001)
ARA AND TEEN PREGNANCY

Adolescent girls in
physically abusive
relationships were
3.5 times more likely to
become pregnant than
non-abused girls

Pregnant adolescents 23 times more likely to
have experienced
violence during and
after pregnancy than
older pregnant women
(Roberts et al, 2005)
ARA AND SEXUAL RISK FOR
ADOLESCENTS
Partner violence among teen girls linked with:
 Early sexual intercourse (before age 15)
 Condom inconsistent use or non-use at last sex
 Multiple partnering (3+) in past 3 months
 Use alcohol or drugs before sex
 Have a past or current sexually transmitted infection
 Have a partner with known HIV risk factors
(Silverman,et al. 2004; Kim-Goodwin et al, 2009; Wu et al, 2003)
ARA AND MENTAL HEALTH
Over 50% of
youth reporting
both physical and
sexual violence in
their relationship
also reported
attempting
suicide.
(Bossarte et al, 2008; Ackard &
Neumark-Sztainer , 2002)
ARA AND MENTAL HEALTH
Young women who have
experienced partner abuse have
higher rates of:
 Depression and anxiety
 Disordered eating
 Substance abuse
 more likely to report
sadness, hopelessness
or suicide ideation
(Kim-Godwin YS, et al 2009;Howard DE, et al ,2008;Brossard RM, et al,
2008)
WHAT HAPPENS AT SCHOOL FOR
THESE TEENS?
 Victim s and perpetrators are more
likely to carry weapons as well as
engage in physical fighting and other
high risk behaviors .
 Physical and sexual victimization is
associated with an increased risk for
school dropout, lower grades, and less
connectednes s to school.
 A third (32%) of female homicides
among adolescents between the ages
of 11 and 18 are committed by an
intimate partner.
(Champion et al, 2008; Goldstein et al, 2009; Banyard
& Cross, 2008; Coyne-Beasley et al, 2003)
NEW STRATEGIES
ARA PROJECTS INVOLVING
HEALTHCARE PROVIDERS
Project Connect
HEART (Healthcare Education,
Assessment & Response Tool for Teen
Relationships)
SHARP (School Health Center Healthy
Adolescent Relationship Program)
PROJECT CONNECT
 National Initiative to improve collaboration between public health
and domestic violence program s
 Worked in 8 states and 2 tribes in phase one and now working in
6 new states and 5 new tribes beginning 2013
 Trained over 6,000 providers from over 150 clinical sites
 Changed health policy at the state level
 Integrated violence prevention into teen pregnancy prevention
 New statewide requirements for all school based health settings to
screen and respond to ARA
SHARP
Model
 Provider training
 Provider Assessment at every encounter
 Distribute Safety Card at every encounter
 Peer activities
PROMOTING HEALTHY
RELATIONSHIPS
Every adolescent clinical encounter is an
opportunity to:
 convey prevention education
messages about healthy relationships
 share with youth that your clinical
space is safe and confidential
 identify and support youth who may
be experiencing controlling and
abusive behaviors in their
relationships
GOALS FOR UNIVERSAL EDUCATION
ABOUT HEALTHY RELATIONSHIPS
 Distinguish between healthy and
unhealthy relationship behavior
 Encourage safe and respectful
relationships
 How to help a friend in an unhealthy
relationship
 Educate sexually active adolescents about
sexual coercion and the importance of
consent
 Create an environment where youth will
see the clinic or provider’s office as a
safe place to seek related advice and
assistance for relationship abuse
GETTING STARTED
First things first: Always review
the limits of confidentiality-even if you are not asking
DIRECT questions about abuse-in case there is disclosure and
you need to report
For more information, please refer to
Future’s Mandatory Reporting: Using a
Trauma-informed Approach module
PROVIDING UNIVERSAL EDUCATION ON
HEALTHY RELATIONSHIPS
The way you start the conversation
sets the tone:
“I talk about this with all
my patients because it’s
so common…”
MAKING HEALTHY RELATIONSHIP
CONVERSATIONS
SIMPLE
“We’ve started
talking to all the
teens in our
clinic about what
they deserve in
relationships
and giving them
this card, it talks
about health
and unhealthy
relationships.”
“Everyone
deserves to be
treated with
respect- but
defining what
that looks like
can be
confusing.”
“This panel of the
card breaks it
down a little
more...”
Video: Olivia
The following video clip
demonstrates providing
universal education on
healthy relationships
during an adolescent
health visit.
OLIVIA DEBRIEF
Universal education and focusing on friends
opens the door for direct assessment.
“So Olivia is
anything like this
happening to
you?”
Talk about
healthy
relationships
with girls
and boys:
“We find a
lot of the
teen that
come to the
clinic have
situations
like this
come up
with people
they are
seeing...”
Adolescents
report disclosing
abusive
relationship
experiences to
friends far more
than to health
professionals,
suggesting that
education within
clinic settings
about “how to
tell a friend”
may resonate
with youth.
VOICES FROM THE FIELD
"I learned long ago not to make assumptions
about our patients and that by screening every
patient for domestic violence and reproductive
coercion, you uncover unlikely stories of
abuse. The study helped reinforce the practice
of normalizing my screening questions .”
-Nurse Practitioner at New Generation Health Center, San Francisc o
SHARP PEER ACTIVITIES
Each team led by an adult ally
Each team received training from Kat
Gutierrez, CSHC
Peers organized one school wide project
Peers organized a bathroom campaign
EXAMPLES OF ACTIVITIES
 Lunchtime session on Valentine’s Day called
"Hearts or Bombs" during which students
describe healthy and unhealthy relationship
qualities.
 Theater production on healthy relationships.
Production is an interactive piece that will
engage audience members in acting out
relationship trauma that they or a loved one
might have experienced.
EXAMPLES OF ACTIVITIES
Mock dating game with three
contestants, each representing
healthy, unhealthy, and abusive
relationship tendencies.
Two cupids passing out wallet
cards with candy.
EVALUATION DATA
HEART EVALUATION RESULTS
 Tech abuse victimization in the past 3 months
decreased in both sites: 65% to 22% (school
health center) and from 26% to 7% (teen/young
adult health center)
 In the teen/young adult health center site, past 3
month reproductive coercion decreased from 13%
to 2%.
-no significant difference in the school health center
site (baseline reproductive coercion was low).
HEART EVALUATION RESULTS:
CLIENT EXIT SURVEYS
Clients were overwhelmingly positive about receiving
this information from their provider:
 70% of the time clients reported talking to their provider
about healthy and unhealthy relationships during the
clinical encounter
 57% reported receiving this information helped them know
how to help someone in an unhealthy relationship
 77% agree that it is helpful for health care providers to
talk about healthy and unhealthy relationships
 84% state they would bring a friend to the health center if
they were experiencing an unhealthy relationship
HEART EVALUATION RESULTS:
PROVIDERS
Since being trained:
 26% reported an increased number of disclosures
about ARA by youth
 26% reported having more contact with domestic
violence and sexual assault advocates since the
training
 66% reported increased counseling about harm
reduction strategies with their clients (strategies to
stay safer, reduce risk for unintended pregnancy)
SHARP PRELIMINARY RESULTS
Prevalence of ARA
 Approximately 27% (n=197) of students experienced
ARA
 63% experienced technology-based abuse
 10% of females experienced reproductive coercion.
SHARP PRELIMINARY RESULTS
 A majority of students (87%, n=688) identified their
SBHC as an ARA resource at baseline.
 Post-visit, intervention SBHC students were
significantly more likely to have discussed ARA with
their provider compared to control students.
 Among those who had experienced ARA, intervention
SBHC students were more likely to disclose this
history of abuse to a provider compared to controls,
but this did not persist in adjusted analysis.
BUILDING A MULTI -DISCIPLINARY TEAM
 Develop protocol
 Develop a collaborative model of care
 Have a private place to talk with
patients
 Use safety care intervention and
response
 Resources and displaying educational
materials
RESOURCES
For more informatio n about how to do
direct assessment for adolescent
relatio nship abuse and pregnancy
prevention for adolescents, please see
Futures eLearning:
Reproductive Coercion Module
CONTACT INFORMATION
S a n d i G o l d st e i n, D i r e c to r
( 5 1 0 ) 2 8 5 - 57 11
s a n d i g @ c al i fo r n i a t e e n h e al t h . o r g
w w w. c al i fo r n i a t e e n h e al t h . o r g
L i s a J a m e s, D i r e c t or o f H e a l t h
Futures Without Violence
( 4 1 5 ) 6 7 8 - 55 00
l j a m e s @ fu t u r e s w i t h o u t vi o l e n c e . o r g

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