Marina Tolou-Shams, Ph.D. - US grants

DESCRIPTION (provided by applicant): This Mentored Patient-Oriented Research Career Development Award (K23) will enable the candidate, a clinical psychologist, to become an independent researcher in the area of adolescent risk behaviors, with a focus on family processes, emotion regulation, adolescent substance abuse and HIV risk. The overarching goal of this training award is for the candidate to apply research findings to the development of efficacious HIV prevention and substance abuse interventions for substance abusing juvenile offenders. Juvenile offenders are at elevated risk for substance abuse and HIV risk behaviors secondary to higher rates of psychopathology and emotional distress than their non-offending peers. Higher rates of substance use and psychopathology substantially increase offenders'risk for HIV infection. Although, family-based treatments have demonstrated some efficacy in changing substance use, they have failed to target adolescent sexual risk behavior and have not focused on a construct (emotion regulation) that may be central to long-term behavior change for the entire family. Thus, the research goal for the Award period is to adapt (and test) a current adolescent-only Affect Management HIV Prevention Intervention for Substance-Abusing Juvenile Offenders into an effective Family-Based Affect Management for HIV Prevention Intervention for Substance- Abusing Juvenile Offenders. This study will have three phases. In Phase 1, qualitative data will be collected from 45 adolescent-parent dyads via focus groups and pilot run-throughs of the adapted intervention. In Phase 2, 60 dyads will be randomized to either the Family-Based Affect HIV prevention or General Health Promotion condition with baseline and 3 month follow-up assessments. Differences in intervention response (e.g., changes in adolescent substance use and sexual risk) between subjects in each condition will be examined in order to estimate the effect size of the Family-Based intervention. Phase 3 will involve project summation and data analysis. The candidate will achieve all of the above with five years of rigorous training and strong mentorship in 1) developing clinical trials, 2) treating adolescent substance abuse, 3) developing family-based interventions that address family emotion dysregulation, and 4) working within the juvenile justice system. Future treatment development work for an adolescent population at great risk for HIV infection will be informed by the results of this project.

DESCRIPTION: Cross-sectional studies have identified that court-involved, non-incarcerated (CINI) juveniles exhibit similar substance use and HIV/STI risk behavior rates as those detained or incarcerated. Yet, among first-time offending, CINI juveniles, there is a gap in our knowledge about who might develop drug use problems, engage in HIV/STI risk behaviors, have psychiatric difficulties and/or recidivate and what risk and protective factors may be related to their outcomes. The objective of the proposed research is therefore to investigate 24 month trajectories of drug use, HIV/STI risk behavior, psychiatric symptoms, and recidivism from the point of first juvenile court contact among a cohort of 400 first-time offending, CINI juvenile offenders. Specifically, we seek to characterize the two-year developmental course and co-occurrence of drug use, HIV/STI risk, psychiatric symptoms and recidivism in this population and to identify the individual, family and extrafamilial- level risk and protective factors associaed with these outcomes. First-time offending juveniles, ages 13-17, and a caregiver (N= 40 dyads for Phase I pilot study; N=400 for Phase II survey study) will be recruited from the Rhode Island Family Court, Juvenile Intake Department to participate in computerized survey assessments. In Phase I (first eight months of Year 1), 40 juveniles and a caregiver will be randomly sampled to complete the computerized survey measure once (at baseline, i.e., time of first contact with the juvenile court) to allow for pilot testing of sampling methodology and to provide quantitative and qualitative feedback related to survey development, administration and implementation. In Phase II (last quarter of Year 1 through Year 4), 400 juvenile/caregiver dyads (N=800 total) will be recruited (using a systematic disproportionate stratified sampling approach) at baseline and then re-assessed at 4, 8, 12, 16, 20 and 24 months subsequent to the juvenile's first court contact. Biological specimens for juvenile drug use and sexually transmitted infections (STIs) will also be collected at each assessment. Baseline and follow-up data will be used to construct individual and latent class growth analyses to characterize longitudinal trajectories of CINI juvenile's drug use, HIV/STI risk behaviors, psychiatric symptoms, and recidivism.

DESCRIPTION (provided by applicant): Compared to both non-offending females and male offending counterparts, offending girls are at significantly greater risk for the development of substance use disorders, psychiatric symptoms and negative health outcomes, such as HIV/AIDS or other sexually transmitted infections (STIs). Research suggests that girls may have different developmental pathways to drug use, initial legal involvement and co-occurring negative health outcomes that support the importance of testing gender-specific treatments for juvenile justice girls. Although there is recent increased emphasis on gender-specific programming in juvenile justice, empirically supported gender specific interventions to improve health, mental health and/or legal outcomes among juvenile justice girls are lacking. The objective of this Stage II treatment trial is therefore to test the efficacy of a pre-existing, widly disseminated gender-responsive drug use treatment (VOICES) among 200 court-involved, non- incarcerated (CINI) girls. We seek to test the effect of VOICES on CINI girls' drug and alcohol use, HIV/STI risk, psychiatric symptoms and recidivism as well as explore moderators and mediators of outcomes. CINI girls, ages 12-18 (N= 6 juveniles for Phase I Intervention Run-Through; N=200 for Phase II RCT study) will be recruited from the Rhode Island Family Court and randomized to either the VOICES (active) intervention (n=100) or a Standard of Care (control) condition (n=100). In Phase I (first six months of Year 1), 6 juveniles will be recruitedto complete the Intervention Run-Through and research assessment once to allow testing of RCT intervention and assessment procedures prior to the RCT phase. In Phase II (last half of Year 1 through Year 4), 200 juveniles will be recruited and randomized at baseline and then re-assessed at mid-treatment, end of treatment, and 3, 6, 9 and 12 month post-intervention follow-ups. Biological specimens for juvenile drug use and sexually transmitted infections (STIs) will also be collected at each 3-month assessment. Efficacy trial results can be used to make immediate changes to current widespread program delivery resulting in direct impact on the field of evidence-based gender-responsive substance use interventions for juvenile justice girls.

? DESCRIPTION (provided by applicant): Racial and ethnic minority youth are disproportionately represented in the juvenile justice (JJ) system, just as they are overrepresented among those living in poverty, those growing up in disorganized neighborhood environments and those with sexually transmitted infections (STIs) and unwanted pregnancies. Multiple societal and structural factors are associated with poorer sexual health outcomes for these youth, including limited access to, and availability of, health care services and their socia (and sexual transmission) networks. JJ youth are likely to accrue further legal charges and be incarcerated into adulthood, thereby perpetuating racial and ethnic health disparities within the adult criminal justice system. Despite that racial and ethnic disparities exist in both health and legal systems, the relationship between juvenile justice involvement and health (including sexual) disparities is highly understudied. Constitutional mandates require access to medical testing and treatment in correctional settings, including free access to sexual health care services; however, confined juveniles only represent approximately twenty percent of arrested youth and the current trend in juvenile justice is away from confinement. Waiting until youth are confined to provide increased access to sexual health services misses a tremendous opportunity to improve sexual health outcomes and reduce disparities for a broader group of juveniles. The objective of this study is therefore to provide data that will inform public health and juvenile justice structural intervention development and policy geared toward increasing access to and uptake of sexual health prevention, treatment, care and support services for court- involved, non-incarcerated (CINI) youth. We seek to collect qualitative and quantitative data from juvenile court and department of health key informants that will provide novel documentation of the barriers to and facilitators of increasing access to and uptake of sexual health services for CINI juveniles. A combination of qualitative semistructured interviews and a large-scale survey of a diverse US sample of court and department of health settings (N=300 respondents) will provide data on system attitudes, perceptions, practices and policies that limit or enable access to sexual health services for CINI juveniles.

DESCRIPTION: Cross-sectional studies have identified that court-involved, non-incarcerated (CINI) juveniles exhibit similar substance use and HIV/STI risk behavior rates as those detained or incarcerated. Yet, among first-time offending, CINI juveniles, there is a gap in our knowledge about who might develop drug use problems, engage in HIV/STI risk behaviors, have psychiatric difficulties and/or recidivate and what risk and protective factors may be related to their outcomes. The objective of the proposed research is therefore to investigate 24 month trajectories of drug use, HIV/STI risk behavior, psychiatric symptoms, and recidivism from the point of first juvenile court contact among a cohort of 400 first-time offending, CINI juvenile offenders. Specifically, we seek to characterize the two-year developmental course and co-occurrence of drug use, HIV/STI risk, psychiatric symptoms and recidivism in this population and to identify the individual, family and extrafamilial- level risk and protective factors associaed with these outcomes. First-time offending juveniles, ages 13-17, and a caregiver (N= 40 dyads for Phase I pilot study; N=400 for Phase II survey study) will be recruited from the Rhode Island Family Court, Juvenile Intake Department to participate in computerized survey assessments. In Phase I (first eight months of Year 1), 40 juveniles and a caregiver will be randomly sampled to complete the computerized survey measure once (at baseline, i.e., time of first contact with the juvenile court) to allow for pilot testing of sampling methodology and to provide quantitative and qualitative feedback related to survey development, administration and implementation. In Phase II (last quarter of Year 1 through Year 4), 400 juvenile/caregiver dyads (N=800 total) will be recruited (using a systematic disproportionate stratified sampling approach) at baseline and then re-assessed at 4, 8, 12, 16, 20 and 24 months subsequent to the juvenile's first court contact. Biological specimens for juvenile drug use and sexually transmitted infections (STIs) will also be collected at each assessment. Baseline and follow-up data will be used to construct individual and latent class growth analyses to characterize longitudinal trajectories of CINI juvenile's drug use, HIV/STI risk behaviors, psychiatric symptoms, and recidivism.

PROJECT SUMMARY / ABSTRACT The purpose of this K24 MidCareer Investigator Award is to support Dr. Marina Tolou-Shams, a child clinical psychologist who has been continuously funded since 2007, to conduct research and to mentor others in the areas of substance use, mental health, and co-occurring health risk behaviors for justice-involved youth. This candidate proposes to utilize K24 support to a) expand her existing program of juvenile justice behavioral health research into the field of digital behavioral health intervention and b) mentor junior PhD and MD researchers in rapidly moving the science forward in identification and dissemination of ways to improving substance use, mental and sexual health outcomes for youth in the juvenile justice system, including the development and testing of digital health approaches for improved outcomes. Taking advantage of a rich institutional environment, the candidate has assembled a group of expert interdisciplinary collaborators to ensure that she and her mentees will be on the cutting edge of digital behavioral health research with vulnerable populations. Digital mobile health (mHealth) technologies have been increasingly demonstrated as an efficacious, low-cost way of reaching underserved, vulnerable, populations to engage them into and/or deliver quality care. Mobile health therefore represents a promising approach to improving substance use and psychiatric outcomes for justice-involved youth. Dr. Tolou-Shams? research project will focus on conducting a pilot trial of a tailored SMS text-messaging platform to engage court-involved, non-incarcerated (CINI) youth into substance use or dual diagnosis treatment services. Study aims include 1) determining whether and how a tailored dyadic (youth/caregiver) SMS text-messaging intervention increases CINI youth treatment engagement and 2) identifying real-world factors critical to consider for justice and behavioral health systems eventual adoption and sustainability of an SMS text- messaging intervention for youth treatment engagement. This K24 research and protected time for mentoring will lead to ways in which the field will learn about how to develop, test and implement individual and system-level digital health interventions for unmet juvenile justice substance use and mental health treatment services needs across various points in the continuum of care (e.g., screening, referral, treatment engagement, treatment delivery).

Project Summary Youth in the child welfare system have documented high rates of mental health symptoms and experience significant disparities in mental health care services access and engagement relative to youth not in the child welfare system. Navigator models have been developed in the healthcare field to address challenges of service access, fragmentation and continuity that impact quality of care, but at present there is no empirically supported mental health navigator model to address the unique and complex mental health needs of child welfare involved (CWI) youth. This developmental study will be conducted in three phases consistent with study aims. The study will take a mixed-methods, multi-informant participatory research approach to developing, iteratively refining and pilot testing a Foster Care Family Navigator (FCFN) model to improve mental health service outcomes for adolescents (ages 12-17) involved in the child welfare system. The navigator model will leverage digital health technology to engage with and improve care coordination, tracking and monitoring of mental health service needs for these youth and families. The study will adapt the JJ- TRIALS Behavioral Health Services Cascade framework to support a data-driven decision-making approach to improving identification of mental health service needs and outcomes. The study will first utilize a combination of interagency collaborative meetings, youth and family focus groups and qualitative individual interviews with multisystem stakeholders to guide the development of the FCFN protocol. Next an open trial of the 6-month FCFN intervention will be conducted and the protocol iteratively refined through direct participant feedback. The last phase of the study will focus on conducting a modified roll-out design of the FCFN intervention with 75 child welfare involved youth. Three cohorts of 25 youth and caregivers each will receive FCFN services for 6 months and will be compared on primary outcomes of mental health initiation and engagement to 50 youth and caregivers who receive services as usual. We will explore mediators (e.g., satisfaction with navigator, youth treatment motivation, perceived barriers to care) and moderators (e.g., race, ethnicity, sex) of intervention impact to inform intervention mechanisms of change and key demographic and other contextual factors associated with trial outcomes. Finally, we will also conduct qualitative exit interviews with trial participants and navigators to gain a deeper understanding of influences on pilot outcomes that can inform future larger efficacy and effectiveness trials.