Transcript Community Mental Health

Adapting the CHAMP Family Program to
Prevent HIV Risk in Children and Youth
Carl C. Bell, M.D.
C.E.O./President
Community Mental Health Council, Inc.
Director Institute for Juvenile Research
Professor Psychiatry and Public Health
Director of Public & Community Psychiatry –
Department of Psychiatry
University of Illinois at Chicago
Description of CHAMPSA Family
Program
 The CHAMPSA Family Program was delivered
through multi-level group modalities, which
included both multiple family sessions and
parent/child group sessions.
 Given the goals of promoting communication and
support both within and between families, the
idea of combining families into groups is a logical
format for program delivery.
 In addition to whole family needs, however,
children and parents within families have
somewhat individual needs as well.
Description of CHAMPSA Family
Program
 For parents, these needs include support from
other parents, and frank discussion of strategies
for supervision and monitoring, as well as
chances to discuss information and
communication strategies and their own sexual
risk behaviour separately from their children.
 For children, these needs include developing
peer supports, as well as social problem skills to
assist in recognizing different types of risk
situations, and negotiation/self-assertion skills to
deal with such situations.
Description of CHAMPSA Family
Program
Thus, a combination of multiple family
sessions and parent/child sessions are
used.
In both the 4th/5th and 6th/7th grade
intervention, groups meet weekly for 12
weeks, approximately 1.5 hours per
session.
Pre-adolescent CHAMPSA Family
Program (9/10 years of age)
Curriculum Goals
 Discussion of sexual possibility situations
 Intensive practice in family communication, making
links between family processes and children’s
participation in sexual possibility situations (in
particular, stressing family communication, rule
setting, monitoring, support, and provision of clear
values)
 Discussing information relevant to puberty and
HIV/AIDS in order to prepare families for the coming
changes of adolescence.
Pre-adolescent CHAMPSA Family
Program (9/10 years of age)
Curriculum Methods
All groups discuss these issues from the
perspective that pre-adolescent youth are
too young to consider engaging in
heterosexual activity, and that parent and
child goals are to avoid sexual possibility
situations whenever possible.
Sessions include group discussions as well
as structured activities and games, to
enhance interest and engagement.
Pilot Study
Children and Family Subjects
Methodology


Two groups, one made up of 10 families with a
preadolescent children and caregivers, and one
involving early adolescent children and
caregivers were convened to pilot the 1st
revision of the program manuals.
Each group was facilitated by 2 leaders - a health
educator/mental health educator and a peer
educator; all South African nationals.
Pilot Study
Children and Family Subjects
Methodology
Revisions of the manual were based on
feedback from focus groups, videotapes of
family sessions, feedback from group
facilitators, and process observers.
This information was used to inform a 2nd
revision to the program manual and
assessments.
This program was now be considered the
CHAMP South African Family Program.
Multiple Family Groups
Participants summarize discussions and
activities that occurred in the parent and
child only meetings
 Individual families meet and work separately
on family activities
 Families come together and report on their
discussions, goals, plans and solutions
developed

Targets of CHAMPSA
Family Program
Family Process
 Family Support
 Child Supervision, monitoring
 Child assertiveness, refusal skills
 All within context of preventing child
exposure to sexual possibility situations and
HIV risk

Adapting the CHAMPSA Family
Program - Methodology
 The CHAMP Manual and assessments was reviewed
by a Xhosa, female, research assistant; a Zulu, male,
parent co-director; two U Durban-Westville CoInvestigators (an East Indian male, born in South Africa
and an European, White female, born in South Africa);
and the project director (an East Indian female, born in
South Africa).
 Their task was to provide information on the:
 suitability of overall program for (manual and assessments)
 applicability of language, role scenarios, and problem solving
situations in the CHAMP materials for parents and
adolescents
 the focus and sequencing of topics
 additional themes which should be included in an HIV
program
Adapting the CHAMPSA Family
Program - Methodology
The results of the initial review suggested that
there needed to be a several additional session
that covered topics specific to the SA context.
Considering the punitive methods of parenting in
many South African families, a new session on the
rights of children was added.
Considering the high rate of death from AIDS, a new
session on bereavement was added.
Considering the issue of stigma in SA, a new
session on stigma was added.
Sessions on Talking and Listening, Puberty,
HIV/AIDS, Support Networks, and Identifying
Risk were retained.
Adapting the CHAMPSA Family
Program - Methodology
The content of the CHAMPSA Manual was
translated into a storyline that captured the key
elements of each session in the format of
cartoons using indigenous Black South African
artists.
This group reviewed the content and developed
story boards designed to illustrate the themes
and health behavior change principles of the
CHAMPSA Manual.
Adapting the CHAMPSA Family
Program - Methodology
 Considerable discussion was given to the archetype of
the Black South African Family and what was the best
was to represent this archetype in a way that would be
familiar and welcoming to CHAMPSA research
subjects.
 Metaphors (e.g. when Themba’s mother dies the
grandmother of the AmaQhawe family suggests that
they take down the fence between their home and
Themba’s home as “In the olden days, we did not
have fences between people”) to symbolize health
behavior change field principles such as “rebuilding the
village” were also constructed.
Adapting the CHAMPSA Family
Program - Methodology
Subsequently, the CHAMPSA Manual was
printed and piloted on low income, rural, South
African community members consisting of 20
pre-adolescent subjects, approximately 9 to 10
years of age, and their families and low income,
shanty town, South African community members
consisting of 21 pre-adolescent subjects,
approximately 9 to 10 years of age, and their
families.
The feedback from this process is informing the
second revision of the CHAMPSA Manual.
Valley of A Thousand Hills
FOCUS GROUP
INFORMATION
40% of Embo subjects believe that a woman
using birth control pills will be protected from
HIV virus infection
31.1% are not sure
17.8% of Embo subjects believe there is a cure
for HIV virus (AIDS)
33.3% are not sure
FOCUS GROUP
INFORMATION
17.1% of Embo subjects don’t talk to their child
about puberty
19.5% of Embo subjects feel very
uncomfortable talking to their children about
having sex.
20.5% of Embo subjects believe that a person
can be cured of HIV/AIDS by having sexual
intercourse with a virgin
31.8% are not sure.
Embo School
Embo School
Triadic Theory of Influence








Sociological theories of social control and social
bonding (Akers et al., 1979; Elliott et al., 1985)
Peer clustering (Oetting & Beauvais, 1986)
Cultural identity (Oetting & Beauvais, 1990-91)
Psychological theories of attitude change &
behavioral prediction (Fishbein & Ajzen, 1975; Ajzen,
1985)
Personality development (Digman, 1990)
Social learning (Akers et al., 1979; Bandura, 1977,
1986)
Integrative theories (e.g., Jessor & Jessor's, Problem
Behavior Theory; Brook’s Family Interaction Theory,
Hawkins’ Social Development Theory)
See Petraitis, Flay and Miller (1995).
C ultural/
Attitudinal
Stream
Soc ial/
N ormativ e
Stream
Intrapers onal
Stream
Community Psychiatry
Protective Factor Field
Principles





Rebuilding the Village/Constructing Social Fabric
Access to Modern and Ancient Technology
Connectedness
Social and Emotional Skills
Self Esteem
–
–
–
–


Activities that create a sense of power
Activities that create a sense of connectedness
Activities that create a sense of models
Activities that create a sense of uniqueness
Reestablish the Adult Protective Shield
Minimize the Effects of Trauma
Embo School
CHAMPSA Family Program
Multiple Family Groups for 4th/5th graders










Meeting 1: Parents’ and Children’s Rights and Responsibilities
Meeting 2: Parenting Styles
Meeting 3: Talking and Listening
Meeting 4: Puberty
Meeting 5: Hard to Tell Stuff
Meeting 6: Identifying Risk
Meeting 7: What is HIV/AIDS?
Meeting 8: Dealing with Stigma
Meeting 9: Surviving Loss and Bereavement
Meeting 10: Support Networks
Rebuilding the Village/Constructing Social Fabric
Resource silos
Activity-driven
Different language
Different goals
How are we functioning?
Common
language
Evidence
based
Outcome
driven
Maximize
resources
We need Synergy and a Integrated System
Number of Child Experimental and Control and
Adult Experimental and Control Subjects and their
community areas
Area
Molweni
Child Child Totals Adult Adult Totals
Exp Con
Exp Con
93
78
171
74
69
143
KwaNyuswa
99
146
245
94
95
189
KwaNgcolosi
54
40
94
36
36
82
Qadi
35
34
69
31
33
64
Totals
281
298
579
245
233
478
ADULT
Neighborhood Social Control
22.5
22
21.5
Intervention
Comparison
p < .0224
Effect size = 0.226
21
20.5
20
19.5
Pretest Means
Posttest Means
ADULT
Neighborhood disorganization
15.8
15.6
15.4
Intervention
Comparison
p < .0026
Effect size = -0.3134
15.2
15
14.8
14.6
14.4
14.2
Pretest Means
Posttest Means
Access to Modern Medical Technology
Manualized Family Intervention
Project uses an open-ended cartoon-based
storyline comprising a series of episodes
centred around a number of topics to initiate
renegotiation of social representations and
practices related to parenting, HIV/AIDS.
 Topics include parental and child rights and
responsibilities, communication, puberty, risk
management, HIV/AIDS, stigmatisation and
acceptance of people living with HIV/AIDS,
dealing with death and bereavement, and
the importance of support networks

Access to Modern Medical Technology
Manualized Family Intervention
Storyline centers around two 'typical'
families, called the AmaQhawe (Champions)
and the Xakekile (Unfortunate) families, who
live adjacent to each other and are subject to
trauma and loss as a result of HIV/AIDS.
 Use of simplified cartoon characters
facilitates a process of 'distancing', that allow
participants to discuss the sensitive topics
through the cartoon characters

COMMUNITY EDITORIAL
INTERVENTION
Psychiatric First Aid
PRESCHOOL
3rd - 5th GRADE
6th GRADE AND UP
ADOLESCENTS
a. Helplessness & passivity - First aid:
Provide support, rest, comfort, food, & an
opportunity to play
a. Preoccupation with their actions during
the event - First aid: Help to express
secret imaginations about the event
a. Detachment, shame, and guilt - First
aid: Encourage discussion of the event &
realistic expectations of what could have
been done
b. Generalized fear - First aid: Reestablish adult protective shield
b. Specific fears from traumatic reminders
- First aid: Help to identify and articulate
traumatic reminders; and encourage not
to generalize
b. Self consciousness
about fear,
sense of vulnerability - First aid: Help to
understand the adult nature of these
feelings; encourage peer understanding
and support
c. Cognitive confusion - First aid: Give
repeated concrete clarifications
c. Traumatic play - First aid: Permission to
talk or act it out; & address distortions, &
acknowledge normality of feelings and
reactions
c. Post traumatic acting up - drug use,
delinquency, sexual behavior - First aid:
Help to understand the acting up as an
effort to numb their responses or to voice
their anger about the event.
d. Lack of
verbalization - First aid:
Help to verbalize general feelings and
complaints
“Inside Him - Video”
d. Fear of being
overwhelmed - First
aid: Encourage the expression of their
feelings in a supportive environment
d. Self destructive or accident prone
behavior - First aid: Address the impulse
toward reckless behavior; link it to the
challenge for impulse control associated
with violence
e. Sleep disturbances - First aid:
Encourage them to let their parents and
teachers know
e. Impaired concentration and learning First aid: Encourage them to let their
parents and teachers know when
intrusions interfere with learning
e. Abrupt shifts in relationships - First aid:
Discuss the expectable strain on
relationships with family and peers
Psychiatric First Aid
f. Anxious attachment First aid: Provide
consistent caretaking
“Clingy Thing - Video”
f. Sleep disturbances - First aid:
Encourage them in reporting their
dreams; & explain why we have bad
dreams
f. Desires and plans for revenge - First aid: Elicit actual
plans of revenge; address realistic consequences of these
actions; encourage constructive alternatives that lessen the
sense of traumatic helplessness
g. Regressive symptoms First aid: Tolerate
regressive symptoms in a
time-limited manner
g. Concerns about safety of self and
others - First aid: Help to share worries;
reassure with realistic information
g. Change in life attitudes - First aid: Link attitude changes
to the event's impact
h. Anxiety about death First aid: Give
explanations about the
physical reality of death
h. Aggressive and recklessness - First
aid: Help to cope with the challenge of
their own impulse control
h. Premature entry into adulthood - First aid: Encourage
post-phoning radical decisions in order to process the
response to the event and grief
i. Somatic complaints - First aid: Help to
identify the physical sensations they felt
during the event
k. Concern for victims - First aid:
Encourage constructive activities on
behalf of the injured or deceased
l. Grief - First aid: Help to retain positive
memories as they work through the more
intrusive, traumatic memories.
Pynoos R & Nader K. "Psychological First Aid for Children who
Witness Community Violence". Journal of Traumatic Stress 1988,
Volume 1, Number 4, p. 445 - 473.
Bonding and Attachment Dynamics
 Family
relationship processes attributes of the family
– Beliefs and values held by the family
– Emotional warmth between family members
– Support provided by family members
– Organization and communication among
family members
ADULT
Social Networks – Primary
43
42.5
42
Intervention
Comparison
p < .01
Effect size = 0.2653
41.5
41
40.5
40
Pretest Means
Posttest Means
ADULT
Social Networks - Secondary
41
40.5
40
Intervention
Comparison
p < .0002
Effect size = 0.4531
39.5
39
38.5
38
37.5
37
Pretest Means
Posttest Means
Social and Emotional Skills
 All
of the successful family
interventions have combined
behavioral parent training techniques
with other intervention components
based in family systems theory that
are designed to improve family
relations
Social and Emotional Skills
 Discipline
– Use of positive parenting
– Effectiveness of discipline
– Avoidance of discipline
 Supervision
and monitoring of the child
– Extent of involvement
– Knowledge of child’s activities and
whereabouts
SOCIAL & EMOTIONAL SKILLS
CHAMP - AmaQhawe
CHAMP works to help youth develop good
communication skills by helping youth and
parents learn about and practice their
communication skills in multiple family groups.
 We also give parents social skills that help them
in supervision and monitoring of the child that
increase involvement with the child, and
knowledge of children's activities and
whereabouts.

McKay MM, Chasse KT, Paikoff R, McKinney LD, Baptiste D, Coleman D, Madison S, &
Bell CC. Family-level Impact of the CHAMP Family Program: A Community
Collaborative Effort To Support Urban Families and Reduce Youth HIV Risk
Exposure. Family Process, Vol. 43, No. 1: 79 – 93, March 2004.
Facilitating discussion
of sensitive topics
Facilitating discussion
of sensitive topics
Facilitating discussion
of sensitive topics
ADULT
Hard to Talk-Comfort
27
26
25
Intervention
Comparison
p < .0001
Effect size = 0.4067
24
23
22
21
Pretest Means
Posttest Means
ADULT
Hard to Talk-Frequency
22
21.5
21
20.5
20
19.5
19
18.5
18
17.5
17
16.5
16
Intervention
Comparison
p < .05
Effect size = 0.1969
Pretest Means
Posttest Means
CHILD
Hard to Talk About Frequency
18
17.5
17
Intervention
Comparison
p < .066
Effect size = 0.24
16.5
16
15.5
15
14.5
14
Pretest Means
Posttest Means
Self Esteem
Sense of power.
– A feeling competent to do what they must.
 Sense of uniqueness.
– Acknowledging and respecting the qualities
and characteristics about themselves that are
special and different.

Bean R (1992). The Four Conditions of Self-Esteem: A New Approach for
Elementary and Middle Schools, ed 2. Santa Cruz, CA: ETR Associates.
Self Esteem
Sense of models.
– Models that they can use make sense of the
world.
 Sense of being connected.
– Feeling satisfaction from being connected to
people, places or things.

Bean R (1992). The Four Conditions of Self-Esteem: A New Approach for
Elementary and Middle Schools, ed 2. Santa Cruz, CA: ETR Associates.
Sense of Models
 Provide
people with models and practice,
practice, practice on how to:
– Communicate
– Solve problems
– Provide leadership
– Manage resources
– Remove barriers to success
– Plan
Sense of Models
Racial identity serves as a buffer against stress
and helps African American youth to function
with competence under adverse conditions.
 An Afrocentric orientation positively moderates
the relationship between psychobehavioral
variables and drug use in 1/3 of Af-Am youth.

– Miller DB & MacIntosh R. Promoting resilience in
urban African American adolescents: Racial
socialization and identity as protective factors. Soc
Work Res 23 (3): 159 – 169: 1999.
ADULT
AIDS Transmission Knowledge
3.8
3.6
3.4
3.2
3
2.8
Intervention
Comparison
p < .0004
Effect size = 0.6306
2.6
2.4
2.2
2
Pretest Means
Posttest Means
CHILD
AIDS Transmission Knowledge
2.6
2.4
2.2
Intervention
Comparison
p < .0001
Effect size = 0.496
2
1.8
1.6
1.4
1.2
1
Pretest Means
Posttest Means
ADULT
Stigma
23.5
23
22.5
Intervention
Comparison
p <. 0001
Effect size = 0.403
22
21.5
21
20.5
20
19.5
Pretest Means
Posttest Means
CHILD
Stigma
19.5
18.5
Intervention
Comparison
p < .0001
Effect size = 0.698
17.5
16.5
15.5
14.5
Pretest Means
Posttest Means
Re-establishing The Adult
Protective Shield
Family-oriented intervention to change
parenting style and practices can
reduce risk for serious antisocial
behavior and violence
 Increase predictability
 Parental monitoring of children
 Decrease negative parenting methods

ADULT
Caregiver monitoring – Family Rules
40.5
40
39.5
Intervention
Comparison
p <. 0018
Effect size = 0.3074
39
38.5
38
37.5
37
Pretest Means
Posttest Means
CHILD
Caregiver involvement
26
25.5
25
Intervention
Comparison
p < .03
Effect size = 0.2
24.5
24
23.5
23
Pretest Means
Posttest Means
ADULT
Punitive parenting
3
2.8
Intervention
Comparison
p <. 001
Effect size = 0.xxx
2.6
2.4
Pretest Means
Posttest Means
Outcomes in McLean County
FY00 through FY02
Reported Abuse and Neglect by Race
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
149
43.3
31.1
37.4
25.1
FY00
FY02
EuropeanAmerican
(- 19.3%)
AfricanAmerican
(- 1.5%)
Hispanic
(- 13.6%)
Outcomes in McLean County
FY00 through FY02
Children Removed by Race
40
35.05
35
EuropeanAmerican
(- 57.2%)
AfricanAmerican
(- 61.3%)
Hispanic
(0%)
30
25
20
13.58
15
10
5
3.69
1.16
1.58
1.16
0
FY00
FY02
Parameter Estimates, Standard Errors, Probability Values and Effect Size for Intervention Effects on
Scale Change Scores - Caregiver Data
Items
General
Health
Estimate Std Error
P Value
Effect Size
2.3072
0.7415 < 0.002
0.3031
Global indicator
of wellbeing
0.6812
0.2256
< 0.0027
0.2934
HIV transmission 1.0253
knowledge
0.2894
< 0.0004
0.6306
Less stigma toward
HIV infected people
1.8391
0.479
< 0.0001
0.403
Caregiver monitoring
Family rules
1.8928
0.6038
< 0.0018
0.3074
Caregiver
communication
comfort
2.3983
0.578
< 0.0001
0.4067
Parameter Estimates, Standard Errors, Probability Values and Effect Size for Intervention Effects on
Scale Change Scores - Caregiver Data
Items
Estimate
Std Error
P Value
Effect
Size
Social Networks 1.5581
Primary
0.6068
< 0.0106 0.2653
Social Networks 2.8756
Secondary
0.7549
< 0.0002 0.4531
Social Networks -0.7172 1.5499
Tertiary
< 0.6444 -0.0833
Neighborhood
disorganization
-1.1166 0.3688
< 0.0026 -0.3134
Neighborhood
Social Control
1.7976
< 0.0224 0.226
0.7845
Parameter Estimates, Standard Errors, Probability Values and Effect Size for Intervention Effects on
Scale Change Scores - Caregiver Data
Items
Estimate
Std Error
HIV transmission
knowledge
0.9148
0.2131 < 0.0001
0.496
Less stigma toward
HIV infected people
5.7192
0.8987 < 0.0001
0.698
Caregiver
Involvement
-0.9059
04134
Caregiver
1.1437
Communication
Frequency
P Value
Effect
Size
< 0.0289
0.2
0.6202 < 0.0657
0.24
Parameter Estimates, Standard Errors, Probability Values
and Effect Size for Intervention Effects on Scale Change
Scores - Child Data
Items
Estimate
Std Error
P Value
Effect
Size
HIV transmission
knowledge
0.82
0.27
< 0.0647
0.50
Less stigma
toward HIV
infected people
3.86
0.92
< 0.0045
0.70