Volume 4, Issue 1 • Winter 2015

Table of Contents

Foreword

Modifying Dialectical Behavior Therapy for Incarcerated Female Youth: A Pilot Study

The Impact of Child Protective Service History on Reoffending in a New Mexico Juvenile Justice Population

Social Distance Between Minority Youth and the Police:
An Exploratory Analysis of the TAPS Academy

Rural Youth Crime: A Reexamination of Social Disorganization Theory’s Applicability to Rural Areas

How to Help Me Get Out of a Gang: Youth Recommendations to Family, School, Community, and Law Enforcement Systems

Exploratory Research Commentary:
How Do Parents and Guardians of Adolescents in the Juvenile Justice System Handle Adolescent Sexual Health?

Exploratory Research Commentary:
How Do Parents and Guardians of Adolescents in the Juvenile Justice System Handle Adolescent Sexual Health?

Jennie Quinlan, UT Teen Health, University of Texas Health Science Center at San Antonio; Elise Hull, University of Texas Health Science Center at San Antonio; Jennifer Todd, UT Teen Health, University of Texas Health Science Center at San Antonio; Kristen Plastino, UT Teen Health, University of Texas Health Science Center at San Antonio.

Correspondence concerning this article should be addressed to Kristen Plastino, Department of Obstetrics & Gynecology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900. E-mail: plastino@uthscsa.edu

Keywords: adolescent development, parents, high-risk behaviors, needs assessment, juvenile probation

Abstract

This study explores the perceptions of guardians of youth involved in the juvenile justice system regarding sex education content and implementation, challenges, clinic access, and contraceptive use. Nine guardians participated in a focus group at the Bexar County Juvenile Probation Department (BCJPD), San Antonio, Texas. Data were analyzed using an inductive approach. The guardians strongly endorsed sex education for youth. They believed that, ideally, sex education should be communicated from parent to child but that in reality this tends not to occur. Even guardians who communicate with their teens said they feel unequipped to do so because they lack accurate information. They said they support sex education implementation in schools as well as under the terms of juvenile probation. Guardians proposed that bolstering life skills was a worthwhile measure to reduce risky behavior and said that peer pressure, social media, and gang activity influence risky teen behavior. Guardians identified religious beliefs and a reticence to accept sexual activity as issues for the juvenile justice system to consider when providing access to contraceptives. Research documents that guardian involvement during youths’ experiences with the juvenile justice system is crucial. Results of this study point to guardians’ need for further resources and expansion of sex education programs among BCJPD services.

Introduction

Minorities in the Juvenile Correctional System

In the United States, millions of adolescents enter the juvenile justice system each year. The juvenile offenders comprise a special group of the nation’s youth who have their own unique challenges. Juvenile offenders are a high-risk population with special needs and they experience health problems at a higher rate than the general population (Committee on Adolescents, 2011; Golzari, Hunt, & Anoshiravani, 2006). Adolescents in the Texas juvenile justice system range in age from 10 to 17 years and represent all races, ethnicities, and socioeconomic backgrounds.

Despite the representation of various races and ethnicities, researchers have found that Hispanic and African American populations are disproportionately represented in the Texas juvenile justice system (Carmichael, Whitten, Voloudakis, 2005). In Texas, all minorities comprise 55% of the general adolescent population: 13% identify themselves as African American and 40% identify themselves as Hispanic. However, of the detained juvenile population in Texas, approximately 32% identify as African American and 39% identify as Hispanic (Carmichael et al., 2005). In the United States, whereas all minorities combined contribute to 37% of the adolescent population (Carmichael et al., 2005), minorities constitute 60% of the detained juvenile population, according to data collected in 2001 (Carmichael et al., 2005).

The population of adolescents entering the juvenile justice system, who generally comprise high-risk minority populations (Armour & Hammond, 2009; Lauritsen, 2005; The Sentencing Project, 2014), have special health needs (Committee on Adolescents, 2011; Golzari et al., 2006). Specific strategies call for a variety of studies to understand best practices in order to address the special needs of these high-risk youth (Chassin, 2008; Greenwood, 2008; Kelly, Owen, Peralez-Dieckmann, & Martinez, 2007; Lauritsen, 2005; Liddle, 2014; Marvel, Rowe, Colon-Perez, Diclemente, & Liddle, 2009).

The purpose of this paper is to explore how parents and guardians of children involved in the juvenile justice system handle the children’s health needs, including sex education. Better understanding of the needs of juvenile offenders and their parents’ beliefs may pave the way for determining best practices and more effective strategies for reducing high-risk behavior, such as sexual activity. The demographics of the individuals who participated in the focus group described in this article reflect the minority populations that make up the juvenile justice populations of Texas (where the focus group took place).

Risk Indicators

Adolescents in the juvenile justice system report a higher rate of engagement in high-risk behaviors than adolescents in the general population (Committee on Adolescents, 2011; Golzari et al., 2006). This led the American Academy of Pediatrics and the National Commission on Correctional Health Care to declare a policy on the health care of adolescent populations in correctional facilities (Committee on Adolescents, 2011; Rizk & Alderman, 2012). The policy recommends a complete medical history and physical, including a gynecological assessment as indicated by gender, age, and risk factors (Committee on Adolescents, 2011; Rizk & Alderman, 2012), as well as sexually transmitted disease (STD) and pregnancy testing for youths entering a detention center (Committee on Adolescents, 2011; Rizk & Alderman, 2012; Spaulding et al., 2013). The high-risk behaviors of this population include sexual debut at a younger age, having multiple sexual partners, and drug/alcohol use (Chassin, 2008; Rizk & Alderman, 2012). Of the adolescents involved in the United States juvenile justice system in the year 2000, 56% of boys and 40% of girls tested positive for substance use (Chassin, 2008).

Substance use substantially increases the likelihood of engaging in other risky behaviors, especially using substances during sex, engaging in unprotected sex, and having multiple sexual partners, which puts youth at higher risk for acquiring an STD, including human immunodeficiency virus (HIV) (Chassin, 2008; Teplin et al., 2005; Tolou-Shams, Hadley, Conrad, & Brown, 2012). According to a mini review conducted in the United States in 2012, chlamydia infection rates among detained adolescent females ranged from 14% to 22%, and for gonorrhea, from 5% to 6% (Rizk & Alderman, 2012; Spaulding et al., 2013). Other studies have found that in addition to being twice as likely to contract an STD as their nonincarcerated peers, incarcerated female adolescents are also more likely to become pregnant and to endure high-risk pregnancies (Gallagher, Dobrin, & Douds, 2007). Unplanned pregnancy has been a widespread consequence of the risky sexual behaviors of this population, leading some to recommend that teens be screened for pregnancy on admission to detention centers (Committee on Adolescents, 2011; Rizk & Alderman, 2012). Although birth rates among adolescents in the United States have continued to decline since the peak in 1991 (61.8 births per 1,000) to a record low in 2012 (29.4 births per 1,000) (Finer & Zolna, 2011; National Center for Health Statistics [NCHS], 2013), adolescents with a history of entering into correctional facilities are more likely to become pregnant or already be parents than their peers in the general population. For example, 15% of incarcerated teen males are likely to be fathers compared to 2% of nonincarcerated teen males, and 9% of incarcerated teen females are likely to have had children compared to 6% of nonincarcerated teen females. (Committee on Adolescents, 2011).

Cultural Influence

Studies suggest that cultural values may explain why Hispanic women desire marriage and children at a younger age than do African Americans, Southeast Asians, and Whites (Caal, Guzman, Berger, Ramos, & Golub, 2013; Romo, Berenson, & Segars, 2004; Russell & Lee, 2004). Cultural values may influence behaviors such as educational attainment and contraceptive use, which in turn affects pregnancy outcomes (Caal et al., 2013; Romo et al., 2004; Russell & Lee, 2004). Studies have found that attitudes toward contraceptives are not the only issue as parent-child discussions about sexuality are also taboo in this culture (Russell & Lee, 2004). The Hispanic culture values family and a traditional family model beginning at a young age, resulting in Latinos being more likely to experience their sexual debut at a younger age (Romo et al., 2004; Russell & Lee, 2004). One qualitative study explored the role of young women’s perceptions of their parents’ opinions about reproductive health services. The study found that parents played a significant role in the reproductive health-seeking behavior of their teens, often times preventing the women from seeking reproductive health services such as STD screening/treatment, as well as contraceptive counseling. The majority of the women reported that their parents did not support having access to reproductive health services and even reported hiding contraceptive use from their parents (Caal et al., 2013). The fear of parental criticism could pose an obstacle to adolescents seeking reproductive health services. Despite the challenge of gaining the support of families, professionals working to prevent teen pregnancy (e.g., school staff, health or social services agencies, and nonprofit organizations) believe that the involvement of the family is critical in Hispanic teen pregnancy prevention among Hispanic youth (Burke, Mulvey, Schubert, & Garbin, 2014; Russell & Lee, 2004).

Parent Involvement

Parental/guardian attitudes toward their adolescent’s health care, including pregnancy prevention and STD screening, is important because studies have shown that parental/guardian involvement in an adolescent’s development can have a crucial impact in the success or failure of that individual (Burke et al., 2014; Jerman & Constantine, 2010; Kim, Gebremariam, Iwashyna, Dalton, & Lee, 2011). The literature on the power of parental influence and connectedness to youth is extensive and points to communication between parents and their children as a fundamental process through which youth’s ideas, values, beliefs and expectations around sexual health are established (Burke et al., 2014; Caal et al., 2013; Huebner & Howell, 2003; Jerman & Constantine, 2010; Kim et al., 2011; Markham et al., 2010). Douglas Kirby and colleagues have found that parental connectedness proves to be a protective factor that promotes healthy decision making, which reduces risky behaviors (such as sex without contraception and sex with multiple partners) and therefore increases the likelihood of avoiding negative outcomes, such as pregnancy or contracting an STD (Kirby & Lepore, 2007). Other studies highlight the notion that parental monitoring, parent-adolescent communication, and parenting style are all important variables to consider when understanding sexual risk taking among adolescents (Huebner & Howell, 2003). A national survey was conducted in the general population in order to assess attitudes and opinions of parents regarding sexual behaviors among adolescents (Abt Associates Inc., 2009). The survey results indicated that the majority of parents surveyed were opposed to premarital sex both in general and for their own adolescents (Abt Associates Inc., 2009). It also found that there were differences in opinion among minority parents compared to non-minority parents in that patterns of permissiveness among minority parents varied by specific context (Abt Associates Inc., 2009). Parents were more in favor of sexual activity among adolescents when contraception was used, and if their adolescent was likely to marry their sexual partner (Abt Associates Inc., 2009). Abt Associates Inc. (2009) found that parents/guardians were more opposed to sexual activity “if the adolescent and his or her partner think that it is okay” (p. 9). The survey revealed that general parent/guardian views about sex and abstinence were more conservative among non-Hispanic blacks, Hispanics, parents from lower-income households, and parents attending religious services more frequently (Abt Associates Inc., 2009). The majority of parents surveyed were in favor of their adolescent receiving sex education messaging and had preferences about where the message came from (Abt Associates Inc., 2009). Abt. Associates Inc. (2009) found that survey responses indicated that parents preferred sex education information come from (in order of preference): “a place of worship (85% ), a doctor’s office or health center (85%), school (83%), a community organization (71%), and the Internet (55%)” (p. 9). While these results shed light on the attitudes of parents from the general population, attitudes of parents among special populations, such as juvenile offenders, are unknown due to a lack of research on the topic.

Lack of family involvement is identified as one of the most important issues faced in the juvenile justice system. There is also a lack of validated tools to measure the family involvement construct (Burke et al., 2014). Despite the widespread research of increased risky behaviors and outcomes associated with juveniles involved in the juvenile justice system, as well as the proven importance of parental opinion and involvement, little research has been conducted to explore the opinions and attitudes of parents and guardians of adolescents involved in the juvenile justice system. While studies have been conducted on access to sexual health services in the juvenile justice system, as well as the high-risk behaviors that necessitate these services, literature reviews point to the fact that there is a dearth of research regarding parent/guardian attitudes toward access to sexual health services for adolescents in the juvenile justice system. This paper describes a qualitative study that assessed the attitudes and opinions of parents whose teens are involved in the juvenile justice system. Its results highlight parents’ attitudes on youths’ information-seeking behavior, sexual activity, pregnancy risks, contraceptive use, clinical visits, challenges, and other specifics regarding sex education programs. The focus group results described in this paper aim to explore how the culture and religion of parents residing in a largely Hispanic community influences juvenile justice–involved youths’ access to contraceptives in clinics and sex education programs.

Positive Youth Development Programs

Evidence-based programs (EBPs) have been shown to change behaviors in youth after educating them about risky sexual behaviors (Bryan, Schmiege, & Broaddus, 2009; Cronin, Heflin, & Price, 2014; Inman, Van Bakergem, La Rosa, & Garr, 2011; Thomas, 2000). Further, some programs have been specifically tested and proven effective in youth involved in the juvenile justice system (Bryan et al., 2009). These sex education programs offer a range of approaches—from not discussing condoms and contraception to educating on condoms and contraception use (Thomas, 2000). Implementing programs that offer the appropriate approach and are shown to be effective in promoting healthy sexual behaviors in special populations (such as minority youth in the juvenile justice system) is crucial to successful outcomes (Inman et al., 2011; Thomas, 2000). The focus group conducted for the UT Teen Health initiative was part of a community needs assessment in order to identify an EBP that fit the needs of the population.

Methodology

Data Collection

The study described in this paper was conducted as part of a community needs assessment by the University of Texas Health Science Center at San Antonio–UT Teen Health (UTTH). The objective of the focus group was to better understand the perspectives of parents/guardians of youth who have been referred to the Bexar County Juvenile Probation Department (BCJPD) in order to select the best EBP for the department’s goals and objectives regarding teen pregnancy prevention. Parents/guardians were defined as the person responsible for a child’s care, custody, or welfare (Bolen, Lamb, & Gradante, 2002). The focus group session was held on April 10, 2012 using procedures approved by the University of Texas Health Science Center at San Antonio Institutional Review Board and the Centers for Disease Control and Prevention. The stakeholders (parents/guardians) who participated in the focus group were recruited using convenience sampling methods: The BCJPD staff in charge of running mandated parenting groups for parents of youth in the juvenile justice system advertised the opportunity to participate in the focus group to approximately 20 parents/guardians who were participating in the parenting classes at that time. Parents/guardians who participated in the focus group were compensated with a $20 gift card to a local grocery store chain. Participation was voluntary and did not affect parents’/guardians’ standing in the parenting classes. The focus group was limited to the first 9 parents/guardians in order to promote strong participation among individuals.

Focus group participants (both male and female) were representative of the target population: parents/guardians of youth who had been referred to the BCJPD. The focus group was held on-site at the administrative offices of the BCJPD where the parenting classes were facilitated. To promote candid responses from the participants, the focus group was conducted in a private room without Bexar County staff present. The focus group discussion explored important aspects of sex education curricula, as well as attitudes and beliefs toward contraceptives and condom use.

The UTTH evaluator who conducted the focus group was trained on focus group facilitation and analysis during one-on-one sessions. Training included relevant literature and background information on the scope and purpose of the focus group–based research, and a review and discussion of the moderator’s guide.

An original moderator guide, consisting of 8 questions and 13 sub-questions (see Appendix), was developed by the evaluator of UTTH with the counsel of Jeff Tanner and Associates, the Centers for Disease Control and Prevention, and Edward Saunders, associate professor and director of social work at the University of Iowa College of Liberal Arts & Sciences. The semi-structured design guide was developed to identify social norms of the following topics: (a) Challenges facing teens; (b) Information-sharing behavior; (c) Sexual activity; (d) Programming; (e) Clinics; (f) Birth control; and (g) Curriculum.

At the beginning of the session, the participants were asked to complete a demographic form and sign a research study consent form. To promote confidentiality, participants were asked to use only their first names. Questions were posed in an open-ended manner followed by more specific prompts to generate further discussion. The discussion lasted 40 minutes. The discussion was recorded using a hand-held audio-recording device.

Analysis

After the focus group, discussion recorded on the audiotape was transcribed verbatim by the UTTH evaluator. Transcripts were analyzed using a quasi-inductive approach (Thomas, 2006). The evaluator created preliminary codes based on the moderator’s guide. Additional topic domains and subcategories were created inductively during the analysis process. The following codes were used based on the focus group discussion: (a) Challenges for parents of high-risk teens; (b) Consequences of teen sex; (c) Prevention; (d) Contraceptive use; (e) Parent-teen communication; (f) Emergency contraceptives; (g) Clinics; and (h) Sex education. The evaluator coded the raw data (the scripts) using Word documents to organize the data into levels of codes (Thomas, 2006): themes, categories, and subcategories. Each level of code was collapsed to identify broader themes during the analysis process. In a separate document, the quotes were summarized to generate concepts, key themes, and patterns. To ensure validity and strengthen credibility of the results, an investigator triangulation method (Guion, Diehl, McDonald, 2011) was utilized whereby the evaluator and an additional researcher coded the transcript from the focus group discussion independently (using the same cut and paste procedure). The evaluator and the researcher met to discuss the coding process, coding decisions, and the subsequent data organization. Comparison of the analysis summaries reached by the evaluator and the researcher revealed that the findings from the evaluator and the researcher were comparable and thus heightened the validity of the findings.

Sample description

There were 9 parents/guardians (6 mothers, 1 grandmother, and 2 fathers) who participated. There were parents/guardians of teens ranging in age from 13 to 16 years old. Two of the parents had teens who were parenting. The group of parents (56% Latino, 22% African American, 22% other) had teens who had been involved in the juvenile justice system at durations from 1 month to more than 1 year.

Results

Challenges for Parents of High-Risk Teens

The parents/guardians in the focus group agreed that peer pressure was the most challenging factor in raising teens. Focus group results indicated that teens experienced peer pressure on a daily basis that led to high-risk behaviors because adolescents desired popularity. The desire for acceptance from their peers caused some teens to ignore the boundaries set by their parents. The parents agreed they had trouble enforcing boundaries on their teens because the teens felt they could do whatever they wanted and they did not have to answer to parents. Parents felt that access to technology had increased peer influence. The accessibility of social media has increased the gap between younger generations who are technologically savvy versus older generations who are unfamiliar with technology. One grandmother of a teen on probation commented, “Peer influence, definitely: my granddaughter wanted to be popular and have tons of friends. Technology allows them to have their network of friends, their database of friends. It’s hard because I did not grow up in that generation. I am raising my granddaughter so it’s harder even than raising my own daughters.” Parents/guardians felt that peer pressure rendered teens susceptible to engaging in risk-taking behaviors such as drug and alcohol abuse, gang activity, and sexual activity.

Parents/guardians of teens on probation felt that risky behaviors were very likely to lead to detrimental effects on teen health and the family unit. They pointed to the trouble their kids had already experienced as evidence of this. The participants in the group recognized that even though they came from a variety of backgrounds, their shared commonality was facing challenges when raising a teen in today’s society.

Consequences of Teen Sex

The parents/guardians in the focus group unanimously agreed that an incurable disease (such as HIV/AIDS) was the worst thing that could happen to teens as a result of sexual activity. The parents also agreed that teen pregnancy was a grave consequence, but an incurable disease was still worse.

The parents/guardians perceived that teens involved in the juvenile justice system had a greater likelihood of both contracting HIV/AIDS, due to intravenous drug use, and becoming a teen parent by engaging in sex while under the influence. They perceived that the risk to their teen of suffering the consequences was great, “Especially because the drug of choice is heroin. And the best high they can get off of it is shooting it up,” one dad stated.

Prevention

Parents/guardians suggested that education was the best preventive factor for avoiding high-risk behaviors. The parents/guardians thought that sex education should be taught to the teens before issues arose. Some of the parents did not think their teens were getting the life skills they needed while in the juvenile justice system. One mother commented, “I think that a lot of times, the detention doesn’t help them at all. It just sends them to another place.” Where implementation of sex education classes should take place was debatable among the parents: some felt sex education should come from the schools, while others felt it should come from the parents. One mother remarked, “The thing is, it is not the schools’ responsibility to educate them [sex education]… It’s the parents’ responsibility.” Some felt that the schools should integrate sex education into the curriculum and all felt it should be offered as part of the BCJPD services. The parents also suggested that sex education information be promoted using social media such as YouTube.

Contraceptive Use

The parents/guardians of youth on probation expressed that the hardest thing for most parents to accept was the concept of their teen having sex, especially in a Catholic community. Despite religious ties and willingness to accept teen sexual activity, parents/guardians were in favor of teens using contraceptives to avoid unplanned pregnancy. One mother said, “A lot of parents don’t want to think that … I didn’t want to think that my daughter was having sex, but it was like a reality check. I had to snap out of it … I didn’t want her getting pregnant and I didn’t want her to get a sexually transmitted disease. I had to snap out of it and I finally did put her on birth control.” Another mother concurred as she grappled with her religious views, “Because I know myself, I had reservations about birth control. I wondered if I should keep pushing abstinence because we were a devout Catholic family. So, I spoke with a friend who is also Catholic and she told me, ‘I put my daughter on birth control because you don’t want to face with that [sic].’ I have regrets about not having put her on birth control.”

Some parents said that other parents may even be open to the idea of a teen seeking access to contraceptives without parental consent, but they agreed that this viewpoint may vary among individual parents. One mother commented, “That is iffy. I would be glad because she is making the step to protect herself. But every parent is different. They would have to accept that their kid is having sex.”

Parents were also open to the idea of teens using long-acting reversible contraceptives, such as an IUD or an implant; however, they wanted more information about long-acting methods. They suggested parenting classes on this topic. They wanted teens to understand that even though they were decreasing their risk of pregnancy by using contraceptives, they must use a condom in order to reduce the risk of contracting an STD. They stressed the importance of conveying condom use as a necessary part of messaging to teens.

Parent-Teen Communication

The parents/guardians felt that in general, there was a lack of communication between teens and parents about sex. They observed that there were some exceptions to this generalization, but for the most part, teens went to their friends and to media to learn about sex and relationships. The parents/guardians said that when they were raised, kids of their generation had more respect for parents/guardians, but this did not mean that there was more communication between parents and teens about topics such as sex and relationships. Therefore, the parents lacked role models and other resources for guidance on good parent-teen communication about sexual health topics. Another concern was that parents felt they did not always have accurate information about STDs and birth control to impart to their adolescents. They voiced a desire for more parent education programs in order to equip themselves with knowledge and prepare for conversations with their teens.

Emergency Contraceptives

Parents said they would only be comfortable with a teen obtaining access to emergency contraceptives without parental consent in the cases of rape or incest. But, for reasons other than rape or incest, they would want more information about emergency contraceptives before they could make statements about parental consent and emergency contraceptive (EC) access. One mother said, “I don’t think it [giving parental consent for a teen to access EC] would go over very well. That is controversial.” And another mother concurred, “We would need more information about it. The parents should be educated about it.”

Clinics

When parents were asked how they felt about requiring a clinical well-child visit as part of a court-ordered mandate (conditions associated with probation), the parents were open to this idea. One mother said, “I think having an individual check-up with somebody [a doctor] that is open to them [teens] if they cannot be open to the parent [is a good idea].” All of the other parents agreed. They said that many of their teens were embarrassed to go to the clinic with parents. Other parents said they did not think teens would seek clinical services without the parents escorting them to and from an appointment. Few felt parents should be responsible for taking their teen to the clinic. Parents indicated that perceived barriers about teens accessing clinical services were, in general, that teens were defiant against anything the parents asked of them, and that teens were embarrassed to go to the clinic.

Sex Education

The parents/guardians agreed that messaging about sex education and life skills in general should come from the parents or the schools. However, they felt that with influences from peers and media, it was hard to establish boundaries and broach conversations. They felt that if messaging was not coming from parents or schools, probation/detention was a good place to address topics such as STDs, healthy decision making, and self-esteem. They felt that society today did not encourage parental support and influence; even when parents attempted to influence their teens, the teens did not abide. Additionally, they felt that schools should offer sex education as part of the curriculum beginning in middle school or elementary school. All of the study participants agreed that sex education should be mandated and consistent in detention/probation programs, rather than mandating it case by case.

Parents felt it was necessary to teach teens to use a condom correctly and unanimously agreed that teens would learn best if they saw a condom demonstration led in person by a facilitator. They unanimously agreed that written instructions would not suffice stating that, “They [teens] are visual and auditory in this generation.” They felt that lessons should also include messaging about the consequences of improper condom use.

Gangs

In addition to topics such as goal setting, pregnancy prevention, STDs, healthy decision making and refusal skills, the parents/guardians felt that sex education curricula should also include information on gangs and sex trafficking. The parents/guardians perceived that much of the teens’ behavior could be attributed to gang involvement. The parents felt their teens were drawn to gangs out of curiosity and because they idealized the lifestyle of a gang member. One mother said that she knew that her teen was curious about gangs because her teen had watched movies on Netflix to learn more about gangs.

Discussion

Few, if any, studies have looked at the perspectives of the parents or guardians of adolescents in the juvenile justice system. This study investigates the opinions and attitudes of the parents/guardians regarding reproductive health education of teens on probation. The parents/guardians, overall, agreed that outside influences from peers, social media, and technology were the biggest hurdles to overcome when raising teens.

Parents believed that many of the teens’ external influences, such as friends and social media, led to involvement in drug use and gang activity. Moreover, since gang activity and substance abuse have been demonstrated to increase the likelihood of high-risk sexual behaviors, the beliefs of parents/guardians that much of their teens’ behaviors stemmed from involvement in or fascination with gangs are validated by research (Chassin, 2008; Minnis et al., 2008). While social media allows teens to influence one another, other media outlets can also have an influence on the actions of adolescents. Even something as seemingly benign as a Netflix documentary about gangs can start a teen down a path to poor decision making, according to some of the study participants. Ultimately, the concerns expressed by the parents in these focus groups—that the influence of gangs, with their typically high-risk behaviors—increased teen-pregnancy rates, increased STD rates, and lowered goal planning, has been confirmed (Chassin, 2008; Minnis et al., 2008).

While parents in the general population, as well as parents of juvenile justice–involved youth, shared favorable attitudes and opinions on the importance of providing sex education (Abt Associates Inc., 2009), opinions about where the education should be delivered differed slightly by venue and preference between the two groups. Parents in the general population preferred (in order of preference) that sex education messaging come from: places of worship, health care provider, school, community based organization, and the Internet (Abt Associates Inc., 2009). Parents of adolescents on probation preferred it come from: parents, the probation department, schools, and the Internet.

Parents/guardians of teens on probation perceived that their teens were at increased risk of STDs, unplanned pregnancies, and drug use as compared with the general adolescent population, which previous research in this at-risk population proves true (Chassin, 2008; Committee on Adolescents, 2011; Golzari et al., 2006; Greenwood, 2008; Teplin et al., 2005). Strategic, multi-pronged approaches that include a variety of educational venues should be considered in order to change teen behavior and outcomes regarding high-risk teens involved in the juvenile justice system. Comprehensive approaches should be expanded in the community to include EBPs implemented with BCJPD in addition to school and community-based programs. All parents/guardians agreed that encouraging sex education as a preventive measure before teens are exposed to risky situations was a solution to mitigating negative outcomes. In addition, parents recognized the importance of parent-child communication as an avenue for sex education, but felt limited in their knowledge of the topic and the challenge of competing with outside sources such as peer and media influence. Parents/guardians desired education classes for themselves so they would be prepared to communicate with their teen and be able to impart medically accurate information. It is likely the parents and teens alike would benefit from an education program designed to provide guidance to parents who want to discuss reproductive health issues with their teens.

A variety of sex education programs exist that have been proven to be effective in specific populations. Some programs include condom demonstrations, while others do not. The parents interviewed unanimously agreed it was necessary to teach teens correct condom application with an in-person facilitator conducting a demonstration. There are many EBPs endorsed by Office of Adolescent Health, Health and Human Services. Few have been studied in the juvenile justice population except for Sexual Health and Adolescent Risk Prevention (SHARP) and Rikers Health Advocacy Program (RHAP) curricula (MacDonald, 2013; Magura, Kang, & Shapiro, 1994). Both have been shown in randomized control trials to improve condom use and reduce sexual risks. Including acceptable programs that are evidence-based could serve to reduce unintended pregnancy and reduce STDs in this vulnerable population.

Studies support the notion of parents/guardians that adolescents’ feelings of embarrassment are a barrier to accessing clinical services (Garcia, Ptak, Stelzer, Harwood, & Brady, 2014). The focus group participants also felt that the reasons teens would not go to the clinic were because they wouldn’t follow through with an appointment or would have feelings of embarrassment. Some of the parents had reservations about how distribution of birth control/condoms by clinics would be received in the community because of the strong religious ties to the Catholic Church. Parents drew from personal experience when conveying reluctance to encourage birth control due to religious beliefs, as well as a lack of acceptance that their teen was sexually active. However, most of the study participants felt they would be able to reconcile their religious and personal beliefs with the knowledge that their teens were seeking and receiving the necessary care they need to prevent any unplanned pregnancies and STDs. These views coincided with those of the parents of the general population who were less likely to disapprove of sexual activity among adolescents if contraception was used (Abt Associates Inc., 2009). There was no consensus on whether access to birth control should be allowed without parental consent because they felt this perspective could vary among individuals. This is consistent with previous findings that patterns of permissiveness for minority parents vary by specific context (Abt Associates Inc., 2009). The only exception was that in the case of emergency contraceptives, parents felt parental approval should not be required in cases of rape or incest because the teen should not be held responsible for the possibility of pregnancy in this case. Parents/guardians were in favor of teens receiving more information about reproductive health care services as long as the parents were also provided with the same information.

Conclusion

The results of this study confirm the acceptance of sex education within the juvenile justice system by parents and the need for a linkage to clinical services for extremely high-risk youth. It also confirms that parents are supportive of long-acting reversible contraceptive methods and the importance of educating about these methods and condom use. Evidence-based interventions and increased clinical access can be effective approaches to changing behavior and decreasing unplanned pregnancy (Bryan et al., 2009; Eisenberg, Bernat, Bearinger, & Resnick, 2008; Thomas, 2000). This study involved participants that were reflective of a minority community (72% identified as Hispanic or African American) and minorities make up a disproportionately high number of youth in the juvenile justice system. This study truly reflects opinions of parents who are affected by their teens engaging in high-risk behaviors. This study also implies the need for further research to confirm findings in order to generalize concepts to include all parents/guardians of youth on probation regardless of ethnicity. An increased understanding of parental perceptions and increased programming to include parents and youth within the juvenile justice system could lead to a greater impact in ameliorating the deleterious outcomes associated with high-risk behaviors.

Recommendations

Based on the feedback from parents/guardians in the study, it was clear they favored offering sex education that included information about contraceptives and condom use. UTTH provided recommendations to the juvenile probation department after sharing the focus group data. First, a strategic teen pregnancy prevention plan was developed to include a basic foundation for sexuality education known as Sex Ed. 101. The Sex Ed. 101 training was attended by over 360 probation officers to reiterate basic anatomy and puberty, and to increase understanding of STDs and contraceptives. Additionally, 55 probation officers interested in teaching the EBP, Reducing the Risk, attended a 2-day training of facilitators and began implementation in 2013.

To date there have been 361 youth ages 12 to 17 years old that have been reached with the EBP, Reducing the Risk. Additional recommendations include identifying probation officers that have implemented Reducing the Risk to become trainers of the curriculum to sustain the program.  Further recommendations include providing additional training to all probation officers on answering sensitive questions, engaging parents and students in the topic of sexuality education, and identifying resources in the community for parents and teens. The content in this study explains the parental perspective and contributes to the body of knowledge about this less than visible population. The focus on parents and the importance of factors that influence risk-taking behavior makes this study and subsequent recommendations an important contribution, as parents are critical stakeholders in health education that affects their children. Until now, their views were rarely studied explicitly. This study reveals how parents of juveniles on probation concur and differ from the parents of the general population.

Limitations

Several limitations exist: The study was conducted as part of a community needs assessment in Step 1 of the Getting to Outcomes framework. The purpose of the needs assessment was to guide program planning in selecting an evidence-based sex education program that would best fit the BCJPD. It aimed to garner understanding of cultural norms and attitudes of parents whose teens have been referred to the BCJPD. The sample size of the focus group was small (N = 9), therefore it is possible that the views of the parents who participated may not be the views of all parents whose teens have been referred to the BCJPD, or in other parts of Texas and the United States. Due to the small sample size, analysis of participant perspectives based on gender, age, and race were not conducted. The preliminary results of this study are compelling; however the matter of parental/guardian perspectives on adolescent sexual health in the juvenile justice system deserves further investigation.

About the Authors

Jennie Quinlan, BS, MPH, is the program evaluator for UT Teen Health at the University of Texas Health Science Center at San Antonio.

Elise Hull, BS, is a 2016 MD candidate at the University of Texas Health Science Center at San Antonio.

Jennifer Todd, BSN, JD, is the program coordinator for UT Teen Health at the University of Texas Health Science Center at San Antonio.

Kristen Plastino, MD, is the director of UT Teen Health at the University of Texas Health Science Center at San Antonio.

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Appendix

Moderator’s Guide—Parents (of high-risk teen) Focus Group

  • Welcome—the group will be welcomed and reminded that they each represent a portion of the parents in the area. Not all represent the same portion—thus, they should speak their mind as they would if all like them were given a voice.
  • There are no right or wrong answers in terms of what we’re looking for.
  • Tonight we’re going to talk about teenagers and the challenges of helping them make healthy decisions. We could cover a lot on the topic of parenting, but in order to keep this meeting to the time limit I promised you, we need to lay a few ground rules. This conversation will be audio-recorded. First, feel free to share specifics as to any experiences you’ve had, but just keep the stories short. If you are uncomfortable sharing specifics, general points are fine too. Second, if someone is talking, please let them finish. Third, no side conversations, please. Finally, do speak up and speak clearly. If you shake or nod your head, the tape recorder doesn’t pick that up, so from time to time I will repeat what you said or say things just to clarify for the audiotape. We will ask you to fill out an information sheet, but when this meeting is finished, we will transcribe these tapes and then erase them. Please only use your first name for confidentiality purposes. Anything you say will be held in the strictest confidence. Finally, if there are any questions you do not feel comfortable answering, you don’t have to.
  • Please state your name and the ages and genders of your teen(s).
  1. CHALLENGES FACING TEENS: What are the biggest challenges when raising healthy teens today? (Explore the degree of connection between risks.)
    1. Move from actual risks to parental actions to prevent.
    2. Probe to determine feelings of shortcoming or needs.
    3. If necessary: “Research shows that parental closeness is an important protective factor—not necessarily being their friend, rather, staying a parent but staying close. What are the challenges to that? How is that accomplished?”
  2. INFORMATION-SHARING BEHAVIOR: How often do you talk to your teen about sex? Where do you think kids should go for information about sex and relationships?
  3. SEXUAL ACTIVITY: What is your impression of your teen’s peers? Are most of them sexually active or not?
    1. In general, what do you think are the possible consequences of teen sex?
    2. What do you feel is the worst thing that could happen to a child as a consequence of teen sex? (Follow-up questions for each person: “How likely is that to occur?” Probe for percentages—are half of those who have sex likely to have this happen?) What is the most likely consequence? What is the best prevention?
  4. PROGRAMMING: Do you think sex education would be helpful for your child?
    1. How would you feel if making a sex education curriculum became one of the conditions of your child’s probation?
  5. CLINICS: How would you feel if making a clinic visit for a well-child exam became one of the conditions of probation?
    1. Do you know of any clinics in the community that provide family planning services to teens?
    2. Have you visited any of the clinics with your teen?
  6. BIRTH CONTROL: What do parents think about birth control? How comfortable would you be assisting your child with gaining access to birth control? How comfortable would parents be if their children gained access to birth control while on probation or in detention?
    1. Are you familiar with long-acting reversible birth control methods such as an implant or an IUD?
    2. How do you feel about your teen or your teen’s partner being on a long-acting reversible contraceptive like an implant or an IUD? Would you feel comfortable giving consent for your teen to have access to this at a clinic?
    3. What are your thoughts about emergency contraception (aka “the morning after pill”)? Would you feel comfortable giving your child consent to access this kind of birth control?
  7. CURRICULUM: There are many parts to a sex education curriculum. One part is teaching teens how to use condoms. We want to know from you what would be the best way to help teens learn this skill and what method parents would find most acceptable. There are three options. I am going to describe the options and I want you to tell me which option you think would be the most useful and the most acceptable to parents:
    • Watching the teacher in person apply the condom to a model of a penis while describing the steps.
    • Watching a video of a teacher apply a condom to a model of a penis while describing the steps.
    • Receiving handouts with written instructions (no diagrams or pictures or drawings) describing the steps of how to apply a condom.
    1. Do you think it would be useful and appropriate for teens to have a condom demonstration lesson at all?
    2. What sorts of things do parents feel teens should learn about?
      If needed, probe:
      • Pregnancy prevention?
      • STDs?
      • How to make better decisions?
      • Goal setting?
      • Refusal skills?
  8. Is there anything else you would like to add?

Thanks very much for attending, and don’t forget that you need to fill out the data sheet before you go. If there is any question on the sheet that you would prefer not to answer, that is ok. Thanks again!

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