Conduct disorder and HIV risk behaviors among runaway and homeless adolescents

Conduct disorder and HIV risk behaviors among runaway and homeless adolescents

DEPENDENCE Drug and Alcohol Dependence 48 (1997) 69-76 Conduct disorder and HIV risk behaviors among runaway and homeless adolescents1 Robert E. ...

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DEPENDENCE Drug

and Alcohol

Dependence

48 (1997)

69-76

Conduct disorder and HIV risk behaviors among runaway and homeless adolescents1 Robert E. Booth a,*, Yiming Zhang b a Addiction

Research

b Department

and Treatment of Preventive

Services, Medicine

Department

and Biometrics,

Received

of Psychiatry, University of Colorado Health Sciences Center, Denver, CO 80211, USA University of Colorado Health Sciences Center, 1643 Boulder CO 80211, USA 3 October

1996; accepted

1643 Boulder Street,

Street,

Denver,

8 June 1997

Abstract This study was designed to assess the prevalence of conduct disorder (CD) among runaway and homeless adolescents and to investigate associations between CD and HIV risk behaviors. The Diagnostic Interview Schedule for Children and a standardized HIV risk assessment questionnaire were administered to 219 runaway and homeless adolescents recruited from a drop-in center serving high-risk youth. One-half of the males and 60% of the females were diagnosed with CD. In multivariate analyses, CD was the strongest predictor of lifetime use of heroin and/or cocaine and exchanging sex for money, drugs, food or shelter, as well as the number of drugs used and the number of sex partners in the 3 months preceding the interview. The high rate of CD in this population, and the association between CD and both drug and sex-related HIV risk behaviors, indicate a need for interventions that consider the influence of this psychiatric diagnosis on high-risk behaviors. 0 1997 Elsevier Science Ireland Ltd. Keywords:

Runaways; HIV; Conduct disorder

1. Introduction In the United States, through December 1996, 2754 casesof acquired immunodeficiency syndrome (AIDS) had been reported among youth aged 13- 19 and 102904 cases reported among young adults 20-29 years of age (Centers for Disease Control and Prevention, 1997), many of whom were likely infected with the human immunodeficiency virus (HIV)-the etiological agent for AIDS (BarreSinoussi et al., 1993)-while adolescents (Gayle and D’Angelo, 1991). Moreover, one-fourth of all new HIV infections are estimated to occur in young people between the ages of 13 and 21

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author.

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0376-8716/97/$17.00 PII SO376-8716(97)001

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and Koopman,

1991a), due

both to drug (Yates et al., 1988) and sex risk factors (Anderson et al., 1994) including survival sex (e.g.

exchanging sex for food, money, or shelter) (Yates et al., 1988; Anderson et al., 1994). It is estimated that l-2 million youth runaway each year in the United

States (Rotheram-Borus et al., 1991b). There have been very few studies on possible associations between HIV risk behaviors and other problem

behaviors

among runaway and homeless adolescents.

psychiatric disorder cited in the Diagnostic and Statisti-

scientific meeting Scottsdale, AZ,

Ltd.

tings (Rotheram-Borus

This is an important omission, since such associations, if found, could have major implications for interventions with this population. Conduct disorder (CD) is a

4586772.

’ Parts of this paper were presented at the annual of the College on Problems of Drug Dependence, June 10-15, 1995.

(Office of National AIDS Policy, 1996). Among runaway and homeless adolescents, HIV seroprevalence rates are higher than among adolescents in other set-

cal Manual of Mental Disorders (American Psychiatric Association, 1987). It is reflected by a persistent pattern reserved

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of behavior, under the age of 18 (or if 18 or older, not meeting the criteria for antisocial personality disorder), in which the basic rights of others and major age-appropriate norms are violated. CD is characterized by such antisocial behaviors as fire setting, forced sex, physical cruelty, and stealing with confrontation. It is one of the most common psychiatric disorders in the general population, with prevalence estimates ranging from 3.2 to 6.9% among adolescents (Rutter et al., 1970; Offord et al., 1987; Connell et al., 1982). According to the DSM-III R, 9% of males and 2% of females under 18 have this disorder (American Psychiatric Association, 1987). It is also the most common reason for referral to treatment (Robins, 1991). Recent studies have reported CD rates of 38.9% among adolescents admitted to inpatient treatment for alcohol abuse (Martin et al., 1993), and 23.2% among adolescents seen in New York City hospital-based programs for severe emotional and behavioral disorders (Gabel and Shindledecker, 1993). Studies have found significant associations between an admission diagnosis of CD and poor treatment outcome (Gabel et al., 1988, 1990; Gabel and Shindledecker, 1992). Developmentally, CD is linked with adult personality disorder (Robins and Price, 1991), and the DSM-III, DSM-III-R, and DSM-IV require that a history of CD symptoms be present for a diagnosis of antisocial personality disorder (American Psychiatric Association, 1980, 1987, 1994). Little attention has been paid to assessing the extent of CD among runaways and other high-risk youth. An exception was Feitel et al. (1992), who investigated the prevalence of diagnosable behavioral and emotional disorders among youths in a New York City homeless shelter. They found that 90% met the criteria for at least one DSM-III-R diagnosis, including 59% who had CD. More recently (Booth and Zhang, 1996), we examined the prevalence of CD among runaway and homeless adolescents seen in a Denver drop-in center for at risk youth and found that 55% met the criteria for a diagnosis. Neither of these investigations, nor any others, examined the relationship between CD and HIV risk behaviors. In view of published findings establishing a relationship between antisocial personality disorder and HIV risk behaviors among adults (Brooner et al., 1990; Compton et al., 1995; Gill et al., 1992) as well as HIV infection (Brooner et al., 1993), this is a critical gap in our knowledge. In the present study, we report on the relationship between CD and both sex and drug-related HIV risk behaviors in a population of runaway and homeless adolescents. Based upon earlier studies of antisocial personality disorder in adults, we hypothesized that CD would be strongly associated with HIV risk behaviors in adolescents.

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2. Methods Respondents included 219 runaway and homeless adolescents participating in an ongoing longitudinal assessment of an intervention intended to reduce HIV risk behaviors among high risk youth. The intervention was delivered in four sessions over 2 consecutive days. Youths were interviewed before the intervention, immediately afterward, and 3 months later. In this paper, we report on data obtained from the initial interview, when CD was assessed. Due to time constraints in the longitudinal study, it was not possible to conduct a comprehensive psychiatric evaluation of study participants. Eligibility criteria included an age of 12- 19 years, on the streets for a minimum of 3 months without more than 2 weeks in the homes of immediate family (i.e., parents, brothers or sisters), and from families who were not homeless. Participants were recruited from a community drop-in center serving this population when they went to the center for assistance/support, when contacted by staff from the center in the course of performing outreach activities, or through chain referral by study participants. Eligibility was initially determined by staff members and confirmed by interviewers. Informed consent was obtained prior to study participation and participants were compensated $10.00 for their time. All procedures were approved by the Institutional Review Board of the University of Colorado. 2.1. Instruments CD was assessed using the Diagnostic Interview Schedule for Children, Revised version (DISC-R), a highly structured instrument based on DSM-III-R criteria. Reliability (Shaffer et al., 1993; Schwab-Stone et al., 1993) and validity (Piacentini et al., 1993) assessments of the DISC-R support its use with this population. Information on HIV risk behaviors was obtained from the Adolescent Health Survey, a standardized, structured interview schedule developed after a comprehensive literature review on runaway and homeless adolescents and an analysis of more than 300 taperecorded, semi-structured interviews with runaway and homeless youth in six U.S. cities (Watters and Beschner, 1994). The survey instrument assessed demographics, living situations while growing up, history of running away, sexual and physical abuse, suicide attempts, drug use, sex risk behaviors, mental health experiences and criminal justice involvement. In addition, knowledge about HIV was assessed using an 18-item scale. Risk periods assessed included the previous 30 days, previous 3 months, as well as lifetime. In this paper we will focus primarily on lifetime and 3-month time periods. Test-retest reliability of the instrument was assessed on variables not expected to change greatly, if at all,

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between the initial and follow-up interviews. For continuous variables, Pearson correlation coefficients ranged from 0.70 (problems getting enough to eat) to 0.99 (date of birth) between the first and second interviews, and from 0.73 (age first ran away) to 0.93 (date of birth) between the first and third interviews. For categorical variables, the Kappa statistic (Cohen, 1960) ranged from 0.71 (ever drank alcohol) to 1.0 (ever been pregnant) between the first two interviews, and from 0.75 (ever lived in a group home) to 0.78 (ever been sexually abused) between the first and third interviews. Four graduate students in anthropology served as interviewers. DISC-R training was provided by a licensed psychiatrist who was experienced with the instrument. For reliability purposes, the training included five observations of the DISC-R administered by a trained interviewer, and five observations where the study’s interviewers were observed administering the instrument. To eliminate possible bias resulting from knowledge of the diagnostic status of subjects, interviewers administered the HIV risk behavior questionnaire first, followed by the DISC-R. 2.2. Statistical

analyses

To assess univariate relationships between CD, HIV risk behaviors and demographics, x2 tests based on two-by-two tables were used with categorical variables. Comparisons were also made using Fisher’s exact test for categorical variables with small cell sizes. For continuous variables, such as age and number of drugs used, two sample t-tests were used, assuming equal or unequal variances based on the calculated F statistics. Logistic regression and multiple linear regression, for dichotomous and continuous response variables, respectively, were used to examine the relationship of demographics, CD, concern about getting AIDS, knowing someone infected with HIV, past receipt of HIV testing and counseling, and AIDS knowledge, with four HIV-related dependent variables, including lifetime use of heroin and/or cocaine, ever exchanged sex for money, drugs, food, or shelter, and, in the 3 months prior to the interview, the number of drugs used and the number of sex partners. For each independent variable entered in logistic regression, odds ratios were adjusted for all other variables included in the model. Confidence intervals for ,odds ratios and linear regression parameters were computed. All statistical inferences were based on two-sided tests of significance.

3. Results

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mean age was 17.4 (SD. = 1.47) 73% were white, 12% Latino, 6% African American, 6% Native American, and 3% Asian American. They averaged 9.9 (S.D. = 1.6) years of education. Nearly one-fourth had never lived with their birth mother and 42% never with both parents at the same time. Among those who had lived with a birth parent, the average number of years with their mother was 8.3 (S.D. = 5.5), father 4.2 (S.D. = 4.2) and both parents 7.6 (S.D. = 5.7). Only 8% were raised solely by their birth parent(s) and not placed in other living situations. Youth averaged 2.8 (S.D. = 1.6) placements, including: adoptive parents (16%), foster parents (29%), grandparents (36%) other relatives (36%), group homes (47%) and other social service agencies (16%). One-half reported they had been sexually abused and 55% physically abused. Of the total, 52% were raised in a home with someone who had a serious drinking problem and 54% with someone who used drugs. Most (85%) had left home on their own, while the remainder were told to leave. The mean age when the first runaway episode occurred was 13.1 (S.D. = 3.1) and respondents had been away from home for an average of 88.5 (S.D. = 93.9) continuous weeks at the time of their initial interview. When interviewed, 62% considered themselves homeless and 73% lacked a permanent place to stay. Lifetime use of drugs, other than alcohol, was reported by 95% of study participants, including 78% who had used in the 3 months prior to the interview. Users averaged 4.0 (SD. = 2.6) different illicit drugs in their lifetime and 1.8 (S.D. = 1.8) in the preceding 3 months. Lifetime use of heroin and/or cocaine was reported by 48%, including 12% who had used heroin, 41% cocaine, 24% crack, and 6% speedball, a combination of heroin and cocaine. Overall, 12% had injected drugs in their life. In the 3 months prior to the interview, 3% reported using heroin, 13% cocaine, 6% crack, and 1% speedball. Overall, 16% had used heroin and/or cocaine. In addition, 76% reported use of marijuana, 20% amphetamines, 37% psychedelics, 6% tranquilizers, 3% barbiturates and 10% other drugs. Injection drug use was reported by 3%. Only one participant indicated no prior sexual intercourse. Those who were sexually active averaged 33.3 (SD. = 122.5) partners in their lifetime. During the 3 months prior to the interview, 87% reported sexual intercourse (M = 2.5 partners; S.D. = 3.1). Nearly onefourth had exchanged sex for money, drugs, food, or shelter in their lifetime, and 24% reported having a sex partner who they knew was a drug injector. 3.2. Prevalence and demographic conduct disorder

associations

with

3.1. Study sample

In the sample, 54% was male and 46% female. Their

Among the 219 youth assessed, 54% met DSM-III-R criteria for CD. Proportionally, more females were

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Table 1 Comparisons in drug use between runaway and homeless adolescents with and without conduct disorder Variable

Subjects with conduct disorder

Subjects without conduct disorder

Test statistic

P

Mean (S.D.) N drugs used: lifetime Percent heroin use: lifetime Percent cocaine use: lifetime Percent crack use: lifetime Percent speedball use: lifetime Percent heroin or cocaine use: lifetime Mean (S.D.) N drugs used: last 3 months Percent heroin or cocaine use: last 3 months

5.5 (2.8) 15.0 46.1 33.0 1.5 54.2 3.2 (2.0) 21.5

4.3 (2.3) 8.1 33.3 13.1 3.0 39.4 1.9 (1.5) 1.9

3.34” 2.28b 4.00b 12.07b 2.09b 4.?5b 5.35” 4.35b

0.001 0.12 0.05 0.001 0.15 0.03 0.0001 0.01

diagnosed than males (60% versus 50%, respectively), although this difference was not significant. There was also no significant difference between white and nonwhite subjects (53 versus 59%, respectively). Respondents with CD averaged 17.5 (S.D. = 1.6) years of age compared to 18.5 (S.D. = 1.3) years for those without CD (t = 5.00, df = 216.7, P < 0.0001). 3.3. Univariate associations between conduct disorder and HIV risk behaviors Drug and sex risk behaviors of runaways with and without CD are compared in Tables 1 and 2. As illustrated in Table 1, runaways with CD used significantly more drugs in their lifetime and in the 3 months prior to when they were interviewed than did runaways without CD. They were also more likely to have used powdered cocaine, crack, and heroin in their lifetime, and heroin or cocaine in the 3 months before their interview than were those without CD. In the 30-days prior to the interview (table not shown), runaways with CD used an average of 2.6 drugs (S.D. = 1.7) compared to 1.4 (S.D. = 1.2) for those without a diagnosis (t = 5.77, df = 212.0, P < 0.0001). Table 2 presents associations between lifetime and 3-month sex behaviors and CD. Youth with a diagnosis were significantly more likely to have exchanged sex during their lifetime than those without a diagnosis, and they had more sex partners in the 3 months prior to their interview. Although not illustrated, during this 3-month period they were also more likely to have had sex with a prostitute (11 versus WO), sex with two or more people at the same time (33 versus 22%), and sex when drunk or on drugs (84 versus 73%). In the 30-days preceding the interview (table not shown), runaways with CD reported an average of 1.3 sex partners (SD. = 1.5), while runaways without CD averaged.9 (SD. = 0.74; t = 2.74, df = 179.8, P < 0.01).

3.4. Multivariate behaviors

analysis of predictors

of HIV

risk

Multivariate analyses were conducted on two lifetime dependent variables, use of heroin and/or cocaine and exchanged sex, and two on measures in the 3 months before the interview, the number of drugs used and the number of sex partners. Predictors in the models, in addition to demographics and CD, included the following four HIV-related variables: concern about HIV infection; knowing someone who was infected; having been tested and counseled about HIV; and AIDS knowledge. Descriptive information on these variables revealed the following: according to concern about getting infected, 9% were not at all concerned, 16% slightly concerned, 2 1% somewhat concerned, 24% very concerned and 31% extremely concerned; 48% of study subjects knew someone who was HIV positive; 69% had been tested for and counseled about HIV; and the mean knowledge score on the 18-item measure was 14.3 (S.D. = 2.5). Tables 3 and 4 present results from the multivariate analyses using logistic and linear regression models, respectively. The logistic regression analysis on use of heroin and/or cocaine revealed that white youth and those with a diagnosis of CD were 2.0 and 2.3 times more likely, respectively, than nonwhite youth and youth without CD to have used these substances. No other variables were associated with heroin and/or cocaine use. CD, as well as gender, was also significantly and independently associated with exchanging sex. Runaways with CD were nearly three times more likely than runaways without CD to have exchanged sex, and females were 2.5 times more likely than males to have exchanged sex. Youth with greater concern about getting infected with HIV and youth with greater knowl-

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Table 2 Comparisons in sex behaviors between runaway and homeless adolescents with and without conduct disorder Variable

Subjects with conduct disorder

Subjects without conduct disorder

Test statistic

P

Mean (SD.) N sex partners: lifetime Percent exchanged sex: lifetime Percent sex with a drug injector: lifetime Mean (S.D.) N sex partners: last 3 months

38.0 (129.6) 27.5 27.2 2.7 (3.9)

26.7 (115.2) 15.6 19.4 1.9 (2.5)

0.61” 4.35b 1.74b 2.05”

0.55 0.04 0.19 0.05

“F bx2.

edge about AIDS were also more likely to have exchanged sex, although the significance level of these variables was slightly greater than 0.05. In multiple linear regression, four variables were significantly associated with the number of drugs used in the 3 months prior to the interview: ethnicity, CD, receipt of HIV testing and counseling and AIDS knowledge. In univariate analyses, white youth averaged 2.7 (S.D. = 1.9) drugs used in this period compared to 2.0 (SD. = 1.4) for nonwhite youth (F= 6.43; P < 0.02); youth with CD averaged 3.0 (S.D. = 1.9) drugs compared to 1.8 (S.D. = 1.4) for those without CD (F= 28.69, P < 0.00001); and the average number of drugs used by youth not tested for HIV was 2.9 (S.D. = 2.1) compared to 2.3 (S.D. = 1.6) for those tested (F= 4.71; P < 0.05). HIV knowledge was positively associated with greater drug use: for every correct answer on the knowledge scale, 0.07 more drugs were used (t = 1.17, P = 0.24). In multivariate analysis of the number of sex partners in the preceding 3 months only CD was significant. An average of 2.6 (S.D. = 3.6) sex partners was reported by runways diagnosed with CD, compared to an average of 1.7 (S.D. = 2.3) for those without a diagnosis (F= 4.29, P < 0.05). 4. Discussion

The main findings of this study are that CD is highly prevalent among runaway and homeless adolescents and that it is associated with HIV risk behaviors. The high prevalence of CD in this population was demonstrated by the finding that more than half of the youth we interviewed were diagnosed with this disorder, including 60% of the females. The higher rate of CD in females as compared to males is inconsistent with previous published reports. For example, a household survey of adolescents in Ontario reported CD rates of 8.9 and 2.0% among boys and girls, respectively (Boyle et al., 1992). Robins, in fact, commented that the most stable of all findings relative to risk factors for this disorder was the consistent greater rate of CD in males over females (Robins, 199 1). Why, among runaways, females were more likely to have a diagnosis is unknown and an important area for further investigation.

The hypothesized relationship between CD and HIV risk behaviors was supported. On every variable, youth with a diagnosis engaged in greater drug and sex risk behaviors than did youth without a diagnosis: they used more drugs, were more likely to have used heroin or cocaine, had more sex partners, and were more likely to have engaged in high-risk sex behaviors. In multiple logistic and linear regression analyses, CD was the strongest predictor of exchanging sex and the only variable associated with the number of sex partners. Although others have reported an association between antisocial behavior and high-risk sex behavior among school-attending adolescents (Biglan et al., 1990) as well as inner-city youth (Stiffman et al., 1992), few have used standardized diagnostic criteria and extended the investigation to drug-related behaviors. An exception was Greenblatt and Robertson’s (1993) study of homeless adolescents in Hollywood. While not indicating the specific rate, they reported that the prevalence of CD in this population was high and that 39% met diagnostic criteria for drug abuse or dependence. A number of other important findings also emerged from this study. In multivariate analyses, white youth were more likely than nonwhites to have used heroin and/or cocaine and, in the 3-month period before the initial interview, they used a greater number of drugs. It is unclear how representative these finding are, since there have been few studies reporting ethnic differences in drug use among runaway adolescents. One investigation did find higher rates of drug use among Latin0 than African-American runaways in New York City, however, very few whites were included in the assessment (Koopman et al., 1994). Among non-runaways, recently published data from the National Household Survey showed that adolescents 12 to 17 years of age had very similar drug use patterns according to ethnicity, with rates of 8.5% for whites, 8.3% for African Americans and 8.1% for Latinos in the month prior to the survey (Substance Abuse and Mental Health Services Administration, 1995). While the survey found greater ethnic differences among those aged 18-25, with 14.6% of whites, 12.8% of African Americans and 9.1% of Latinos reporting drug use, these differences were not as marked as those we found among runaways

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Table 3 Factors associated with lifetime use of heroin or cocaine and exchanging sex among runaway and homeless adolescents Variable

Age Gender Ethnicity Conduct disorder AIDS concern Know someone infected HIV tested AIDS knowledge

Use of heroin or cocaine Adjusted odds ratio

95% confidence interval

1.21 0.98 1.96 2.28 0.79 1.40

0.98-1.50 0.53-1.81 1.02-3.75 1.2334.20 0.40-1.55 0.77-2.53

0.96 1.11

0.52-1.80 0.97- 1.28

in Denver. Additional research, in other settings, is required to determine if these findings are generalizable and, if so, what factors can account for ethnic differences in drug use patterns. Increased knowledge about AIDS was also associated with greater risk behaviors, including both the number of drugs used and exchanging sex. Increasing knowledge about HIV has been the focus of efforts to reduce the threat of this disease among adolescents (Walter and Vaughan, 1993; St. Lawrence et al., 1995; Jemmott et al., 1992), as well as adults (Stephens et al., 1991; McCusker et al., 1992; Martin et al., 1990). While some studies of adolescents receiving these interventions have reported significant associations between knowledge and reduced HIV risk (Greenblatt and Robertson, 1993; Koopman et al., 1994; Substance Abuse and Mental Health Services Administration, 1995), other investigations have found knowledge unrelated or only slightly related to risk behavior and to change in risk behavior (Rotheram-Borus and Koopman, 1991a; Greco et al., 1992; Shafer and Boyer, 1991). Still others have found, as we did, high levels of knowledge among adolescents engaging in high risk behaviors (Greenblatt and Robertson, 1993; Keller et al., 1991). This relationship may be due to the presence of mental health problems, other than conduct disorder, including depression, anxiety, and posttraumatic stress, known to be associated with risk behaviors (Stiffman et al., 1992; Deykin et al., 1987; Hein and Hurst, 1988) and common among runaway adolescents (Feitel et al., 1992; Keller et al., 1991). Clearly, basic information about AIDS and risk factors associated with HIV transmission need to be included in any intervention with at-risk groups, however, for many adolescents, education alone may be insufficient given their perceived lack of vulnerability (Boyer and Ellen, 1994). Changing the risk behaviors of runaways, whose concerns are far more immediate than contracting HIV, is an enormous challenge, particularly for those with CD and other mental health disorders.

P<

Exchanged Sex

P<

Adjusted odds ratio

95% confidence interval

0.08 0.95 0.05 0.01 0.49 0.27

1.18 0.40 1.37 2.82 2.36 1.29

0.91-1.52 0.19-0.84 0.63-3.01 1.28-6.20 0.9445.96 0.63-2.65

0.21 0.02 0.43 0.01 0.07 0.49

0.91 0.14

1.06 1.20

0.4992.31 1.00-1.44

0.89 0.06

Youth who received HIV testing and counseling services used fewer drugs than those not tested. Although this finding may offer support for the effectiveness of testing and counseling in reducing risk, a review of 50 studies of testing and counseling failed to find compelling evidence of an effect on drug or sex risk behaviors (Higgins et al., 1991). Others have reported that testing and counseling may, in fact, increase high-risk behaviors in some individuals (Otten et al., 1993). In our study, it is likely that youth who went to testing and counseling services had greater concern about their health than those not tested and, concomitantly, were using fewer drugs than those not tested. There were some potential limitations to this study. First, the sample was drawn exclusively from one city and the results may not generalize to other locations, particularly those with greater nonwhite representation. Second, participants were not randomly selected. Acceptance rates cannot be calculated due to the reliance on chain-referral. Since compensation was offered, selection bias likely over represents youth who had the time to participate and those for whom the stipend was worth the effort. Third, results were based on self-reports, which may have been affected both by recall and social desirability. Based upon test-retest reliability findings, however, we feel that the results reported are reasonably accurate for the study’s purposes. Runaway and homeless adolescents are at extreme risk from a wide variety of dangers, including HIV. Numerous studies have documented the extent of their sex and drug related behaviors (Rotheram-Borus and Koopman, 1991a; Yates et al., 1988; Anderson et al., 1994; Rotheram-Borus et al., 1991b; Substance Abuse and Mental Health Services Administration, 1995), which far exceed that of youth living in more stable environments (Yates et al., 1988; Koopman et al., 1994; Sugerman et al., 1991; Robertson, 1989). Few investigations, however, have looked at factors underlying these risk behaviors. Results from our study may offer additional insight on this topic, in particular, the high rate

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Table 4 Factors associated with the number of drugs used and number of sex partners in the past 3 months among runaway and homeless adolescents Variable

Number of drugs used

P<

-

As Gender Ethnicity Conduct disorder AIDS concern Know someone Infected HIV tested Knowledge

Parameter estimate

95% confidence interval

- 0.46 0.30 0.78 I .30 - 0.36 0.24

-0.22-0.13 -0.22-0.82 0.24-1.33 0.79-1.81 -0.94-0.21 -0.26-0.74

- 0.65 0.12

-1.18-0.12 0.00-0.24

of CD among runaway and homeless adolescents and the strong association between CD and HIV risk ‘behaviors. Our data indicate that efforts to prevent the spread of HIV infection in this population are of critical importance. Furthermore, these efforts need to consider the influence of CD on the behaviors that they are intended to affect. The developmental association between CD and antisocial personality disorder (American Psychiatric Association, 1980, 1987, 1994) and the relationship between antisocial personality disorder and HIV infection (Brooner et al., 1993), point to the urgency with which these efforts should be pursued.

Acknowledgements This study was supported by the National Institute on Drug Abuse, Contract No. 271-90-8402. We acknowledge the assistance provided by the following individuals: John K. Watters, Ph.D., Carol Kwiatkowski, Ph.D., Thomas J. Crowley, M.D., George M. Beschner, Richard Needle, Ph.D., MPH, Susan Coyle, Ph.D., and the anonymous reviewers for their thoughtful suggestions to an earlier version of this paper. John Watters passed away November 20, 1995.

References American Psychiatric Association, 1980. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association, Washington DC. American Psychiatric Association, 1987, Diagnostic and Statistical Manual of Mental Disorders. Third edition, rev. American Psychiatric Association, Washington DC. American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. American Psychiatric Association, Washington DC. Anderson, J.E., Freese, T.E., Pennbridge, J.N., 1994. Sexual risk behavior and condom use among street youth in Hollywood. Fam. Plann. Perspect. 26, 22-25. Barre-Sinoussi, F., Chermann, J.C., Rey, F., et al., 1993. Isolation of a T-lymphotropic retrovirus from a patient at risk for the ac-

Number of sex partners

P<

Parameter estimate

95% confidence interval

0.61 0.27 0.01 0.0001 0.22 0.35

0.11 0.62 -0.02 1.14 0.01 0.19

-0.23-0.44 -0.36-1.60 - 1.05-1.01 0.18-2.11 - 1.08-1.09 -0.76-1.14

0.53 0.22 0.97 0.03 0.99 0.70

0.02 0.05

- 0.48 0.00

- 1.48-0.53 -0.22-0.22

0.36 0.99

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