OBJECTIVE:

With this study, we examined the efficacy of a health intervention program that was focused on emotion regulation (ER) skills in reducing sexual risk behaviors among early adolescents with suspected mental health symptoms.

METHODS:

Seventh grade adolescents with suspected mental health symptoms participated in a 6-week, after-school sexual risk prevention trial in which a counterbalanced, within-school design comparing an ER focused program to a time- and attention-matched comparison group was used. Adolescents completed a computer-based survey regarding their sexual behavior at 6-month intervals for 2.5 years.

RESULTS:

Adolescents who received ER skills training exhibited a delay in the transition to vaginal sex over 30 months compared with those in the comparison condition (adjusted hazard ratio = 0.61; 95% confidence interval [0.42 to 0.89]). They also reported fewer instances of condomless sex over the follow-up period (adjusted rate ratio = 0.36; 95% confidence interval [0.14 to 0.90]). Among those who were sexually active, those in the ER condition reported fewer instances of vaginal or anal sex (adjusted rate ratio = 0.57; 95% confidence interval [0.32 to 0.99]).

CONCLUSIONS:

An intervention used to teach ER skills for the context of health decision-making resulted in lower risk among young adolescents with suspected mental health symptoms by delaying the onset of vaginal sex as well as reducing penetrative acts without a condom. Incorporating emotion education into health education may have important health implications for this age group.

What’s Known on This Subject:

Sexual debut before age 15 is a risk factor for future sexual risk. Emotion regulation skills appear to be related to risky behaviors among adolescents.

What This Study Adds:

With this study, we evaluate the efficacy of an emotion regulation intervention on reducing sexual risk behaviors of at-risk middle school students.

Those who have sexual intercourse in early adolescence (before age 15) have greater future sexual risk, including more sexual partners, multiple unintended pregnancies, and more sexually transmitted infections (STIs) than their later-debuting peers.1,4 Interventions used to address vulnerabilities of early adolescents are necessary for effective prevention of early onset sexual activity and associated negative health outcomes. Emotion regulation (ER), which has been conceptualized as “shaping which emotions one has, when one has them, and how one experiences or expresses these emotions,”5 is one such vulnerability, particularly among adolescents with mental health symptoms. Indeed, suggested in data from the neuroscience literature is that changes in affective processing during adolescence may be critical to understanding risk behavior in this age period.6,7 Thus, interventions used to integrate social-emotional context may be superior to those in which rational decision-making processes are assumed.8 

Teenagers who engage in risk behaviors, such as unprotected sex, are more likely to report difficulty with ER.9 Moreover, poorer self-regulation of emotions and behavior in early adolescence has been associated with more sexual risk-taking and more sexual partners later in adolescence.10,11 Adolescents with mental health concerns may be more vulnerable to deficits in ER skills,12 and subsequently, risky sexual activity. Indeed, mental health symptoms are related to greater sexual activity among early adolescents13,14 and with sexual risk behaviors in later adolescence.15,17 

Talking About Risk and Adolescent Choices is a developmentally tailored intervention used to target ER and sexual risk behavior in early adolescents with mental health symptoms. In the structured curriculum, sexual health information is combined with ER education, and focus is placed on (1) increasing awareness and monitoring of emotions, (2) recognizing the impact of emotions on behavior and benefits of managing emotional intensity during decision-making, and (3) learning ER techniques. Authors of previous findings from the clinical trial evaluating Talking About Risk and Adolescent Choices indicated lower rates of sexual debut through 1-year follow-up.18 However, at 1 year, other sexual risk targets (eg, condom use) were underpowered because of the lower frequency of intercourse behaviors among eighth-graders. With this article, we report the extended follow-up (30 months) from this trial, allowing for a more detailed examination of sexual risk behavior in addition to delayed sexual debut. We hypothesized less sexual risk among participants in the experimental treatment (ER) versus a comparison condition (health promotion [HP]) and that this reduction in risk would be attributable to both delayed sexual debut and less sexual risk behavior after debut.

Additional details regarding study methods have been previously published.18,19 With institutional review board approval, students from 5 urban Rhode Island public schools were enrolled between September 2009 and February 2012. Inclusion criteria included being in the seventh grade, 12 to 14 years old, English-speaking, and exhibiting at least 1 symptom of emotional or behavioral problems or suspected sexual or substance use behavior. School professionals identified at-risk students by using a form listing mental health symptoms (eg, withdrawing, hyperactivity, nervousness). Exclusion criteria included a history of sexual aggression, HIV infection, current pregnancy, developmental delays, or a participating sibling.

Approximately 27% of students attending seventh grade during the 3 study years were referred to the program, consistent with national prevalence data for adolescent mental health disorders.20 Consent and assent were obtained for 40% of referred students (n = 420; Fig 1). Sample size was determined by power analysis by using the following primary study outcome: time to first vaginal sex. Using well-validated psychiatric screening instruments (adolescent-reported Youth Inventory-4 and parent-reported Adolescent Symptom Inventory),21 we found that 65% of the sample had a T-score of ≥65 for at least 1 of 7 subscales (attention-deficit/hyperactivity disorder [any type] was 46%, conduct disorder 21%, oppositional defiant disorder 20%, generalized anxiety disorder 16%, major depressive disorder 31%, dysthymic disorder 37%, and bipolar disorder was 32%).

FIGURE 1

CONSORT summary of participant retention through 30 months. CONSORT, Consolidated Standards of Reporting Trials.

FIGURE 1

CONSORT summary of participant retention through 30 months. CONSORT, Consolidated Standards of Reporting Trials.

Close modal

The sample was composed of 53% boys, and the average age was 12.94 years (SD = 0.53) at baseline. Racial backgrounds included 32% white, 28% African American, 3% native Hawaiian or other Pacific Islander, 2% American Indian, 1% Asian American, and 18% multiracial (16% did not endorse a racial category). Thirty-eight percent of participants reported Hispanic ethnicity. Thirty percent of parents reported an annual family income <$20 000 (18% did not report family income). Vaginal or anal sex before baseline assessment was reported by 11% of participants. There were no statistically significant baseline differences by intervention condition on age, sex, race, ethnicity, household income, previous sexual activity, or presence of clinically significant symptoms on mental health screening. There was no difference between conditions on attendance at the 12 after-school sessions ([9.1 vs 9.0]; t [418] = 0.20; P = .84).

Adolescents participated in 1 of 2 after-school interventions in which structured curricula (ER or HP) were used. Each consisted of 12 twice-weekly, hour-long sessions, run in single-sex groups of 4 to 8 adolescents. Two booster sessions were provided to both conditions at 6- and 12-month follow-ups. Groups were led by male-female pairs that included a mental health clinician (or clinician in training) and a research assistant. In both interventions, the same techniques were used to convey and personalize information, including interactive games, videos, group discussions, and workbook activities. ER sessions contained education in ER (eg, recognizing feelings in self, strategies for reducing momentary emotional arousal) and sexual health (eg, sexual anatomy, STIs). Addressed in HP sessions were health topics including sexual risk, substance use, and nutrition but not emotion education.

To minimize contamination effects that might reduce the treatment effect and to avoid nesting treatment condition within schools, a cluster-randomized crossover design22 was used. Schools were randomly assigned by coin flip to an order of conditions over 2 school years (eg, ER in year 1 and HP in year 2). Thus, the 2 conditions were offered in each school over different school years to different groups of seventh-graders.

ER Intervention

The ER intervention was aimed to enhance ER skills to reduce poor decision-making associated with risk behaviors. The program was used to present the relationship between emotions and behaviors and approaches to recognizing and labeling emotions and recognizing their sources (eg, feeling pressured to have sex). It was used to present developmentally appropriate strategies for regulating emotions (both positive and negative) during moments of decision-making by using the following 3 strategies: (1) “Get Out,” getting away (physically or cognitively) from triggers for strong emotions, (2) “Let It Out,” releasing emotional energy in healthy ways (verbally or physically), and (3) “Think It Out,” changing cognitions and appraisals about emotional triggers. Games and role plays were used to apply these strategies to various risk situations. Sexual health education was integrated, including information about sexual development, STIs, and disease and/or pregnancy prevention, which included discussions of abstinence, nonpenetrative sexual behaviors, and condom use.

HP Intervention

The comparison condition was loosely modeled on another intervention23 that was used to encourage healthy decision-making through information, similar to many public school health curricula. Topics, which were matched for time and delivered using similar activities, included internet safety, substance use, violence, nutrition, exercise, sleep, and cigarette smoking. The sexual health content of the ER intervention was included, with modifications to eliminate discussion of emotions related to decision-making.

Curriculum Training and Fidelity

Facilitators were trained in the structured curriculum through mock groups, practiced for each session. Annual trainings were used to review session goals, role plays, behavior management, and protocol adherence. Facilitator-completed ratings revealed excellent (98%) manual adherence, as did senior project staff observations (observed for 15% of sessions; 97% adherence).

Participants completed audio computer assisted self-interviews of sexual behavior at baseline and every 6 months postbaseline for 30 months (6 assessments). Data from an abbreviated assessment given immediately postintervention were used only for providing information for time to sexual initiation; the effects of the intervention immediately after program completion and at 1-year follow-up have been published elsewhere.18,19 Parents completed baseline demographics and adolescent mental health symptom questionnaires on laptops in the language of their choice (English, Spanish, or Portuguese).

Delay of Sexual Initiation

Participants were asked at each assessment whether they had ever engaged in vaginal sex (the primary outcome). Adolescents responding yes were asked additional questions about the last 6 months, including whether this was the first time they had vaginal sex and, if so, in which month it had occurred.

Sexual Risk Behaviors

Adolescents were also asked whether they had engaged in anal sex in the last 6 months, although not whether this was the first time. Adolescents who endorsed vaginal or anal sex in the previous 6 months were asked about the number of vaginal and/or anal sexual partners, number of vaginal and/or anal sex acts, number of times condoms were used, how often (on a 5-point Likert scale) they used drugs or alcohol in the 4 hours before sex, and whether they used substances before their last sexual encounter. Behavioral definitions were provided to ensure understanding; definitions did not reference partner gender to allow for both opposite- and same-sex encounters.

Reported vaginal and anal sexual acts were summed across the 30-month follow-up period. The same procedure was repeated for condomless sexual acts. At each assessment, the number of partners in the last 6 months was asked; however, the identity of partners was not recorded, meaning that the cumulative number of partners could not be determined (ie, having 1 partner at each of 4 assessment periods could reflect 1 partner for 2 years or 4 different partners). Instead, with our analyses, we used a dichotomous variable (any versus none) examining the presence of any 6-month period during follow-up in which participants endorsed ˃1 partner.

Sexual Risk Composite

A sexual risk composite was calculated such that those who reported ˃1 partner during any 6-month period, any condomless vaginal or anal sex, or any substance use before sex were coded as “1.” Paricipants reporting none of these behaviors or no sexual activity during the 30-month follow-up were coded as “0.”

Nesting of Participants Within Schools

To account for participant nesting within the 5 schools, school was included in all statistical models as a categorical covariate, entered as a set of 4 dummy-coded contrasts.

Missing Data

Unless otherwise specified, analyses included all 420 participants. Seventy-two percent of participants completed all 5 follow-up assessments with 12% completing 4, 6% completing 3, 4% completing 2, 3% completing 1, and 4% completing no follow-up assessments. Fifty multiple imputations, generated by using chained equations,24 were used for all analyses to address potential bias because of dropout.

Imbalance in Baseline Characteristics

In accordance with current recommendations, inverse probability of treatment weights were used to adjust for potential imbalance between conditions on baseline characteristics.25,26 Weights were generated by using boosted decision trees, a flexible, semiparametric ensemble modeling approach found to balance baseline characteristics among treatment conditions.27 Weights were stabilized by dividing the baseline probability of being assigned a treatment by the estimated probability from the boosted regression. Stabilized weights have been shown to improve performance in smaller samples.28 

Primary Analyses of Entire Sample

To assess the delay of sexual initiation, we used a Cox-proportional hazard model to test differences between conditions. Time in months from beginning the study to first vaginal event was calculated for each participant. Those who reported vaginal sex before beginning the study (HP = 12%, n = 24; ER = 9%, n = 20; χ2(1) = 1.09; P = .30) were not included. Multiple imputations were used to protect against violations of the independent censoring assumption of the proportional hazard model.29 

To assess the impact of the intervention on sexual risk behaviors, we used negative binomial models to evaluate behavioral counts of vaginal or anal sex acts through the 30-month follow-up. The sexual risk composite was evaluated by using logistic regression. Baseline values were not included in the models given the low rate of risk behavior at baseline.

Sexual Risk Behavior Among Sexually Active Youth

Subgroup analyses were conducted to determine whether the intervention had an impact on sexual risk behaviors among those who were sexually active. Sexual behavior was summed for the period from vaginal or anal sexual initiation (for some, this was baseline) to the end of the study for each participant. The rate of sexual behaviors across this period was evaluated by using negative binomial models. The risk composite was evaluated by using logistic regression.

Kaplan-Meier survival curves representing time to sexual initiation are presented in Fig 2. Of those who had not had sex at baseline, 68 participants in the HP condition (39%) and 63 participants in the ER condition (31%) reported having vaginal sex for the first time between baseline and the 30-month assessment. Controlling for school, we found that the adjusted hazard ratio (AHR) for the difference between conditions indicated a delay in the transition to vaginal sex over 30 months for participants in ER compared with participants in HP (AHR = 0.61; 95% confidence interval [0.42 to 0.89]).

FIGURE 2

Proportion of adolescents who initiated vaginal sex by intervention condition.

FIGURE 2

Proportion of adolescents who initiated vaginal sex by intervention condition.

Close modal

Unadjusted imputed means for cumulative (over 30 months) behavioral counts and probabilities for cumulative dichotomous outcomes along with adjusted odds ratios (aORs) and adjusted rate ratios (ARRs) of sexual risk behaviors are listed in Table 1. Effect sizes are depicted in Fig 3. ER participants were less likely than HP participants to endorse any behavior in the sexual risk composite during the 30-month follow-up (aOR = 0.52; 95% confidence interval [0.32 to 0.84]). ER participants were less likely than HP participants to endorse multiple partners in any 6-month period (aOR = 0.54; 95% confidence interval [0.30 to 0.99]) and less likely to endorse substance use before sex (aOR = 0.42; 95% confidence interval [0.23 to 0.75]). The groups exhibited less difference with respect to whether they had any condomless sex (aOR = 0.81; 95% confidence interval [0.45 to 1.45]). However, examination of the number of condomless sex acts by group indicated that ER participants reported fewer condomless vaginal or anal sex acts during follow-up than those in the HP condition (ARR = 0.36; 95% confidence interval [0.14 to 0.90]). They also reported fewer total vaginal or anal sex acts (ARR = 0.39; 95% confidence interval [0.20 to 0.77]).

TABLE 1

Imputed Means and Probabilities of Adolescent Sexual Behaviors Over 30 Months by Intervention Condition

Imputed Mean or Probability (95% CI)Adjusted Effect Sizea (95% CI)
ER (n = 222)HP (n = 198)
Full sample  
 No. vaginal or anal sex actsb 3.12 (1.55 to 4.69) 5.77 (2.51 to 9.03) ARR = 0.39 (0.20 to 0.77)* 
 No. condomless vaginal or anal sex actsb 1.28 (0.34 to 2.22) 3.46 (0.91 to 6.01) ARR = 0.36 (0.14 to 0.90)* 
 Any sexual risk behaviorc 0.21 (0.16 to 0.26) 0.29 (0.23 to 0.35) aOR = 0.52 (0.32 to 0.84)* 
 Any multiple partners (2+ in 6-mo period) 0.13 (0.09 to 0.17) 0.18 (0.12 to 0.24) aOR = 0.54 (0.30 to 0.99)* 
 Any condomless vaginal or anal sex 0.15 (0.10 to 0.20) 0.15 (0.10 to 0.20) aOR = 0.81 (0.45 to 1.45) 
 Any substance use before sex 0.13 (0.09 to 0.17) 0.20 (0.14 to 0.26) aOR = 0.42 (0.23 to 0.75)* 
Among sexually actived  
 No. vaginal or anal sex actsb,e 10.67 (2.87 to 18.47) 14.04 (6.61 to 21.47) ARR = 0.57 (0.32 to 0.99)* 
 No. condomless vaginal or anal sex actsb,e 5.71 (−1.32 to 12.74) 8.66 (2.49 to 14.83) ARR = 0.53 (0.24 to 1.17) 
 Any sexual risk behaviorc 0.50 (0.40 to 0.60) 0.58 (0.48 to 0.68) aOR = 0.66 (0.39 to 1.13) 
 Any multiple partners (2+ in 6-mo period) 0.30 (0.21 to 0.39) 0.36 (0.26 to 0.46) aOR = 0.70 (0.38 to 1.30) 
 Any condomless vaginal or anal sex 0.36 (0.26 to 0.46) 0.30 (0.21 to 0.39) aOR = 1.08 (0.59 to 1.97) 
 Any substance use before sex 0.30 (0.21 to 0.39) 0.40 (0.30 to 0.50) aOR = 0.52 (0.28 to 0.95)* 
Imputed Mean or Probability (95% CI)Adjusted Effect Sizea (95% CI)
ER (n = 222)HP (n = 198)
Full sample  
 No. vaginal or anal sex actsb 3.12 (1.55 to 4.69) 5.77 (2.51 to 9.03) ARR = 0.39 (0.20 to 0.77)* 
 No. condomless vaginal or anal sex actsb 1.28 (0.34 to 2.22) 3.46 (0.91 to 6.01) ARR = 0.36 (0.14 to 0.90)* 
 Any sexual risk behaviorc 0.21 (0.16 to 0.26) 0.29 (0.23 to 0.35) aOR = 0.52 (0.32 to 0.84)* 
 Any multiple partners (2+ in 6-mo period) 0.13 (0.09 to 0.17) 0.18 (0.12 to 0.24) aOR = 0.54 (0.30 to 0.99)* 
 Any condomless vaginal or anal sex 0.15 (0.10 to 0.20) 0.15 (0.10 to 0.20) aOR = 0.81 (0.45 to 1.45) 
 Any substance use before sex 0.13 (0.09 to 0.17) 0.20 (0.14 to 0.26) aOR = 0.42 (0.23 to 0.75)* 
Among sexually actived  
 No. vaginal or anal sex actsb,e 10.67 (2.87 to 18.47) 14.04 (6.61 to 21.47) ARR = 0.57 (0.32 to 0.99)* 
 No. condomless vaginal or anal sex actsb,e 5.71 (−1.32 to 12.74) 8.66 (2.49 to 14.83) ARR = 0.53 (0.24 to 1.17) 
 Any sexual risk behaviorc 0.50 (0.40 to 0.60) 0.58 (0.48 to 0.68) aOR = 0.66 (0.39 to 1.13) 
 Any multiple partners (2+ in 6-mo period) 0.30 (0.21 to 0.39) 0.36 (0.26 to 0.46) aOR = 0.70 (0.38 to 1.30) 
 Any condomless vaginal or anal sex 0.36 (0.26 to 0.46) 0.30 (0.21 to 0.39) aOR = 1.08 (0.59 to 1.97) 
 Any substance use before sex 0.30 (0.21 to 0.39) 0.40 (0.30 to 0.50) aOR = 0.52 (0.28 to 0.95)* 

Imputed means and probabilities estimates result is from 50 multiple imputations generated by using chained equations. CI, confidence interval.

a

aOR; ARR.

b

Behavioral counts converted into yearly rates.

c

“Any sexual risk behavior” defined by composite measure containing any multiple partners (in a 6-mo period), any condomless vaginal or anal sex, or any substance use in the 4 h before sex during the 30 mo study period.

d

Those who reported vaginal or anal sex at baseline or at any follow-up.

e

Behavioral counts from the assessment of vaginal or anal debut until the end of the 30 mo follow-up.

*

P < .05.

FIGURE 3

Treatment effects on adolescent sexual behaviors over 30 months.

FIGURE 3

Treatment effects on adolescent sexual behaviors over 30 months.

Close modal

Among adolescents who endorsed any vaginal or anal sexual experience during the study (ER: 43%; 95% confidence interval [36% to 50%]; HP: 50%; 95% confidence interval [43% to 57%]; aOR = 0.66; 95% confidence interval [0.42 to 1.02]), those in the ER condition were less likely to endorse any of the sexual risk composite behaviors (aOR = 0.66; 95% confidence interval [0.39 to 1.13]), although this did not reach statistical significance, nor did the group difference between those who endorsed multiple sexual partners in any 6-month period (aOR = 0.70; 95% confidence interval [0.38 to 1.30]). Sexually active ER participants were less likely than their HP counterparts to endorse using substances before sex (aOR = 0.52; 95% confidence interval [0.28 to 0.95]). ER adolescents also reported less frequent vaginal or anal sexual activity after sexual debut than HP adolescents (ARR = 0.57; 95% confidence interval [0.32 to 0.99]). Condomless vaginal or anal sex after debut did not reach statistical significance (ARR = 0.53; 95% confidence interval [0.24 to 1.17]), and groups were similar with regards to any occurrence of condomless sex (aOR = 1.08; 95% confidence interval [0.59 to 1.97]).

To explore the impact of mental health symptoms on treatment effect, we examined the endorsement of clinically significant symptoms (T-score ≥65) on any of the Youth Inventory-4 or Adolescent Symptom Inventory subscales as a potential moderator of the primary outcome (sexual initiation) and the presence of any sexual risk among those who were ever sexually active. Neither moderating effect was statistically significant, although the study was not powered for subgroup analysis. The effect sizes suggest relatively similar treatment effects on sexual initiation for participants with and without clinically significant symptoms (AHRno diagnosis = 0.60; 95% confidence interval [0.31 to 1.17]; AHRdiagnosis = 0.65; 95% confidence interval [0.42 to 0.99]). In contrast, regarding the presence of any sexual risk among participants who were ever sexually active, participants with clinically significant symptoms showed a stronger treatment effect (aORdiagnosis = 0.55; 95% confidence interval [0.30 to 1.04]) than those with lower levels of symptoms (aORno diagnosis = 1.01; 95% confidence interval [0.37 to 2.72]).

The inclusion of ER training in a small-group behavioral intervention reduced sexual risk behaviors among seventh-graders with suspected mental health symptoms over a 2.5-year follow-up beyond that achieved with more traditional health education. This was true across a range of behaviors, such as engaging in fewer condomless sex acts, being less likely to have multiple partners, and being less likely to use substances before sex. The intervention conditions were similar in design (ie, they used the same group format, core sexual health information, and interactive teaching techniques) but differed in content. ER skills appear relevant to early adolescent sexual decision-making and amenable to change in this developmental period.

The ER intervention appears to have reduced risk in the following 2 ways: delaying sexual activity and reducing sexual risk behaviors among sexually active youth. First, ER participants delayed onset of vaginal intercourse relative to peers. Teenagers in the HP group were 1.6 times more likely than teenagers in the ER group to initiate vaginal sex. The longer teenagers wait to have sex, the longer they postpone exposure to risk. Delaying the onset of sex beyond early adolescence has been associated with fewer sexual risk behaviors throughout adolescence and early adulthood.1,4 

Second, after participants became sexually active, those who learned ER strategies engaged in vaginal or anal sex less frequently and used substances before sex less often, which also reduces risk of STIs and pregnancy. In addition, although not statistically significant in the smaller sexually active subsample, the treatment effect for the rate of condomless sex acts was sizable (1.89 times higher for HP compared with ER), as were the effects for the sexual risk composite (1.52 times higher) and multiple partners (1.43 times higher). In exploratory analyses, it was also suggested that the treatment effect on sexual risk behaviors after debut may have been stronger among participants with clinically significant mental health symptoms.

With these findings, we suggest that building ER skills among vulnerable adolescents helps to delay sexual debut and reduce the number of sexual risk behaviors after debut. Because ER is a skill that could influence other adolescent risk behaviors such as substance use, violence, and truancy, addressing ER during this sensitive period in adolescent development promises significant public health benefits. The challenge is the scale-up and dissemination of ER interventions. Increasing the reach of programs in which health education is enhanced with emotion education may be an important step toward improving the lives of adolescents, because they are prone to beginning risk behavior. With this study, we selected identified at-risk youth, but additional approaches may be needed for dissemination. Integrating ER concepts into standard classroom-based health education could reach more youth, as well as innovate how young people learn to make health decisions. Other strategies might include mobile health (eg, via electronic games) or pairing ER with other interventions, such as parenting programs that might be used to teach ER skills to parents, who might then teach their children.

This study has limitations. Like many sexual risk studies, the data rely on self-reports. However, audio computer assisted self-interview was used to minimize biases. The sample was selected because of emotional and behavioral health symptoms and may not be generalizable to all early adolescents, although they are a population in need of effective intervention. Randomization was not at the individual level, allowing for the possibility of treatment confounders. Confounders were minimized by conditioning on school and baseline characteristics, but cohort effects may have existed. The sample may not be generalizable to other geographic regions. The measurement of sexual partners did not include identifiers, thus limiting the ability to examine the total number of partners across assessment windows. Finally, the study was powered to examine the delay of vaginal sex. As a result, a portion of the sample was not yet sexually experienced, providing less power for comparisons of sexual behaviors among the sexually active. Nonetheless, with the observed effect sizes, it is suggested that these, too, were influenced by the intervention in expected directions.

With this study, we reduced risk by intervening during the critical period of early adolescence (before the onset of most risk behavior) by using developmentally tailored strategies that may be generalizable to other health behaviors and continue to develop as adolescents gain greater cognitive and emotional maturity. Furthermore, the intervention was effective in teaching ER to adolescents challenged by these skills because of mental health difficulties. Enhancing ER during early adolescence represents a promising direction that deserves continued attention.

     
  • AHR

    adjusted hazard ratio

  •  
  • aOR

    adjusted odds ratio

  •  
  • ARR

    adjusted rate ratio

  •  
  • ER

    emotion regulation

  •  
  • HP

    health promotion

  •  
  • STI

    sexually transmitted infection

Dr Houck conceptualized and designed the study, coordinated and supervised data collection, interpreted analyses, and drafted the initial manuscript; Dr Barker conducted and interpreted analyses, assisted in drafting the manuscript, and reviewed and revised the manuscript; Dr Hadley assisted in drafting the manuscript, interpreted analyses, and reviewed and revised the manuscript; Ms Menefee assisted in drafting the manuscript and reviewed and revised the manuscript; Dr Brown conceptualized the study and reviewed the manuscript; and all authors approved the final manuscript as submitted.

This trial has been registered at www.clinicaltrials.gov (identifier NCT01197404).

FUNDING: Supported by National Institutes of Health grant R01 NR 011906 and by the Providence/Boston Center for AIDS Research (P30AI042853). Dr Barker’s time was supported by grant K23 MH102131. Funded by the National Institutes of Health (NIH).

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-4143.

1
Capaldi
DM
,
Stoolmiller
M
,
Clark
S
,
Owen
LD
.
Heterosexual risk behaviors in at-risk young men from early adolescence to young adulthood: prevalence, prediction, and association with STD contraction.
Dev Psychol
.
2002
;
38
(
3
):
394
406
[PubMed]
2
Magnusson
BM
,
Masho
SW
,
Lapane
KL
.
Adolescent and sexual history factors influencing reproductive control among women aged 18-44.
Sex Health
.
2011
;
8
(
1
):
95
101
[PubMed]
3
Kaestle
CE
,
Halpern
CT
,
Miller
WC
,
Ford
CA
.
Young age at first sexual intercourse and sexually transmitted infections in adolescents and young adults.
Am J Epidemiol
.
2005
;
161
(
8
):
774
780
[PubMed]
4
Sandfort
TG
,
Orr
M
,
Hirsch
JS
,
Santelli
J
.
Long-term health correlates of timing of sexual debut: results from a national US study.
Am J Public Health
.
2008
;
98
(
1
):
155
161
[PubMed]
5
Gross
JJ
. Emotion regulation: conceptual and empirical foundations. In:
Gross
JJ
, ed.
Handbook of Emotion Regulation
. 2nd ed.
New York, NY
:
Guilford Press
;
2014
:
3
20
6
Chein
J
,
Albert
D
,
O’Brien
L
,
Uckert
K
,
Steinberg
L
.
Peers increase adolescent risk taking by enhancing activity in the brain’s reward circuitry.
Dev Sci
.
2011
;
14
(
2
):
F1
F10
[PubMed]
7
Crone
EA
,
Dahl
RE
.
Understanding adolescence as a period of social-affective engagement and goal flexibility.
Nat Rev Neurosci
.
2012
;
13
(
9
):
636
650
[PubMed]
8
Suleiman
AB
,
Brindis
CD
.
Adolescent school-based sex education: using developmental neuroscience to guide new directions for policy and practice.
Sex Res Soc Policy
.
2014
;
11
(
2
):
137
152
9
Brown
LK
,
Houck
C
,
Lescano
C
,
Donenberg
G
,
Tolou-Shams
M
,
Mello
J
.
Affect regulation and HIV risk among youth in therapeutic schools.
AIDS Behav
.
2012
;
16
(
8
):
2272
2278
[PubMed]
10
Hessler
DM
,
Katz
LF
.
Brief report: associations between emotional competence and adolescent risky behavior.
J Adolesc
.
2010
;
33
(
1
):
241
246
[PubMed]
11
Raffaelli
M
,
Crockett
LJ
.
Sexual risk taking in adolescence: the role of self-regulation and attraction to risk.
Dev Psychol
.
2003
;
39
(
6
):
1036
1046
[PubMed]
12
Dahl
RE
.
Affect regulation, brain development, and behavioral/emotional health in adolescence.
CNS Spectr
.
2001
;
6
(
1
):
60
72
[PubMed]
13
Hipwell
AE
,
Keenan
K
,
Loeber
R
,
Battista
D
.
Early predictors of sexually intimate behaviors in an urban sample of young girls.
Dev Psychol
.
2010
;
46
(
2
):
366
378
[PubMed]
14
Schofield
HL
,
Bierman
KL
,
Heinrichs
B
,
Nix
RL
;
Conduct Problems Prevention Research Group
.
Predicting early sexual activity with behavior problems exhibited at school entry and in early adolescence.
J Abnorm Child Psychol
.
2008
;
36
(
8
):
1175
1188
[PubMed]
15
Brooks
TL
,
Harris
SK
,
Thrall
JS
,
Woods
ER
.
Association of adolescent risk behaviors with mental health symptoms in high school students.
J Adolesc Health
.
2002
;
31
(
3
):
240
246
[PubMed]
16
DiClemente
RJ
,
Wingood
GM
,
Crosby
RA
, et al
.
A prospective study of psychological distress and sexual risk behavior among black adolescent females.
Pediatrics
.
2001
;
108
(
5
). Available at: www.pediatrics.org/cgi/content/full/108/5/e85
[PubMed]
17
Elkington
KS
,
Bauermeister
JA
,
Zimmerman
MA
.
Psychological distress, substance use, and HIV/STI risk behaviors among youth.
J Youth Adolesc
.
2010
;
39
(
5
):
514
527
[PubMed]
18
Houck
CD
,
Barker
DH
,
Hadley
W
, et al
.
The 1-year impact of an emotion regulation intervention on early adolescent health risk behaviors.
Health Psychol
.
2016
;
35
(
9
):
1036
1045
[PubMed]
19
Houck
CD
,
Hadley
W
,
Barker
D
,
Brown
LK
,
Hancock
E
,
Almy
B
.
An emotion regulation intervention to reduce risk behaviors among at-risk early adolescents.
Prev Sci
.
2016
;
17
(
1
):
71
82
[PubMed]
20
Merikangas
KR
,
He
JP
,
Burstein
M
, et al
.
Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A).
J Am Acad Child Adolesc Psychiatry
.
2010
;
49
(
10
):
980
989
[PubMed]
21
Gadow
KD
,
Sprafkin
J
.
Adolescent Supplement to the Child Symptom Inventories Manual
.
Stony Brook, NY
:
Checkmate Plus
;
1995
22
Arnup
SJ
,
Forbes
AB
,
Kahan
BC
,
Morgan
KE
,
McDonald
S
,
McKenzie
JE
.
The use of the cluster randomized crossover design in clinical trials: protocol for a systematic review.
Syst Rev
.
2014
;
3
:
86
[PubMed]
23
Brown
LK
,
Houck
C
,
Donenberg
G
,
Emerson
E
,
Donahue
K
,
Misbin
J
.
Affect management for HIV prevention with adolescents in therapeutic schools: the immediate impact of project balance.
AIDS Behav
.
2013
;
17
(
8
):
2773
2780
[PubMed]
24
van Buuren
S
,
Groothuis-Oudshoorn
K
.
mice: multivariate imputation by chained equations in R.
J Stat Softw
.
2011
;
45
(
3
):
1
67
25
Austin
PC
,
Stuart
EA
.
Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies.
Stat Med
.
2015
;
34
(
28
):
3661
3679
[PubMed]
26
Austin
PC
.
The use of propensity score methods with survival or time-to-event outcomes: reporting measures of effect similar to those used in randomized experiments.
Stat Med
.
2014
;
33
(
7
):
1242
1258
[PubMed]
27
McCaffrey
DF
,
Ridgeway
G
,
Morral
AR
.
Propensity score estimation with boosted regression for evaluating causal effects in observational studies.
Psychol Methods
.
2004
;
9
(
4
):
403
425
[PubMed]
28
Thoemmes
F
,
Ong
AD
.
A primer on inverse probability of treatment weighting and marginal structural models.
Emerg Adulthood
.
2016
;
4
(
1
):
40
59
29
Jackson
D
,
White
IR
,
Seaman
S
,
Evans
H
,
Baisley
K
,
Carpenter
J
.
Relaxing the independent censoring assumption in the Cox proportional hazards model using multiple imputation.
Stat Med
.
2014
;
33
(
27
):
4681
4694
[PubMed]

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.