Quality of parent communication about sex and its relationship to risky sexual behavior among youth in psychiatric care: a pilot study

A dramatic rise in teenage sexual activity over recent decades and high rates of risky sexual behavior, including sex with multiple partners and inconsistent condom use, have placed adolescents at increased risk of HIV and other sexually transmitted diseases (Centers for Disease Control and Prevention, 2000). Youth seeking psychiatric care are at especially high risk because they are more likely than other teens to be sexually active, more likely to have multiple partners, and less likely to use condoms (Brown, Danovsky, Lourie, DiClemente, & Ponton, 1997; Donenberg, Emerson, Bryant, Wilson, & Weber-Shifrin, 2001). Thus, understanding factors related to high-risk sexual behavior among adolescents in psychiatric care is an important step in developing prevention and intervention programs to impede the spread of HIV among these youth. The family is one of the earliest and most important influences on adolescent sexual development and sexual socialization (Perrino, Gonzalez-Soldevilla, Pantin, & Szapocnik, 2000) and plays an important role in sexual risk-taking among teens in psychiatric care (e.g., Donenberg, Wilson, Emerson, & Bryant, 2002). One parental influence that has received a great deal of attention regarding its relationship to adolescent sexual risk-taking is parent–adolescent communication. Theory suggests that the quantity and quality of parent communication plays a crucial role in the extent that parents influence their children (Neapolitan, 1981) and bears great potential for reducing adolescent risky sexual behavior by fostering responsible sexual decision-making (Rodgers, 1999). Studies assessing the relationship between parent–teen communication about sex and adolescent sexual behavior have conceptualized communication in a variety of ways, including whether or not it has occurred, its frequency, how much information is conveyed, the content of communication, and the quality or process. The most consistent findings for normally-developing youth suggest that the quality of parent–teen sexual communication is more relevant to reducing risky sexual behavior than other dimensions of the communication process. Specifically, parent–teen communication that is open, receptive, and comfortable is associated with less sexual experience and less risky sexual behavior among adolescents (e.g., Dutra, Miller, & Forehand, 1999; East, 1996; Miller, Norton, Fan, & Christopherson, 1998; Whitaker, Miller, May, & Levin, 1999). Other findings based on retrospective reports of adults and college students suggest that parent communication about sex during childhood and adolescence characterized as more friendly, impression-leaving, attentive, and open and less judgmental, prohibitive, contentious, and dramatic is associated with less sexual behavior and sexual risk-taking during adolescence (Mueller & Powers, 1990; Ward & Wyatt, 1994). Overall, the research suggests that how parents communicate with their teenagers is more important than whether, how frequently, or to what extent they discuss these issues. Research on family factors related to HIV-risk behavior among youth in psychiatric treatment has largely ignored the role of parent–teen communication. Communication in families affected by mental health problems is often strained (Brown et al., 1997), however, and some of the same maladaptive communication patterns associated with adolescent psychopathology are also related to risky sexual behavior. For example, less open and more problematic communication is associated with adolescent depression (Tulloch, Blizzard, & Pinkus, 1997), and communication between parents and youth with externalizing problems has been characterized as hostile and negative (Donenberg & Weisz, 1997; Heller & Baker, 2000). Elevated rates of risky sexual behavior among youth in psychiatric care may be due to or maintained in part by dysfunctional parent–teen communication patterns. Thus, understanding how these factors are linked for youth in psychiatric treatment is an important step in designing appropriate interventions to target this vulnerable group of teens and their families. In addition to addressing a high-risk, yet understudied, group of teenagers, this small-scale pilot study uses behavioral observations, a highly informative yet underutilized methodology, to examine the parent–teen communication process. All of the studies assessing the relationship between parent–teen communication quality and adolescent sexual risk-taking have relied on self-report scales or interviews to assess the quality of parent–adolescent communication about sex. Self-report data, however, are subject to a variety of biases and may not accurately reflect the nature of parent–child communication. Some researchers have used observational techniques to examine the relationship between parent communication about AIDS-related issues and adolescents’ knowledge and attitudes about AIDS (Leftkowitz, Kahlbaugh, Au, & Sigman, 1998; Whalen, Henker, Hollingshead, & Burgess, 1996), but we have found no studies to date that employ observational methods to explore the relationship between parent communication about sex- and AIDS-related issues and troubled adolescents’ sexual risk-taking. The present study is a pilot effort to clarify the link between parent–teen communication and risky sexual behavior for youth in psychiatric treatment using a multidimensional approach to examine both the quality and frequency of communication. We hypothesized that the quality of parents’ communication about sex would predict adolescent sexual risk-taking better than the self-reported frequency of their conversations about sex, birth control, and HIV/AIDS. The literature cited above suggests that more responsible sexual behavior occurs when communication with parents is more open, receptive, comfortable, friendly, attentive, and impression-leaving, and less dramatic, contentious, judgmental, or prohibitive. Based on these findings with normally developing adolescents, we expected less risky sexual behavior among troubled teens whose parents engaged in more open and receptive, or mutual, discussions with them, were more supportive, were less directive, were less withdrawn, and showed less disagreement. These 5 codes were chosen specific-ally for this study because literature supports their association with sexual risk-taking (e.g., Dutra, Miller, & Forehand, 1999; East, 1996; Miller, Norton, Fan, & Christopherson, 1998; Mueller & Powers, 1990; Ward & Wyatt, 1994; Whitaker, Miller, May, & Levin, 1999).