From the Journals

Emotional regulation training lowers risk of adolescents having sex

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Let’s talk about sex ... mitigation strategies?

The work of Houck et al. provides an important contribution in understanding strategies to reduce sexually transmitted infections (STIs) and HIV in adolescents by utilizing emotional regulation skills.

By helping young people understand their emotions and how that relates to behavior in the context of a sexual encounter, the after school intervention program helped teens regulate positive and negative emotions. Specifically, it utilized three strategies: get out, let it out, and think it out. Games and role playing gave teens a chance to practice these strategies in scenarios of varying risk.

Teenagers who underwent emotional regulation training, rather than simply being taught about adolescent health topics, fared much better in reducing the transition to vaginal sex over a 30-month period.

Carol Ford, MD, and her colleague James Jaccard, PhD, pointed out the superiority of the emotional training, compared with just sexual health information.

“Together, these findings reveal the importance of gearing more attention toward emotions and the regulation of emotions when developing interventions aimed at influencing adolescent sexual behavior,” they wrote. “Behavioral decision theory implicates the role of adolescent cognitions about engaging in sex, norms and peer pressure, and adolescent image prototypes surrounding sex.‍”

More broadly, Dr. Ford and Dr. Jaccard, believe that this research is the beginning to designing better interventions.

“As we come to understand the types of cognitions and emotions that dominate working memory in high-risk sexual situations, we can effectively design interventions that help shape cognitive and affective appraisals and how youth process those appraisals when making choices.”

Carol Ford, MD, is the chief of the Craig-Dalsimer Division of Adolescent Medicine at the Children’s Hospital of Philadelphia; she holds the Orton P. Jackson Endowed Chair in Adolescent Medicine. James Jaccard, PhD, is a professor of social work at New York University Silver School of Social Work. This is a summary of their commentary that accompanied the article by Houck et al. (Pediatrics. 2018 May 10. doi: 10.1542/peds.2017-4143). They had no financial disclosures, and there was no external funding.



Emotional regulation (ER) skills training lowers the likelihood that young adolescents with mental health symptoms will have vaginal sex.

“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,” wrote Chistopher Houck, PhD, and his colleagues at Bradley Hasbro Children’s Research Center, Providence, R.I., in Pediatrics. “This was true across a range of behaviors, such as engaging in fewer condom-less sex acts, being less likely to have multiple partners, and being less likely to use substances before sex.”

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Dr. Houck and his colleagues recruited 420 seventh grade students aged 12-14 years from five urban Rhode Island middle schools between September 2009 and February 2012. Students were referred to the study by school personnel who utilized a form to make counseling referrals to determine whether students were eligible for the study. This form asked about symptoms related to behavioral and emotional concerns, such as hyperactivity, withdrawal, and nervousness. Adolescents in the study completed audio computer-assisted self-interviews at baseline and every 6 months until the 30-month mark.

Students in the study participated in one of two after school intervention programs, either ER or health promotion (HP). Both programs consisted of 12 twice-weekly, hour-long sessions composed of single-sex groups of 4-8 adolescents. Two follow-up sessions were provided for both groups at 6 and 12 months. Both interventions used identical techniques, such as interactive games, videos, group discussions, and workbook assignments. ER sessions focused more on recognizing feelings, strategies for reducing momentary emotional arousal, and sexual health topics. HP exclusively focused on health topics like sexual risk and substance abuse but did not include emotional education.

During the 30-month study, 63 in the ER group (31%) and 68 students in the HP group (39%) reported having vaginal sex for the first time. This equated to an adjusted hazard ratio that indicated a delay in vaginal sex in the ER group (0.61; 95% confidence interval,0.42-0.89). Overall, students in the ER group were much less likely to endorse risky sexual behaviors than did participants in the HP group: Students in the ER group were less likely to endorse any risky sexual behavior (adjusted odds ratio, 0.52; 95% CI, 0.32-0.84), to support having multiple partners within 6 months (aOR, 0.54; 95% CI, 0.30-0.99), and to support the use of drugs before sex (aOR, 0.42; 95% CI, 0.23-0.75). Students in the ER group also reported fewer condom-less sex acts, compared with students in the HP group (adjusted rate ratio, 0.36; 95% CI, 0.14-0.90).

According to Dr. Houck and his colleagues, this study had several limitations that are common to sexual risk studies. One limitation is the reliance on self-report data, which can be biased. Dr. Houck and his associates utilized computer-assisted self-interviews to minimize biases. Another, and potentially larger, limitation is that the study was powered to assess delay of vaginal sex. Part of the patient sample was not sexually experienced, which provided less power for comparisons to other sexual behaviors.

Dr. Houck and his colleagues also spoke to the potential that ER training has in reducing risky behaviors of adolescents, as well as the issues in implementing it.

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