Intervention Summary

Project TALC (Teens and Adults Learning to Communicate)

Teens and Parents Parents Learning to Communicate (Project TALC) was initiated to support parents living with HIV/AIDS and their adolescent children, and to build communication skills between them. The program was originally developed before antiretroviral therapies were available; at that time, most parents were expected to die in about one year. The intervention is based on social learning theory, which posits that people change their behavior by taking small steps slowly over time, in response to opportunities and rewards. The intervention has three main foci: (1) responding to one's serostatus (especially negative emotions of anger, depression, hurt, and hopelessness); (2) parenting while ill; and (3) post-death adjustment (when adolescents had new caregivers).

The intervention consists of a series of small group sessions. Each session is held over a one day period. Parents meet together for eight sessions (phase I) and focus on adapting to their HIV status, maintaining healthy lifestyles, coping with negative feelings related to the diagnosis, and making decisions about disclosing their status to others. In the next series of sessions (phase 2), parents and their adolescent children are invited to attend; some sessions are joint and others deal separately with parents and adolescents. Phase 2 aims to reduce the parent's emotional distress, support positive family routines, help their children avoid high-risk behaviors, and make custody plans for their children. Phase 2 also aims to improve the adolescents' coping with the parent's HIV diagnosis and possible death, learn skills to reduce high-risk behaviors (e.g., sexual, substance use acts, and teenage pregnancy), and to reduce emotional distress. If a parent dies, phase 3—which focuses on grief, bereavement, and setting new life goals—is delivered to new caregivers and adolescents.

Adolescents are invited to attend Project TALC only if their parents have disclosed their HIV-positive status to them. Each participant receives a workbook to record their individual goals and accomplishments during the program. To facilitate program participation, transportation assistance, child-care, and meals are provided. Participants who miss a session can take part in a makeup session. The program developers train lay personnel—typically graduate students—for two weeks on how to implement the program in a manner detailed in the implementation manual and provide ongoing training.

Descriptive Information

Areas of Interest	Mental health promotion Substance use disorder prevention Co-occurring disorders
Outcomes	1: Problem Behaviors 2: Emotional Distress 3: Conduct Behavior 4: Drug Dependency
Outcome Categories	Alcohol Crime/delinquency Drugs Education Family/relationships Mental health Social functioning
Ages	6-12 (Childhood) 13-17 (Adolescent) 18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)
Genders	Male Female
Races/Ethnicities	American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or other Pacific Islander White Race/ethnicity unspecified Non-U.S. population
Settings	Other community settings
Geographic Locations	Urban
Implementation History	Project TALC was originally implemented in New York City with 304 families referred through the Division of AIDS Services of New York. The program was implemented a second time in Los Angeles. More than 300 HIV positive mothers and 259 adolescents participated in TALC LA.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	An updated version of Project TALC has been implemented in Los Angeles. Updates were incorporated to reflect the current state of medicine: most people living with HIV now have access to antiretroviral therapies, which was not the case during the original study.
Adverse Effects	No adverse effects were identified.
IOM Prevention Categories	Selective Indicated

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Rotheram-Borus, M.J., Lee, M., Leonard, N., Lin, Y-Y., Franzke, L., Turner, E., Lightfoot, M., & Gwadz, M. Four-year behavioral outcomes of an intervention for parents living with HIV and their adolescent children. AIDS, 17, 1217-1225.

Supplementary Materials

Rotheram-Borus, M.J., Lee, M.B., Gwadz, M., & Draimin, B. An intervention for parents with AIDS and their adolescent children. American Journal of Public Health, 91(8), 1294-1302.

Rotheram-Borus, M.J., Lee, M., Lin, YY, & Lester, P. Six-year intervention outcomes for adolescent children of parents with the human immunodeficiency virus. Archives of Pediatric Adolescent Medicine, 158, 742-748.

Derogatis, L.R., & Melisaratos, N. Brief symptom inventory. Psychological Medicine 13, 595-605.

Outcomes

Outcome 1: Problem Behaviors
Description of Measures	Adolescents and parents completed separate multiple problem checklists. For adolescents, the following problem behaviors were rated as present "recently" (1) or not (0): unprotected sex, alcohol use, drug use, contact with the criminal justice system, trouble at school, and not being enrolled in school. For parents, recent multiple problem behaviors—similar to the adolescents' report, but without the school items—were assessed. The multiple problem checklist was used to collect data every three months for first two years, and then at six-month intervals for a total of 48 months. Items were summed to generate an average score for problem behaviors.
Key Findings	For adolescents, problem behaviors decreased more among intervention participants compared with those in the standard care group during months 3 to 21 after the intervention (p < .0001, effect size = -0.4294), but effects eroded over time and were not significant from months 21 to 48. For parents, problem behaviors decreased more among those in the intervention group than those in the standard care group during months 3 to 21 (p < .05, effect size = -0.2738), but increased in the intervention group compared to standard care from months 21 to 48. Problem behaviors were assessed, controlling for demographic characteristics. For adolescents, parental death was controlled as a time-varying covariate. Effect sizes (Cohen's d) reflect differences in adjusted mean estimates between intervention and comparison group from random effects models that take into account the repeated measures, divided by the standard deviation for the baseline value in the standard care condition.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.2 (0.0-4.0 scale)

Outcome 2: Emotional Distress
Description of Measures	Symptoms of emotional distress over the last week were assessed for adolescents and parent living with HIV using the Brief Symptom Inventory (BSI). Items were rated on a scale from 0 to 4; higher scores indicate more distress. The outcome was measured every three months for the first two years, and then at six-month intervals.
Key Findings	For adolescents, emotional distress decreased more from months 3 to 15 among intervention participants than among those in the standard care group, but effects eroded over time and were not significant from months 15 to 48. For parents, emotional distress decreased more among parents in the intervention group than those in standard care group from months 3 through 15 (p < .01, effect size = -0.40374), but effects eroded over time and were not significant from months 15 to 48. Emotional distress was assessed, controlling for demographic characteristics. For adolescents, parental death was controlled as a time-varying covariate. Effect sizes (Cohen's formula) reflect differences in adjusted mean estimates between intervention and comparison group from random effects models that take into account the repeated measures, divided by the standard deviation for the baseline value in the standard care condition.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.2 (0.0-4.0 scale)

Outcome 3: Conduct Behavior
Description of Measures	Conduct behavior was assessed by summing the presence of 18 recent conduct behaviors. The conduct measures were based on the Child Behavior Checklist (CBCL). Items were measured every three months for the first two years, and then at six-month intervals.
Key Findings	For adolescents, conduct problems decreased more among those in the intervention than those in the standard care group from months 3 to 21 (p < .01, effect size = -0.3526), but effects eroded over time and were not significant from months 21 to 48. Conduct behavior was assessed, controlling for demographic characteristics. Parental death was controlled as a time-varying covariate.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.4 (0.0-4.0 scale)

Outcome 4: Drug Dependency
Description of Measures	Parents' self-reported drug dependency was assessed using items adapted from the NIDA National Household Survey on Drug Abuse (NIDA). It assesses a wide variety of substances (e.g., alcohol, marijuana, cocaine/crack, and heroin) and includes questions about age of initiating use, most recent use, duration of use, most frequent use, and method of ingestion. The study measured drug dependency by the presence or absence of dependency on drugs and relapse into use. The measure was assessed every three months for the first two years, and then at six-month intervals for a total of 48 months.
Key Findings	Controlling for reported drug dependency at the start of the intervention, fewer parents in the intervention group reported drug dependency at 48 months compared with parents in the standard care group (8% vs. 13.1%, p < 0.05).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.2 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	6-12 (Childhood) 13-17 (Adolescent) 18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	64% Female 36% Male	48% Hispanic or Latino 36% Black or African American 10% Race/ethnicity unspecified 6% White 0% American Indian or Alaska Native 0% Asian 0% Native Hawaiian or other Pacific Islander 0% Non-U.S. population

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Problem Behaviors	0.0	2.0	2.5	1.5	3.5	3.5	2.2
2: Emotional Distress	4.0	4.0	2.5	1.5	3.5	3.5	3.2
3: Conduct Behavior	1.0	2.5	2.5	1.5	3.5	3.5	2.4
4: Drug Dependency	0.0	2.0	2.5	1.5	3.5	3.5	2.2

Study Strengths

This was a very rigorous clinical trial, and the analyses based on this trial are rigorous as well. The study Project TALC used a randomized design, had a reasonably large sample size, and collected follow-up assessments over several years. Most of the measures used in this study were suitable to assess the outcomes of interest. The intervention is described in acceptable detail, an implementation manual is available, and fidelity was monitored.

Study Weaknesses

Four of the five outcomes rated lacked evidence of reliability (conduct problems, problem behaviors, and drug dependency). Although the principal investigator stated that conduct behavior and drug dependency measures were derived from the Achenbach Child Behavior Checklist (CBCL) and National Institute on Drug Abuse's National Household Survey on Drug Abuse (NHSDA), the items described in the papers were adapted and do not align with the actual CBCL or NHSDA specifications. More details on the fidelity measures used (or use of more rigorous measures) would provide more support for fidelity. The investigators removed any case that had missing data from the analyses; this "casewise deletion" approach to handling attrition may lead to biased estimates. Potential confounding variables were not mentioned.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

The implementation manual is a session-by-session curriculum with scripts that provide detailed instructions for how the intervention is to be implemented by program staff. The implementation materials reviewed included the following documents accessed in the fall of through the project website.

Phase 1. Taking Care of Myself

Parents' curriculum

1. TALC LA - session 1: Coping with My Illness

2. TALC LA - session 2: Coping with My Fear

3. TALC LA - session 3: Coping with Anger

4. TALC LA - session 4: Coping with Sadness

5. TALC LA - session 5: Coping with the Meaning of My Illness

6. TALC LA - session 6: Coping with Whether to Tell

7. TALC LA - session 7: Coping with Telling Others

8. TALC LA - session 8: Coping with the Future

Phase 2. Illness

Parents' curriculum

1. TALC LA - session 1: What Are My Children's Needs?

2. TALC LA - session 2: Who Will Take Care of My Children?

3. TALC LA - session 3: What Kind of Arrangements Can I Make?

4. TALC LA - session 4: How Do I Start My Plan?

5. TALC LA - session 5: How Can I Really Listen to My Children?

6. TALC LA - session 6: How Can I Tell My Children What I Feel?

7. TALC LA - session 7: How Should I Deal with Problem Behavior?

8. TALC LA - session 8: How Can We Create a Positive Atmosphere at Home?

9. TALC LA - session 9: How Can We Resolve Conflicts at Home? (part 1)

10. TALC LA - session 10: How Can We Resolve Conflicts at Home? (part 2)

11. TALC LA - session 11: How Can We Work Together on Selecting a Custodian?

12. TALC LA - session 12: How Can We Deal with Drugs and Alcohol?

13. TALC LA - session 13: How Do I Prevent Pregnancy and Fatherhood?

14. TALC LA - session 14: Where Am I in Making a Custody Plan?

15. TALC LA - session 15: How Can Mothers Encourage Safer Sex?

16. TALC LA - session 16: What Is the Mother's Legacy and the Youth's Goals?

Adolescents' curriculum

1. TALC LA - session 1: How Do I Make Sense of My Mother's Illness?

2. TALC LA - session 2: Should I Tell Someone My Mother Has AIDS?

3. TALC LA - session 3: How Can I Deal with Stigma?

4. TALC LA - session 4: How Do I Deal with Fear?

5. TALC LA - session 5: How Can I Cope with Feeling Sad?

6. TALC LA - session 6: What If I Feel Angry?

7. TALC LA - session 7: What Can I Do about Feeling Angry?

8. TALC LA - session14: How Can We Encourage Safer Sex?

Phase 3. Adjustment

New caregivers and teens' curriculum

1. TALC LA - session 1: What Do Adolescents and Caregivers/Parents Need from Each Other?

2. TALC LA - session 2: What Role Am I Playing and What Is Expected of Me?

3. TALC LA - session 3: Dealing with Loss and Grief (part I)

4. TALC LA - session 4 (caregivers): Raising an Adolescent

5. TALC LA - session 4 (youths): Planning for My Future (part I)

6. TALC LA - session 5: Dealing with Loss and Grief (part II)

7. TALC LA - session 6: How Can We Improve Communication (part I; effective expressing)

8. TALC LA - session 7: Ways of Helping Someone Cope with Loss and Grief

9. TALC LA - session 8: How Can We Improve Communication (part II; active listening and responding)

10. TALC LA - session 9 (caregivers): Caregiver Support

11. TALC LA - session 9 (youths): How Do I Achieve My Goals?

12. TALC LA - session 10: (joint) How Can We Deal with Anger in the Relationship?

13. TALC LA - session 11: How Can I Cope with Sadness?

14. TALC LA - session 12 (caregivers): How Should I Deal with Problem Behavior?

15. TALC LA - session 12 (youths): How Do I Deal with Fear?

16. TALC LA - session 13: How Do We Practice Safer Sex, Prevent Pregnancy, and Reduce Alcohol and Drug Use?

17. TALC LA - session 14: How Can We Resolve Conflicts at Home?

18. TALC LA - session 15: How Can We Create a Positive Atmosphere at Home?

19. TALC LA - session 16: Looking to the Future Together, What Can We Do?

Young adults' curriculum

1. TALC LA - session 1: How Are Things Going?

2. TALC LA - session 2: Planning for My Future (part I)

3. TALC LA - session 3: Dealing with Loss and Grief (part I)

4. TALC LA - session 4: Where and How Can Young People Get Support?

5. TALC LA - session 5: Dealing with Loss and Grief (part II)

6. TALC LA - session 6: Ways of Coping with Loss and Grief

7. TALC LA - session 7: Planning for My Future (part II; How Do I Achieve My Goals?)

8. TALC LA - session 8: Hearing and Getting Heard

9. TALC LA-session 9: How Can We Deal with Anger?

10. TALC LA - session 10: Relationships and Sex (part 1)

11. TALC LA - session 11: Relationships and Sex (part 2)

12. TALC LA - session 12: How Can I Cope with Sadness?

13. TALC LA - session 13: Pregnancy and Parenthood

14. TALC LA - session 14: How Do I Deal with Fear?

15. TALC LA - session15: How Can I Reduce Substance Use?

16. TALC LA - session 16: Looking to the Future

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
3.8	2.5	2.0	2.8

Dissemination Strengths

The implementation manual was easy to follow and understand. Training and support is available. The quality assurance procedures are adequate.

Dissemination Weaknesses

The materials do not address the fact that transmission modes have changed over time and, specifically, that the primary mode of transmission of HIV among communities of color is among men who have sex with other men who identify as bisexual. Some words used in the manual may be challenging for people with lower levels of literacy. Mechanisms for ongoing supervision, who receives training, the length or the training, and the cost of training are not described. Protocols for gathering process and outcome data are not available. Information about monitoring implementation fidelity is not provided.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
The implementation manual is a session-by-session curriculum with scripts that provide detailed instructions for how the intervention is to be implemented by program staff.	$0	Yes
No cost structure is in place for training, technical assistance, quality assurance or fidelity monitoring. Requests are usually referred to consultants	Estimated consultant fee: $5000	No

Additional Information

All implementation materials can be accessed for free online.