The prevalence of sexually transmitted infections (STIs) and pregnancy among teenagers in the United States remains higher than in other developed countries.1 New HIV infections occur particularly among sexual minority youth,2 and STIs disproportionately affect African American and Latino youth.1,2 In this issue of Pediatrics, Houck et al3 make an important contribution to our understanding of strategies to reduce risk of STIs and HIV among teenagers by testing the impact of an after-school intervention that is used to address emotional regulation skills within the context of decision-making about sexual behaviors.
The intervention is designed to help young people recognize the relationship between emotions and behaviors and regulate positive and negative emotions during moments of sexual decision-making using 3 specific strategies (“get out,” “let it out,” and “think it out”). Games and role-plays enable teenagers to practice the strategies in risk scenarios. The twelve 1 hour-long, small-group, single-sex sessions also included comprehensive information about sexual health and were followed by 6- and 12-month boosters. The comparison group was matched for time and used similar activities to cover broad adolescent health topics. It included the same sexual health content as the active intervention but with no discussion of emotions. The use of boosters is important because this recognizes the need for intervention updates given the rapid developmental changes in middle school youth. However, having 12 sessions with trained facilitators might not be feasible outside of grant-funded research programs.
Outcomes from this project included time to initiation of vaginal or anal sex and, among those who had initiated sex after enrollment, a variety of measures associated with risk of STIs or pregnancy. A strength of this study is that it was not specific to 1 sex (boys or girls) and allowed for both opposite- and same-sex encounters. Given the focus on the delay of first intercourse, the primary analyses excluded adolescents who had already engaged in sexual intercourse at study initiation. This is a relative weakness of the study in that it excludes the early initiators of intercourse who are most at risk and influences the external validity of the study.
Results revealed that participants in the emotional regulation group delayed the transition to vaginal sex over the 30-month follow-up interval. In analyses that were focused on sexually active youth, the emotional regulation intervention revealed favorable impacts on the frequency of sexual activity after sexual debut and substance use before sex. 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. Behavioral decision theory implicates the role of adolescent cognitions about engaging in sex, norms and peer pressure, and adolescent image prototypes surrounding sex.4,–6 Although the role of emotions has also been acknowledged,4,5 there are few randomized control trials in which researchers isolate the exclusive effects of emotion regulation on early adolescent sexual behavior, as Houck et al3 have done.
Evidence reveals that the long-term effects of the program are promising. Evaluating the generalizability of these effects to broader student populations would be helpful. It would be useful for future researchers to identify specific components of the intervention that did versus did not contribute to outcomes, which would allow for streamlining the number of intervention sessions and reducing program costs to schools.
As interventions used to address emotional regulation are developed, it is important to note that although generalized emotional regulation strategies of the type used by Houck et al3 have merit, there also is growing evidence of the need to understand how to influence specific emotions in specific contexts.7 Researchers in cognitive science have firmly established 2 appraisal systems that operate in any given (sexual) situation.8,–10 The first is a cognitive appraisal system, in which people interpret the situation they are in, making note of who is present and what people’s intentions and orientations are, and formulate other cognitions about the setting. The second is an affective appraisal system, in which people are alerted to the emotions, feelings, and affective reactions they are experiencing. Such cognitive and emotional appraisals happen at lightning-fast speeds, often automatically. These cognitive and affective appraisals enter working memory and ultimately form the bases of the (sometimes split-second) decisions people make. 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. This will allow us to meet the challenge of helping adolescents practice cognitive and emotional appraisal and/or regulation skills and then apply these skills in multiple real-life scenarios in a way that reduces the risk of STIs, HIV, and pregnancy. The research by Houck et al3 is an important first step in this direction.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-2525.
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.