In 1989 Dr. Diaz conducted a 1-year survey of her female patients for history of sexual abuse. Related questions were incorporated into her initial face-to-face intake clinical interview. Of 141 girls seen by Dr. Diaz during that study period, 23% revealed a history of sexual maltreatment when directly asked. Sixty-six percent of those who disclosed sexual abuse reported being survivors of incest.

Under a National Institutes of Health (NIH) K23 Career Award in 2002, Dr. Diaz compared four different methods of screening for physical and sexual abuse in a primary care setting. The screening methods included an audio computer-assisted self-interview (ACASI), paper-and pencil self-administered questionnaire, clinician structured interview (all three using the same questionnaire), and a clinician unstructured interview. The MSAHC study completed the recruitment of 600 male and female adolescents who came to the MSAHC for primary care services from December 5, 2005, to April 13, 2007. These data are currently being analyzed.

Dr. Diaz and MSAHC clinicians and researchers have made use of clinical instrumentation to create an open dialogue between clinicians and adolescents in regard to their general medical and mental health. For example, we developed a mental health intake tool, called the Adquest, to assess adolescent risk exposure and problem behaviors across varied life areas (e.g. substance use, sexuality, safety, and violence). Adquest is focused on risk behaviors and protective factors (e.g. having a trusted adult to confide in) and indicators of thriving, and for the past several years has been used as with all patients seen in MSAHC’s mental health program. MSAHC has conducted numerous analyses of aggregate Adquest data from 800+ patients.

In 2000, Dr. Diaz conducted a secondary data analysis using information collected through the 1997 Commonwealth Fund Adolescent Health Survey. The goal of this analysis was to examine the relationship between abuse (physical, sexual, or both) and health status (including mental health and health risk behaviors) in a national sample of girls in grades 5 through 12. The hypothesis was that the magnitude of risk would be highest for girls reporting both types of abuse compared with those reporting no abuse or one type of abuse. This sample was derived from a nationally representative cross-section of 265 public, private, and parochial schools, with an oversampling of 32 urban schools to obtain ethnic diversity. A total of 3,015 girls responded. Approximately 8% (n=246) of girls reported a past history of physical abuse alone, 5% (n=140) reported sexual abuse alone, and 5% (n=160) reported experiencing both physical and sexual abuse.

Compared with female adolescents who did not report any abuse, female adolescents who reported both types of abuse were significantly more likely to experience moderate-to-severe depressive symptoms (adjusted odds ratios [OR]=5.1); moderate-to-high life stress (OR=3.3); history of bingeing and purging behavior (OR=4.4); regular smoking (OR=5.9); regular drinking (OR=3.8); illicit drug use in the past 30 days (OR=3.4); and fair-to-poor health status (OR=1.7), after controlling for grade level, ethnicity, family structure, and socioeconomic status. In contrast, lower adjusted odds ratios (1.8−2.5) were seen for adolescent girls reporting one type of abuse as compared with no abuse across most health outcomes.

Since 1994 Dr. Diaz and others at the MSAHC have participated as a Clinical Trials Unit of NICHD sponsored research with HIV infected adolescents. The Adolescent Medicine HIV/AIDS Research Network (ATN) investigated HIV disease progression and manifestation in adolescents at 16 clinical sites, characterizing immunologic response, establishing normative data, and exploring the influence of co-infections such as STIs. In 2001, the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) initiated therapeutic, behavioral and community intervention research.

Connect-To-Protect ®, the community research arm of ATN, seeks to reduce the incidence of HIV in adolescents and young adults through partnerships with community based organizations that collaborate to implement community intervention research. The ATN is the first to respond to the unique biopsychosocial issues of HIV infected adolescents and the highly challenging prevention issues of at-risk adolescents.

Dr. Diaz has had a long-standing interest in adolescent disclosure of abuse in primary care settings, and screening for and disclosure of childhood maltreatment and trauma among urban adolescents.

Under an NIH R01 award, Dr. Diaz, along with others at the MSAHC were funded until 2012 to study the incidence of Human Papillomavirus (HPV) infection following HPV vaccination in sexually active adolescent girls, ages 14-19 enrolled at the Mount Sinai AHC.

HPV infection is the central etiologic factor in the development of cervical and anal cancers. Recent data suggest that it is causally involved in 30 percent of oral cancers. Studies by our group and others have shown that 30-60 percent of sexually active college age women have cervical HPV infection. Our inner-city adolescence population, with its many high risk (HR) characteristics, has a prevalence of 63 percent cervical, 58 percent anal and 13 percent oral in our pilot study. The new vaccine contains HPV 6, 11, 16 & 18 virus-like particles and has been shown to have a very high efficacy in HPV-DNA negative and HPV seronegative subjects. Little is know about its efficacy and effectiveness in a HR adolescent population, or in anal and oral mucosa. Despite these uncertainties physicians would find it unacceptable to not vaccinate high-risk adolescents, such as our population. The results of our research may demonstrate the need for a formal clinical trial of high risk adolescents.

Dr. Diaz then conducted an exploratory study to examine whether, and if so, to what degree, among female adolescent survivors of sexual abuse, might the abuse experience be associated with impaired psychosocial functioning. She used the sexual abuse framework, developed by Finkelhor and Browne, who identified four traumagenic dynamics that lie at the core of the psychological injury inflicted by abuse: (1) traumatic sexualization, (2) betrayal, (3) stigmatization, and (4) powerlessness. Two hundred adolescent girls participated in Dr. Diaz’s study. One hundred girls had been sexually abused by a relative or other person in a position of trust and/or power. Their abuse history was either known at their initial visit to MSAHC or was elicited during a comprehensive medical history and physical examination as described in the previously mentioned study. The other half (100) were female adolescent patients from similar backgrounds, but who stated they had not been sexually abused.

Dr. Diaz and MSAHC staff developed a face-to-face structured interview designed to elicit demographic information, a detailed history of any sexual abuse, and any history of suicidal ideation or suicide attempts. In addition, study participants completed standardized measures of self-esteem (Coopersmith Self-Esteem Inventory), depressive symptoms (Beck Depression Inventory), and feelings of helplessness (Children’s Attributional Style Questionnaire). Questions were also asked about the following: perceived rejection by mothers, fathers, and peers; perceived social support from family and friends; and current relationships with mothers. Preliminary findings have shown that adolescent girls who were sexually abused had a mean Beck Depression score of 19.2 compared with a mean of 11.2 in the group with no known abuse. Fifty-nine percent of those sexually abused had scores consistent with moderate-to-severe depression, 77% had had suicidal thoughts, and 42% had attempted suicide (from one to seven times). Among those who had no known abuse, 19% had had suicidal thoughts and 8% had attempted suicide. Of those who had been sexually abused, 81% accepted referrals to our onsite mental health service, which provides individual, group, and family psychotherapy.