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National Research Council (US) and Institute of Medicine (US) Committee on Adolescent Health Care Services and Models of Care for Treatment, Prevention, and Healthy Development; Lawrence RS, Appleton Gootman J, Sim LJ, editors. Adolescent Health Services: Missing Opportunities. Washington (DC): National Academies Press (US); 2009.

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Adolescent Health Services: Missing Opportunities.

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2Adolescent Health Status

SUMMARY

  • Most adolescents are considered healthy as defined by traditional medical measures of current health status, such as mortality rates, incidence of disease, prevalence of chronic conditions, and use of health services.
  • Adolescence is a period of both risk and opportunity. Adolescents may take risks that can jeopardize their health during these early years, as well as contribute to the leading causes of death and disease in adulthood. During adolescence, a range of health conditions can be identified and addressed in ways that affect not only adolescents’ functioning and opportunities, but also the quality of their adult lives. Adolescence also provides many opportunities to develop habits that create a strong foundation for healthy lifestyles and behavior over the full life span.
  • Some specific subpopulations of adolescents defined by selected population characteristics and other circumstances—such as those who are poor or members of a racial or ethnic minority; in the foster care system; homeless; in a family that has recently immigrated to the United States; lesbian, gay, bisexual, or transgender; or in the juvenile justice system—have higher rates of chronic health problems and may engage in more risky behavior relative to the overall adolescent population.

Mortality and Morbidity

  • Motor vehicle crashes, homicide, and suicide, rather than infectious or chronic diseases, are the leading causes of mortality among adolescents.
  • Injuries continue to be the leading cause of mortality among adolescents; the majority of these injuries are due to motor vehicle crashes.
  • The prevalence of asthma and diabetes, two common causes of chronic illness in adolescents, has increased in recent years.
  • Between 10 and 20 percent of adolescents are affected annually by mental disorders, and half of all cases of adult lifetime mental disorders start by age 14. The most common mental health disorder in adolescence is anxiety.
  • Sexually transmitted infections are the most commonly reported infectious diseases in adolescents and continue to increase in this population. Non-Hispanic black adolescents have higher rates of chlamydia and gonorrhea than any other racial or ethnic group.
  • The most common oral health problem in adolescence is dental caries. Non-Hispanic black adolescents have a higher prevalence of untreated dental caries than non-Hispanic white adolescents.

Behavior and Health

  • Behavior that is unhealthful and/or risky, rather than infectious or chronic diseases, is the leading cause of morbidity among adolescents.
  • Use of alcohol, tobacco, and illicit drugs and carrying a weapon are adolescent behaviors that pose serious risk.
  • Pregnancy rates among adolescents aged 13–19 have decreased since 1990; declines have been seen among all racial and ethnic groups, although the rate of pregnancy among Hispanic adolescents has been decreasing less dramatically. Pregnancy rates among Hispanic and non-Hispanic black adolescents continue to be twice as high as those among non-Hispanic white adolescents.
  • The percentage of overweight adolescents has more than tripled since 1980, with more than 17 percent of adolescents aged 12–19 being considered overweight.
  • Certain subpopulations of adolescents, especially those who are in the juvenile justice or foster care system, are at significantly increased risk of health and mental disorders.
    • Adolescents who enter the juvenile justice system generally have preexisting health problems, particularly substance abuse, sexually transmitted infections, unplanned pregnancies, dental problems, and psychiatric disorders.
    • Adolescents in foster care face more health challenges and chronic health issues—such as asthma, anemia, neurological abnormalities, emotional and behavioral problems, chronic physical disabilities, birth defects, and developmental delays—than those not in foster care. These adolescents are also at increased risk of unprotected sex and pregnancy, and have higher rates of severe mental health problems and substance use.

Most adolescents are considered healthy as defined by the traditional medical measures of health status, such as mortality rates, incidence of disease, prevalence of chronic conditions, and use of health services. According to the National Survey of Child Health, approximately 83 percent of adolescents aged 12–17 are in either excellent or very good health as reported by their parents, regardless of whether they live in urban or rural areas (Maternal and Child Health Bureau, 2005a,b). According to data from the Behavioral Risk Factor Surveillance System, 91 percent of those aged 18–24 consider themselves to be in good, very good, or excellent health (McCracken, Jiles, and Michels Blanck, 2007).

This chapter explores how timing matters—how adolescence is a critical time for health promotion. Many adolescents behave in risky ways or live in environments that not only affect their immediate health, but also have a significant impact on their health as adults. For example, McGinnis and Foege (1993) and more recently Mokdad and colleagues (2004) have shown that half of deaths among adults are due to health-related behaviors that for many people have their onset during adolescence. For example, tobacco use is the leading actual cause of preventable death in the United States. Other health-related behaviors that are associated with the leading causes of death include poor diet and physical inactivity, drug and alcohol abuse, risky driving, risky sexual behavior, and use of drugs. The effects of such health-compromising behaviors—and the extent to which the health system attempts to prevent and respond to them—are also influenced by socioeconomic status, living circumstances, school environment and quality, and after-school care. This chapter also considers how context matters for adolescents and their health and looks at how the social context and such factors as income, race/ethnicity, geography, and community efficacy may affect the health of adolescents. (The importance of context in adolescents’ access to and utilization of health services is explored more fully in Chapter 3.) Moreover, this chapter addressed differences in how need matters, as some segments of the adolescent population, defined by biology as well as behavior, have health needs that require particular attention in health systems.

A recent analysis of the 21 Critical Health Objectives for Adolescents and Young Adults, a subset of the objectives of the Centers for Disease Control and Prevention’s (CDC’s) Healthy People 2010, highlights how little progress has been made in the overall health status of adolescents (Park et al., 2008; U.S. Department of Health and Human Services, 2006a). Of these 21 objectives, the only ones that have shown improvement since 2000 are unintentional injury-related behavior, pregnancy and sexually related behavior, and tobacco use (see Table 2-1). Moreover, several areas have worsened, including deaths caused by motor vehicle crashes related to alcohol use, which have risen, and obesity/overweight, which has increased along with a decrease in reported physical activity (Park et al., 2006).

With these and many other findings in mind, this chapter explores available evidence on the health status of adolescents as defined by traditional measures (mortality rates, incidence of disease, prevalence of chronic conditions, and use of health services). The chapter also offers a more complex and complete picture of health status by reviewing behaviors that may adversely affect health status not only during adolescence, but also in adulthood. Finally, the chapter highlights the current health status of various subpopulations of adolescents who are especially likely to be affected by several co-occurring health challenges, including those who behave in more than one risky way at the same time. Data on adolescents’ use of health services are discussed in Chapter 3.

As discussed in Chapter 1, the committee focused this study on health services and policies for adolescents between the ages of 10 and 19, and where appropriate and possible, broke this population down into the two subsets of early adolescence (ages 10–14) and adolescence (ages 15–19). Throughout this chapter, health status is described for the adolescent population, and where data are available, is distinguished for these two subsets, adhering as closely as possible to these specific age ranges. Moreover, at some points in the chapter, the health status of those transitioning from adolescence to adulthood (those aged approximately 20–24) is included in the discussion because (1) the data do not always break off at exactly age 19, and (2) health problems in adolescence can have implications for adult health, and the progression of these problems is important to note.

Finding: Most adolescents are considered healthy as defined by tra ditional medical measures of current health status, such as mortality rates, incidence of disease, prevalence of chronic conditions, and use of health services.

TABLE 2-1. 21 Critical Health Objectives for Adolescents and Young Adults and Progress from Healthy People 2010, Ages 10–24.

TABLE 2-1

21 Critical Health Objectives for Adolescents and Young Adults and Progress from Healthy People 2010, Ages 10–24.

Finding: Adolescence is a period of both risk and opportunity. Adoles cents may take risks that can jeopardize their health during these early years, as well as contribute to the leading causes of death and disease in adulthood. During adolescence, a range of health conditions can be identified and addressed in ways that affect not only adolescents’ functioning and opportunities, but also the quality of their adult lives. Adolescence also provides many opportunities to develop habits that create a strong foundation for healthy lifestyles and behavior over the full life span.

MORTALITY AND MORBIDITY

Mortality

More than 17,500 adolescents aged 10–19 die annually according to the National Vital Statistics System Mortality File collected by CDC’s National Center for Health Statistics in 2004. In general, mortality rates increase with age even within this narrow age range. For example, those aged 15–19 have a mortality rate more than three times higher than that of those aged 10–14 (see Figure 2-1). This higher rate is attributable largely to mortality among males—more than twice that among females in this age group. American Indian/Alaskan Native non-Hispanic and black non-Hispanic adolescents generally have the highest mortality rates, while Asian/Pacific Islander non-Hispanics have the lowest (see Table 2-2).

FIGURE 2-1. Adolescent mortality rates (per 100,000) in 2004 by age group.

FIGURE 2-1

Adolescent mortality rates (per 100,000) in 2004 by age group. SOURCE: National Center for Injury Prevention and Control (2007).

TABLE 2-2. Mortality Rates (per 100,000) of Adolescents by Age, Gender, and Race/Ethnicity, 2004.

TABLE 2-2

Mortality Rates (per 100,000) of Adolescents by Age, Gender, and Race/Ethnicity, 2004.

Deaths among adolescents are caused by injuries (unintentional, such as those due to motor vehicle crashes, and intentional, such as those due to suicide or homicide) and by natural causes (such as disease or a chronic health condition). Unintentional injury (the leading cause of mortality among adolescents), homicide, and suicide accounted for almost three-quarters of all deaths among adolescents aged 10–19 in 2004 (National Center for Injury Prevention and Control, 2007; see Figure 2-2). Unintentional injury was also one of the three leading causes of death among adults aged 35–54 in 2004; in contrast with adolescents, however, malignant neo plasms and heart disease—both physical chronic health conditions—were the cause of almost half of all deaths in adults (National Center for Injury Prevention and Control, 2007). Malignant neoplasms, heart disease, and congenital anomalies are the three leading natural causes of mortality among adolescents aged 15–19 and account for about 10 percent of deaths in this age group; they account for a higher proportion—20 percent—of deaths among younger adolescents, aged 10–14 (National Center for Injury Prevention and Control, 2007).

FIGURE 2-2. Ten leading causes of death in adolescents aged 10–19, United States, 2004.

FIGURE 2-2

Ten leading causes of death in adolescents aged 10–19, United States, 2004. SOURCE: National Center for Injury Prevention and Control (2007).

Homicide accounts for the high mortality rates among black non-Hispanic adolescents, whereas suicide and motor vehicle crashes are responsible for the high mortality rates among American Indian/Alaskan Native non-Hispanic adolescents; suicide rates are generally higher among non-Hispanic white than among non-Hispanic black adolescents. Much of the variation in mortality among racial and ethnic groups of adolescents has been shown to be related to differences in socioeconomic status. When analyses adjust adequately for the latter differences among individuals, families, and neighborhoods, the variations in mortality among racial and ethnic groups are much smaller, if not eliminated (Anderson et al., 1994; Gjelsvik, Zierler, and Blume, 2004).

Findings:

  • Motor vehicle crashes, homicide, and suicide, rather than infec tious or chronic diseases, are the leading causes of mortality among adolescents.
  • Injuries continue to be the leading cause of mortality among ado lescents; the majority of these injuries are due to motor vehicle crashes.

Morbidity

Chronic Health Conditions

Chronic conditions, or what are sometimes referred to as adolescents with special health care needs,1 generally encompass learning disabilities; attention-deficit hyperactivity disorder (ADHD); other emotional or behavioral problems; developmental delay or physical impairment; asthma or breathing problems; speech problems; diabetes; depression or anxiety; bone, joint, or muscle problems; autism; severe respiratory, food, or skin allergies; frequent or severe headaches; and hearing or vision problems not correctable with glasses. In 2005, according to parental reports, nearly 10 percent of adolescents aged 12–17 in the United States had special health care needs. Among those adolescents, approximately one-fifth had a functional limitation that lasted 1 year or more, and almost half managed their special health condition with prescription medication (Child and Adolescent Health Measurement Initiative, 2008). Data for the 1980s and 1990s indicate that 10–30 percent of children and adolescents under age 20 had a chronic condition, depending on the definition of such conditions used (Gortmaker and Sappenfield, 1984; Newacheck and Taylor, 1992).

Many adolescents have more than one special health care need. According to parental reports, in 2005 more than 17 percent of adolescents with special health care needs had more than three conditions (Bethell et al., 2008). Approximately one-fifth of adolescents with a severe chronic condition (defined as causing limitations in major daily age-appropriate activities) had more than one condition. Although the prevalence of adolescents with special health care needs does not vary substantially among income groups, adolescents in poor and near-poor families (those at less than 200 percent above the poverty threshold as defined by the U.S. Census Bureau) had substantially higher rates of severe chronic health conditions than adolescents in nonpoor families (those at more than 200 percent above the poverty threshold).

These mental and physical chronic health conditions have significant implications for adult health and health outcomes. Not only has the prevalence of chronic health conditions in children dramatically increased since the 1960s, but it is also important to understand that more children with severe chronic conditions (e.g., leukemia, cystic fibrosis, congenital heart disease) are living longer because of medical technological advances, and that some chronic conditions (e.g., obesity, asthma, ADHD) persist into adolescence and adulthood (Perrin, Bloom, and Gortmaker, 2007; Wise, 2004). This increase in the incidence and prevalence of chronic health conditions and their persistence from childhood into adolescence and into adulthood may have a major impact on health care expenditures and participation in society, including the workforce. The following sections highlight the prevalence of and trends in chronic health conditions—both physical and mental health—in adolescence and note the progression of increasing health problems into adulthood.

Asthma

Asthma is a major chronic illness among adolescents in the United States. In 2005, at least 4 million adolescents (15–17 percent) aged 10–17 were reported to have lifetime asthma, and more than 2.5 million (10–15 percent) were reported to have asthma currently; by comparison, only 7 percent of adults aged 18–44 were reported to have lifetime asthma and 10 percent to have asthma currently (Akinbami, 2006; Eaton et al., 2006; U.S. Department of Health and Human Services and Centers for Disease Control and Prevention, 2007). More recent data indicate that 20 percent of adolescents in high school have lifetime asthma (Eaton et al., 2008). In addition, the reported prevalence of chronic asthma or breathing problems causing limitations in normal daily activities is almost 6 per 100,000 adolescents aged 10–17 (MacKay and Duran, 2007).

The prevalence of lifetime asthma is generally higher among black than white adolescents, and among Puerto Rican and American Indian/Alaskan Native than white adolescents (see Table 2-3). It is generally higher among older male than older female adolescents and among younger female than older female adolescents (Eaton et al., 2006; U.S. Department of Health and Human Services and Centers for Disease Control and Prevention, 2007). Socioeconomic status has also been found to be correlated with the prevalence of asthma in adolescents. Adolescents in poor families have substantially higher rates of chronic asthma that limits normal daily activities relative to adolescents in nonpoor families (MacKay and Duran, 2007). The prevalence (total number of cases) and incidence (rate of new cases) of childhood asthma (ages 10–17) increased dramatically from 1980 to the late 1990s (Akinbami, 2006; Rudd and Moorman, 2007). The current prevalence of childhood asthma has remained at these high levels (Akinbami, 2006).

Diabetes

In 2001, more than 120,000 adolescents aged 10–19 were reported to have diabetes (Duncan, 2006; SEARCH for Diabetes in Youth Study Group, 2006). Data suggest that the prevalence of diabetes increases with advancing age: there were 2.29 cases per 1,000 adolescents aged 10–14 compared with 3.35 cases per 1,000 aged 15–19 (SEARCH for Diabetes in Youth Study Group, 2006). The reported prevalence of diabetes is higher among female than male adolescents, and is lowest overall among Asian adolescents (see Table 2-3). Of those reported to have diabetes, 71 percent are categorized as having type 1 and 29 percent as having type 2 (Duncan, 2006). Non-Hispanic white adolescents (aged 10–19) have the highest prevalence of type 1 diabetes. American Indian and black adolescents aged 10–19 have a higher prevalence of type 2 diabetes than their Hispanic and non-Hispanic white counterparts (SEARCH for Diabetes in Youth Study Group, 2006).

Research has shown that impaired fasting glucose levels have a high rate of conversion to type 2 diabetes in adults. Impaired fasting glucose levels have been reported in 11 percent of adolescents aged 12–19—with important implications for health in adulthood (Duncan, 2006).

The prevalence of diabetes in adolescents has increased in the past decade (Duncan, 2006). However, the contribution of this increase to the prevalence of type 2 diabetes, impaired fasting glucose levels, or the increasing prevalence of overweight and obesity is unclear (Duncan, 2006; Fagot-Campagna et al., 2001). Diabetes has been linked to a number of poor health outcomes in adulthood, including eye and foot problems; dental, kidney, nerve, respiratory, and cardiovascular complications; reproductive health issues; and stroke (Centers for Disease Control and Prevention, 2007a).

Cancer

As noted earlier, cancer is the leading natural cause of death in adolescence. In 2004, nearly 62,000 adolescents aged 10–19 were living with cancer (having received a diagnosis of the disease within the past 14 years), a prevalence twice that among infants and children from birth to age 9 (National Cancer Institute, 2008). Data on the incidence of and trends over time in new diagnoses of cancer in adolescents are not readily available. Among older adolescents aged 15–19, lymphomas, germ cell tumors, and leukemias account for the largest incidence of cancer (Bleyer et al., 2006). For these older adolescents, only a modest improvement was seen in 5-year survival rates from 1975 to 1997 compared with children and younger adolescents (birth through age 14) and adults (over age 45). This modest improvement in survival rates (and even no improvement for some ages) was seen from older adolescence into young adulthood (up to age 39). Data on differences by racial or ethnic and socioeconomic status in the incidence of cancer in adolescents are not readily available. One report on older adolescents and younger adults (ages 15–39) indicates that non-Hispanic whites have the highest incidence of cancer, but also have the highest overall 5-year survival rates; American Indians/Alaskan Natives have the lowest incidence but poorer survival rates; and non-Hispanic blacks have incidence rates between non-Hispanic white and American Indians/Alaskan Natives, but have the lowest 5-year survival rates across the age range (Bleyer et al., 2006).

TABLE 2-3. Prevalence of Morbidity in Adolescents by Age, Gender, and Race/Ethnicity.

TABLE 2-3

Prevalence of Morbidity in Adolescents by Age, Gender, and Race/Ethnicity.

Finding: The prevalence of asthma and diabetes, two common chronic illnesses in adolescents, has increased in recent years.

Chronic Mental Health Conditions

In a review of mental health policy in the United States, Frank and Glied (2006) note that there is continual debate on how to define mental disorder. They describe three ways that epidemiologists generally define people who have a mental disorder: (1) those who have symptoms and signs of a particular disorder, (2) those who have mental health–related impairment in daily life, and (3) those who have sought treatment for a mental health condition. A combination of these three criteria is generally preferred over any one alone because each selects a distinct subgroup of the population, usually with small overlap. Additionally, experts continue to argue about not only the specific mental disorders to include in diagnostic manuals, but also the combination of signs and symptoms to be used to diagnose individuals. (For a more detailed discussion, see Frank and Glied, 2006.) Although in general there is a paucity of data on the prevalence of mental disorders in the adolescent population, the data that are available are based on inconsistent measures. Many of the national surveys on the prevalence of mental disorders among the adolescent population include various predictive symptoms of a disorder, while a few measure the current clinical diagnosis of a disorder; hardly any measure impairment and the seeking of treatment. In this report, therefore, the committee describes the prevalence of mental disorders among adolescents on the basis of both predictive symptoms and clinical diagnosis where the data are available.

Most studies estimate that between 10 and 20 percent of adolescents are affected annually by mental disorders, while estimates for adults aged 25 and older are around 10 percent (depending on the ascertainment methods employed, sampling characteristics, and environmental conditions at the time of the study) (Costello et al., 1996; Kataoka, Zhang, and Wells, 2002; Roberts, Attkisson, and Rosenblatt, 1998; Shaffer et al., 1996; Substance Abuse and Mental Health Services Administration, 2007). The lifetime prevalence of mental health problems may be as high as 37 percent by age 16 (Costello et al., 2003). More important, between 5 and 10 percent of adolescents in any given year are afflicted with severe mental disorders that cause significant impairment in one or more aspects of normal functioning (Costello, 1999). Additionally, about half of those aged 18–29 have reported being diagnosed with a mental disorder at some point their life, and half of all adult lifetime cases start by age 14 (Kessler et al., 2005).

Anxiety disorders are the most common mental health problem among adolescents, 13 percent of whom meet criteria for these disorders (Costello et al., 1996). Depression affects more than 7 percent of the adolescent population, while ADHD and conduct disorder each represent a large portion of the remainder of mental disorders found in adolescents (Roberts, Roberts, and Chen, 1997; U.S. Department of Health and Human Services, 1999). Comorbid mental disorders are common among adolescents. In 2003, 21 percent of those aged 12–17 who were admitted for treatment of mental health and substance abuse disorders had a comorbid mental health problem in addition to an alcohol and/or drug problem, a finding similar to that of other research (Costello et al., 1996; Loeber et al., 2000; Substance Abuse and Mental Health Services Administration, 2005a). Rates of particular disorders vary among subpopulations.

The diversity of the symptoms, onset, and course of mental disorders across and within conditions suggests the multifactorial nature of these disorders and the corresponding variation in risk factors. Nevertheless, some risk factors appear to increase the rate of mental disorders across populations. These include poverty and low socioeconomic status, physical and emotional trauma, neurological disorders, genetic load, and substance abuse (Costello, 1999; Loeber et al., 2000; U.S. Department of Health and Human Services, 1999).

Gender is an important risk factor for mental disorders, although its influence varies by age. In childhood, boys are much more likely to be diag nosed with conduct disorder, disruptive disorders such as ADHD, and other mental health problems (Nock et al., 2006; Roberts, Roberts, and Xing, 2007; U.S. Department of Health and Human Services, 1999). Beginning in early adolescence, however, females are much more likely than males to be diagnosed with depression and anxiety (Roberts, Roberts, and Xing, 2007; Substance Abuse and Mental Health Services Administration, 2007).

An extensive body of research has examined variations in the prevalence of mental disorders among different racial and ethnic groups of adolescents. In general, rates of mental disorders are remarkably similar across different groups after controlling for income, resident status, education, and neighborhood supports (Kubik et al., 2003; Roberts, Roberts, and Chen, 1997; Roberts, Roberts, and Xing, 2007). However, service providers note large variations among adolescents referred for mental health services because of significant referral biases: minority adolescents (Hispanic and black) with mental disorders are often managed in the foster care and juvenile justice systems, while nonminority adolescents with similar presentations are much more likely to be referred to mental health services (U.S. Department of Health and Human Services, 1999).

Anxiety Disorders

As noted above, anxiety disorders are the most common mental disorders in adolescents. They include phobias, general anxiety, panic disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. In 1999, 13 percent of those aged 9–17 had experienced an anxiety disorder in the past year, and in 2003, 30 percent of those aged 19–29 had been diagnosed with an anxiety disorder in their lifetime (Costello et al., 1996; Kessler et al., 2005; U.S. Department of Health and Human Services, 1999). More recently, Chen and colleagues (2005) reported that 40 percent of adolescents aged 12–17 had symptoms of an anxiety disorder according to a predictive scale of diagnosis, although not being clinically diagnosed as having such a disorder (see Table 2-3).

Depression

Major depression can appear during childhood and adolescence, and can lead to school failure and to use of alcohol, tobacco, or other drugs. Most adolescents who commit suicide have a prior history of depression. A majority of adolescents experiencing major depression also report symptoms associated with other mental disorders (Kessler and Walters, 1998). In 2006, almost 3.2 million adolescents (12.8 percent) aged 12–17 had experienced at least one major depressive episode in their lifetime, including 1.9 million who had done so in the past year (Substance Abuse and Mental Health Services Administration, 2007). Additionally, a large number of adolescents report depressive symptoms but do not meet the diagnostic criteria for major depressive disorder. Prevalence rates vary depending on the adolescent population surveyed and the methodology employed, but depressive symptoms have been reported in from 13 to 40 percent of adolescents (Chen, Killeya-Jones, and Vega, 2005; Kubik et al., 2003; see Table 2-3).

Rates of major depressive disorder and symptoms of depression are higher for female than male adolescents. Adolescents having experienced major depressive disorder in the past year are more likely to report use of cigarettes and use of, dependence on, or abuse of illicit drugs or alcohol compared with adolescents without major depressive disorder in the past year. It is unclear whether the rates of major depression among adolescents have changed over time, or the variations are due to differences in survey methodology and sample characteristics. In the 1990s, however, 8–13 percent of adolescents (aged 11–19) reported having experienced major depression (Kessler and Walters, 1998; Roberts, Roberts, and Chen, 1997), and in 2000, 12 percent of those aged 12–17 reported having experienced predictive symptoms of major depression (not a clinical diagnosis) (Chen, Killeya-Jones, and Vega, 2005).

Attention-Deficit Hyperactivity Disorder

ADHD is a mental health problem seen mainly in children and adolescents who consistently display such behavior as inattention, hyperactivity, and impulsivity. In 2005, approximately 2.2 million adolescents (8.9 percent) aged 12–17 had ever been told that they had ADHD (Bloom, Dey, and Freeman, 2006). Additionally, almost 15 percent of adolescents aged 12–17 were reported to have had symptoms of ADHD, but did not meet clinical diagnostic criteria (Chen, Killeya-Jones, and Vega, 2005; see Table 2-3). ADHD is one of the most frequently cited chronic conditions causing activity limitations among adolescents aged 10–17, a fact that indicates its severity (MacKay and Duran, 2007). Activity limitations vary by gender, affecting males more than females. For example, male adolescents are three times more likely than females to have limitations due to ADHD.

Conduct Disorder

Conduct disorder is characterized by a persistent pattern of aggressive, deceptive, and destructive behavior that usually begins in early adolescence, around age 11 (Nock et al., 2006). Adolescents suffering from conduct disorder also are at increased risk of developing other mental disorders, such as oppositional defiant disorder, depression, and anxiety (Lahey et al., 1999). In a recent study, 11 percent of those aged 18–29 reported meeting the criteria for conduct disorder in their lifetime (Kessler et al., 2005). The prevalence of symptoms of conduct disorder peaks in late adolescence (ages 15–17) (Chen, Killeya-Jones, and Vega, 2005). Adolescent males are more likely than females to be diagnosed with conduct disorder; there are no significant racial or ethnic differences (Chen, Killeya-Jones, and Vega, 2005; Nock et al., 2006; see Table 2-3). In the 1980s and 1990s, community studies found that the prevalence of conduct disorder in adolescents ranged from 4 to 16 percent (Cohen et al., 1993; Kashani et al., 1987). It is unclear whether the prevalence of conduct disorder in adolescents has changed over the past few decades, or the variation is due to differences in survey methodology and sample characteristics.

Eating Disorders

Eating disorders frequently co-occur with other mental disorders, such as depression, substance abuse, and anxiety disorders. The three most common eating disorders are anorexia nervosa, bulimia nervosa, and binge-eating disorder (U.S. Department of Health and Human Services, 1999). It is estimated that during 2000–2002, almost 1.5 million (6 percent) of adolescents aged 12 to 17 had predictive symptoms of an eating disorder (not a clinical diagnosis) (Chen, Killeya-Jones, and Vega, 2005; see Table 2-3). Adolescent females are more likely than males to have symptoms of an eating disorder; no significant racial or ethnic differences have been found. As reviewed later in this chapter, subclinical risky eating behaviors (e.g., vomiting or taking laxatives) and overweight are even more prevalent (see the later discussion of unhealthful and risky eating behavior). Hoek and van Hoeken (2003) reviewed the literature on the prevalence of diagnosed eating disorders in the United States and Western Europe and found consistent rates. An average prevalence rate for anorexia nervosa of 0.3 percent was found for females (aged 11–36). The prevalence rates for bulimia nervosa were 1.0 percent for women (aged 12–44) and 0.1 percent for men of all ages. The authors also concluded that the incidence of anorexia nervosa had increased over the past century until the 1970s. Trends in the prevalence of bulimia nervosa are unclear. Additionally, it is important to note that there is a lack of national data available on the prevalence of binge eating disorders in adolescents.

Substance Use Disorders

Many adolescents use alcohol, illegal drugs, and tobacco. These behaviors, which are discussed in a later section, carry appreciable health risks both during adolescence and extending into adulthood. Additional problems are faced by the subset of substance-using adolescents who develop clinical substance use disorders. These disorders are characterized by a maladaptive pattern of heavy or compulsive use despite ensuing negative consequences (American Psychiatric Association, 2000), and they produce impairment in functioning.

In 2006 more than 2 million adolescents aged 12–17 (8 percent) and 7 million adolescents aged 18–25 (21 percent) were estimated to have abused or been dependent on alcohol or an illicit drug in the past year (Substance Abuse and Mental Health Services Administration, 2007). These data show some variation by gender and race and ethnicity. Males aged 18–25 have a higher prevalence of alcohol and illicit drug abuse or dependence compared with their female counterparts. American Indian and Alaskan Native adolescents aged 12–17 and those aged 18–25 have the highest prevalence of both alcohol and illicit drug abuse or dependence relative to any other racial or ethnic group. Asian adolescents tend to have the lowest rates of both alcohol and illicit drug abuse or dependence (see Table 2-3). Prevalence trends for adolescent substance abuse or dependence are unclear because of differences in study methodologies and sampling characteristics. In 2000, however, 7.7 percent of those aged 12–17 (and 15.4 percent of those aged 18–25) were estimated to have been abusing or dependent on alcohol or illicit drugs in the past year (U.S. Department of Health and Human Services, 2006b).

With respect to tobacco use, in 1991–1993, 28 percent of adolescents aged 12–17 who had smoked during the previous month (9 percent of this population) were reported to be nicotine dependent (Kandel and Chen, 2000). Research has suggested that adolescents experience significantly higher rates of dependence on nicotine than adults at the same level of use (Kandel and Chen, 2000; Rubinstein et al., 2007). The first symptoms of dependence have been seen in adolescents within days or weeks of the onset of only occasional use of tobacco (DiFranza et al., 2000), although individuals vary in this regard, and girls aged 12–13 tend to develop symptoms of dependence more quickly than boys of the same age (DiFranza et al., 2002). Although adolescents may develop symptoms of dependence quickly, a longer time elapses between their first cigarette and the development of a full dependence diagnosis than between their first cigarette and their first dependence symptom. Recent data suggest that 25 percent of adolescents develop nicotine dependence within 23 months of the onset of tobacco use (Kandel et al., 2007). In general, although adolescents who smoke more are more likely to develop tobacco dependence, the relationship between the level of tobacco use and dependence is far from clear: nicotine dependence has been reported among college students who smoke at low levels, while substantial numbers of college students who smoke every day still do not develop a dependence diagnosis (Dierker et al., 2007).

Suicidal Ideation and Suicide Attempts

In 2004, suicide was the third-leading cause of death among adolescents aged 10–19 (National Center for Injury Prevention and Control, 2007). According to the National Vital Statistics System Mortality File, the rate of deaths attributable to suicide in adolescents increases with age. After young adulthood, the rate of suicide drops with increasing age among adults aged 35 and older (U.S. Department of Health and Human Services and Centers for Disease Control and Prevention, 2007). In addition, many adolescents seriously consider suicide without attempting, or attempt but do not complete the act. According to the Youth Risk Behavior Survey, in 2007 about one-sixth of all high school students reported having seriously considered suicide 12 months prior to the survey (Eaton et al., 2008). Half of those students who had seriously considered suicide had actually attempted it (7 percent of all students). The rate of completed suicides was significantly higher among male than female adolescents in high school, although attempts were significantly higher among females. Hispanic female students were significantly more likely to report a suicide attempt than non-Hispanic white or black female students; there were no differences by race and ethnicity among male students. The prevalence of students who reported seriously considering suicide decreased in the 1990s and has remained steady in the first part of the current decade (National Center for Chronic Disease Prevention and Health Promotion and Division of Adolescent and School Health, 2008).

Finding: Between 10 and 20 percent of adolescents are affected annu ally by mental disorders, and half of all cases of adult lifetime mental disorders start by age 14. The most common mental health disorder in adolescence is anxiety.

Sexually Transmitted Infections

In 2003, 47 percent of high school students had ever had sexual intercourse, and 37 percent of sexually active students had not used a condom during their last sexual intercourse (Grunbaum et al., 2004). These and other risky sexual behaviors in adolescence contribute to high rates of sexually transmitted infections (STIs).

Chlamydia, gonorrhea, and syphilis are the most common bacterial causes of STIs. In 2005, non-Hispanic black adolescents had higher rates of chlamydia and gonorrhea than adolescents in other racial and ethnic groups, due in particular to the high rates reported among non-Hispanic black female adolescents (see Table 2-4). In 2005 non-Hispanic black adolescents aged 15–19 had a rate of more than 5,500 cases of chlamydia per 100,000, compared with non-Hispanic white adolescents aged 15–19, who had a rate of 769 cases per 100,000 (Centers for Disease Control and Prevention, 2006b). And non-Hispanic black female adolescents continue to have the highest gonorrhea rates of any group. Females aged 10–19 have higher reported rates of chlamydia and gonorrhea than males in the same age group. Chlamydia rates continue to increase, and although the rate of gonorrhea among adolescents aged 15–19 has decreased in recent years, in 2005 it increased 3.9 percent. It is important to note that higher reported rates of STIs in adolescent females have been attributed to higher rates of utilization of services (i.e., more opportunities to screen), as well as the greater availability of practical screening tests compared with those for males (Centers for Disease Control and Prevention, 2006b).

In 2005, an estimated 1,255 cases of HIV/AIDS were diagnosed among adolescents aged 13–19 (see Table 2-3). Black adolescents are disproportionately affected by HIV/AIDS infection, accounting for almost 70 percent of all new HIV/AIDS diagnoses reported among those aged 13–19 (Centers for Disease Control and Prevention, 2007b). Rates of new diagnoses of HIV/AIDS are higher among male than female adolescents. Between 1998 and 2005, AIDS cases among adolescents aged 13–19 increased by about 75 percent. There are more AIDS cases among male than female adolescents, although this differential has been decreasing over time (Centers for Disease Control and Prevention, 2007b). Information from high school students across the nation indicates that black high school students have a higher prevalence of HIV testing than white or Hispanic high school students; black female students (27 percent) are tested more than black male students (17 percent) (Eaton et al., 2008).

Until recently, there was no known nationally representative survey on the prevalence of genital herpes simplex virus in adolescents. Recent analysis of data from the 2003–2004 National Health and Nutrition Examination Survey (NHANES) indicates that 2 percent of U.S. female adolescents aged 14–19 tested positive for the herpes simplex virus-2 (Forhan, 2008).

The first national surveillance system to measure the prevalence of high-risk types of human papillomavirus (HR-HPV) in U.S. women was established only recently. During 2003–2005, a quarter of female adolescents aged 14–19 were reported to have HR-HPV (Datta, 2006). In addition, recent analysis of the NHANES 2003–2004 data indicates a prevalence of 18 percent of female adolescents (Forhan, 2008). This situation may change dramatically with the introduction of the new HPV vaccine and the recommendation to vaccinate early-adolescent females (Garland et al., 2007; Markowitz et al., 2007; Paavonen et al., 2007).

Finding: Sexually transmitted infections are the most commonly re ported infectious diseases in adolescents and continue to increase in this population. Non-Hispanic black adolescents have higher rates of chlamydia and gonorrhea than any other racial or ethnic group.

Oral Health

There is a high prevalence of oral disease among adolescents. Risk factors for oral disease in adolescence mirror those for other diseases and conditions. Risk factors for dental caries include poor eating patterns and poor food choices, coupled with a lack of fluoride use, while those for periodontal disease reflect inadequate personal oral hygiene. The risk for oral and perioral injury is increased by behavior that includes using alcohol and illicit drugs, driving without a seat belt, cycling without a helmet, engaging in contact sports without a mouth guard, and using firearms. Tobacco—both smoked and smokeless—poses a particular risk to oral tissues through direct injury, as well as through systemic effects. Eating disorders are associated with erosion of the teeth and damage to oral soft tissue, while oral sex is linked with oral manifestations of STIs in the form of oral soft-tissue lesions. Finally, pregnancy carries a higher risk of periodontal disease since gingivitis is a common inflammation associated with hormonal changes during pregnancy when other local conditions (poor oral hygiene) are present.

Dental caries The most common dental problem for adolescents is dental caries.2 During adolescence, the burden of caries grows with increasing age, and this progression continues into early adulthood. Fully 89 percent of those aged 20–39 have experienced caries. Rates of tooth decay among adolescents also increase with age, a progression that likewise continues into adulthood (see Table 2-3) (Beltran-Anguilar et al., 2005; MacKay and Duran, 2007).

In permanent teeth, the prevalence of caries is unevenly distributed among different groups of adolescents. Higher prevalence is reported among Mexican Americans3 (48 percent of those aged 6–19), compared with blacks and whites of the same age group (about 39 percent). Likewise, prevalence is higher among low-income children (about 48 percent of poor and near-poor children, compared with 36 percent of the nonpoor). A treatment effect bias resulting from higher levels of dental care among white than among black or Mexican American children partially masks estimates of disparities in the extent of caries. Nonetheless, Mexican American children demonstrate 17 percent more tooth decay than whites and 29 percent more than blacks (Beltran-Anguilar et al., 2005). The preponderance of untreated tooth decay is concentrated in minority populations, with blacks and Mexican Americans aged 6–19 having more untreated caries than whites of the same age (18.1 percent for blacks and 21.8 percent for Mexican Americans versus 10.69 percent for whites). Thus black adolescents have about the same experience with caries but a much lower rate of dental treatment compared with whites, while Mexican American adolescents suffer from both a higher occurrence of caries and lower treatment rates relative to whites. Disparities by gender are much narrower, with females of all ages having slightly higher rates of caries, likely due to higher dental treatment rates.4 Disparities by income are striking, with 2.4 times more adolescents in or near poverty (less than 100 percent and 100–199 percent of the federal poverty level, respectively) experiencing untreated tooth decay than their more affluent peers.

TABLE 2-4. Prevalence of Behavior and Health in Adolescents by Age, Gender, and Race/Ethnicity.

TABLE 2-4

Prevalence of Behavior and Health in Adolescents by Age, Gender, and Race/Ethnicity.

Because caries is progressive and cumulative, and early experience with caries predicts later experience, future dental disease among adolescents can be anticipated based on current experience with caries among young children. Historically, rates of caries for all ages have been decreasing; for the first time since the 1970s, however, rates of caries have been increasing substantially among the youngest children.

Periodontal and other soft-tissue diseases A uniquely adolescent variation of common periodontitis, termed “juvenile periodontitis,” has a particularly early onset and is especially aggressive (Oh, Eber, and Wang, 2002), with a skewed prevalence by race and ethnicity: 10 percent among African Americans, 5.5 percent among Hispanics, and 1.3 percent among whites aged 13–17 (Albandar, Brown, and Löe, 1997). Another study, for example, found that more than half of late adolescents (58 percent of those aged 18–19) have gingivitis, the precursor to destructive adult periodontitis, but far fewer demonstrate the mild or advanced tissue damage of periodontitis (4.7 percent of those aged 13–21 reportedly have mild periodontitis [Reeves et al., 2006], while 0.5 percent of those aged 18–19 have advanced tissue damage [NHANES III data]). The onset and progression of gingivitis and periodontitis are associated with use of tobacco products of all kinds, diabetes, HIV/AIDS, and a variety of other medical conditions and syndromes. Intraoral and perioral soft-tissue lesions (Oh, Eber, and Wang, 2002) are not unique to adolescents, although some such conditions, such as recurrent labial herpes (fever blisters or cold sores), aphthous stomatitis (canker sores), and angular cheilitis (inflammatory lesions at the corner of the mouth), typically present during adolescence.

Trauma As early as ages 11–13, one in six adolescents have experienced trauma to their front teeth; the prevalence continues to rise to one in five (18.9 percent) at ages 14–17 and one in four thereafter (27.5 percent of those aged 18–35) (NHANES III data, 1988 through 1994). Most soft-tissue trauma is self-healing, but much of the damage induced by oral jewelry (piercings of the tongue, lip, or cheek) causes irreversible destruction of both teeth and periodontal tissues. Reported side effects of oral piercings, for instance, include short-term infection, edema, and hemorrhage, and longer-term fractured teeth, chronic soft-tissue inflammation, injury to gums, and gingival recession (De Moor et al., 2005; Zadik and Sandler, 2007).

Finding: The most common oral health problem in adolescence is den tal caries. Non-Hispanic black adolescents have a higher prevalence of untreated dental caries than non-Hispanic white adolescents.

BEHAVIOR AND HEALTH

Many unhealthful behaviors initiated during adolescence extend into adulthood and result in significant morbidity and mortality in the short and long terms (Kolbe, Kann, and Collins, 1993). This section reviews the most salient of these behaviors and some of their health-related consequences.

Finding: Behavior that is unhealthful and/or risky, rather than infec tious or chronic diseases, is the leading cause of morbidity among adolescents.

Risky Driving

As discussed earlier, death rates due to motor vehicle crashes have decreased dramatically since 1970, but continue to be the leading cause of injury death for adolescents aged 10–19. Consumption of alcohol and a lack of seat belt use are often associated with speeding (Juarez et al., 2006)—a lethal combination. A general lack of adequate sleep can also contribute to risky driving.

Alcohol plays a significant role in injury deaths due to motor vehicle crashes. In 2005, almost one-fifth of drivers aged 16–20 involved in fatal motor vehicle crashes were intoxicated, although this proportion was down from one-quarter of drivers aged 15–19 in 1989 (National Highway Traffic Safety Administration, 1989, 2006). In 2007, 29 percent of high school students had ridden in the past month with a driver who had been drinking alcohol, though this was again down from 40 percent in 1991 (Eaton et al., 2008; MacKay and Duran, 2007). While there is no gender variation, Hispanic students were significantly more likely than their non-Hispanic white and black counterparts to ride with a driver who had been drinking (see Table 2-4). Ten percent of 11th- through 12th-grade high school students reported driving after drinking alcohol, a decrease from 17 percent in 1991. Non-Hispanic black 11th- through 12th-grade students were less likely to drive after drinking than non-Hispanic white or Hispanic students. Alcohol use is also an important risk factor for teen drowning deaths and residential fire injuries and deaths.

The most effective means of preventing injury in a crash is use of a seat belt. When properly used, seat belts reduce the risk of injury by 50–60 percent (National Highway Traffic Safety Administration, 2001). As many as 30 percent of adolescents do not wear seat belts, markedly increasing their chances of a fatal outcome in a crash (Glassbrenner, 2003), although one survey revealed that the percentage of high school students (grades 9 through 12) who never or rarely wore seat belts while riding in a car driven by someone else decreased from 26 percent in 1991 to 11 percent in 2007 (Eaton et al., 2008; MacKay and Duran, 2007). While there are no significant differences by race or ethnicity, male high school students are more likely than females not to wear or rarely to wear a seat belt—13 percent versus 8 percent (see Table 2-4).

Sleepiness also contributes to motor vehicle crashes among adolescents. A biological increase in the amount of sleep needed, changing sleep patterns, and social circumstances contribute to a chronic lack of sleep in this population, resulting in more crashes. As reported by Pack and colleagues (1995), the distribution of motor vehicle crashes attributed to drivers who fell asleep at the wheel peaks in the adolescent age range. The effects of this chronic lack of sleep have been compared to alcohol impairment. For example, Pack and colleagues (1995) found that after 17 hours awake, an adolescent’s driving performance is impaired to the same extent that it would be with a blood alcohol content of 0.05 percent.

Violence

Violent behavior among adolescents is associated with other high-risk behavior, such as substance abuse and risky sexual activity. In addition to being a public health problem during adolescence, violence among adolescents is the most common precursor of violence in adults. Data from many long-term longitudinal cohort studies indicate that nearly all adults with violent behavior had such behavior during childhood and adolescence (Farrington, 2001; Loeber, Lacourse, and Homish, 2005). Very little adult violence is perpetrated by individuals who had no violent behavior as youths.

Weapon Carrying

Gun carrying in particular is associated with an increased likelihood of fights and other high-risk behavior, such as substance abuse and risky sexual activity (Callahan and Rivara, 1992; Lowry et al., 1998). Access to and ownership of guns increases the likelihood of violent death among adolescents, including both homicide and suicide (Grossman et al., 2005; Kellermann et al., 1992, 1993). In 2005, as many as one in five high school students had carried a weapon to school in the month before being surveyed for the Youth Risk Behavior Survey, increasing their chances of violence and injury. Five percent of high school students reported carrying a gun (MacKay and Duran, 2007; see Table 2-4). The percentage of students who carried a weapon decreased between 1991 and 1999 and remained steady until 2005. Male students were significantly more likely than females to report carrying a gun or other weapon. Seven percent reported carrying a weapon on school property (Eaton et al., 2006). The percentage of high school students carrying a gun or other weapon did not vary significantly by age, race, or ethnicity.

Violent Crime Victimization

In addition to perpetrating violence, adolescents are often its victims. In 2004, approximately 1.6 million adolescents aged 12–19 were victims of violent crime (rape, robbery, and assault) according to the National Crime Victimization Survey (MacKay and Duran, 2007). Crime victimization rates generally increased among adolescents from 1985 through 1995, and then declined between 1995 and 2005 to levels well below those in 1985. The overall increase in violent crime and homicide during the 1980s was due largely to an increase among adolescents, which peaked in the early 1990s and has been related to the crack cocaine epidemic (Blumstein, Rivara, and Rosenfeld, 2000).

Among adolescents of all ages, males are twice as likely as females to be victims of serious crimes (MacKay and Duran, 2007, see Table 2-4). Dating violence also occurs in this age group. One in 11 adolescents have reported being victims of physical dating violence each year, with the frequency being equal among males and females (Black et al., 2006). Similarly, according to the Youth Risk Behavior Survey of high school students, in 2007 almost 10 percent of male and female students reported dating violence. In addition, 8 percent of students reported that they had ever been physically forced to have sexual intercourse; such reports were more common among females (11 percent) than males (4 percent) (Eaton et al., 2008).

There are large racial disparities in violent crime victimization. Black males have the highest rate of homicide victimization of any gender–racial group, with peaks in late adolescence and emerging adulthood. These trends in victimization are also seen in perpetration, with murder rates being highest among black males (U.S. Department of Justice, 2006, see Table 2-4).

Bullying and Fighting

According to the Youth Risk Behavior Survey, in 2007, 35.6 percent of 9th through 12th graders reported being involved in a physical fight in the preceding 12 months, down from 42.5 percent in 1991 (Centers for Disease Control and Prevention, 2006c; Eaton et al., 2008). Approximately 4 percent of these students had been injured in a fight in the prior year. Fighting is a marker for other high-risk behavior in youths, including school failure, substance abuse, weapon carrying, attempted suicide, and risky sexual behavior (Sosin et al., 1995; Swahn and Donovan, 2006; Wright and Fitzpatrick, 2006). In addition, physical fighting between students who are dating appears to be common among both middle and high school students (12 percent) and college students (5.6 percent) (Centers for Disease Control and Prevention, 2006a; DuRant et al., 2007).

Bullying is very common during adolescence, reported to involve as many as 30 percent of students in grades 6–10 either as victims, bullies, or both (Nansel et al., 2001). Bullying is associated with other problems in children, including lower grades and weapon carrying (Glew et al., 2008). Recently, attention has been focused on Internet bullying, reported by 12 percent of 8th graders and 10 percent of 11th graders in a recent survey (Williams and Guerra, 2007). Internet bullying was as common among girls as boys. As with other types of bullying, Internet bullying and harassment are also associated with other high-risk behaviors, such as weapon carrying (Ybarra, Diener-West, and Leaf, 2007).

Substance Use

Substance use, most frequently involving alcohol, tobacco, and marijuana, is common among adolescents. A recent concern is adolescents’ misuse of prescription medications, including opiate analgesics, stimulants, and cough medicines (Kuehn, 2007). Adolescents’ patterns of substance use can create particular risks for negative consequences. For example, although adolescents drink less frequently than adults, they drink larger quantities. The 2005 National Survey of Drug Use and Health revealed that 19 percent of individuals aged 12–20 consumed five or more drinks per occasion (Substance Abuse and Mental Health Services Administration, 2006). This “binge” pattern places adolescents at risk for drinking-related impairment and for both unintentional and violent injuries, sexual assault, and risky sexual behavior. An appreciable risk for short-term mortality and morbidity from motor vehicle crashes, homicide, and suicide is associated with substance use; for example, underage drinking is responsible for the deaths of approximately 5,000 people below age 21 (National Institute on Alcohol Abuse and Alcoholism, 2006; U.S. Department of Health and Human Services, 2007c). Actions associated with substance use put others at risk as well.

Adolescents may have a particular vulnerability to the negative consequences of substance use,5 such as the effects of alcohol on cognitive skills and memory (Spear, 2000). Early onset of substance use (before age 15) is associated with a heightened risk for later substance use disorder (Grant and Dawson, 1997, 1998; Robins and Przybeck, 1985). Early onset is also associated with more substance-related problems (Hingson and Kenkel, 2004).

Tobacco Use

Tobacco use is the most common cause of mortality in the United States, accounting for more than 400,000 deaths annually (Mokdad et al., 2004). Nearly all of these deaths occur to people well beyond adolescence, but initiation of smoking occurs primarily among adolescents. By 9th grade, half of children have tried cigarettes, a portion that increases to more than 60 percent by 12th grade (Eaton et al., 2006). Fully 82 percent of adults who currently smoke started smoking before age 18, and virtually no adult smokers started smoking after age 25 (U.S. Department of Health and Human Services, 1994). Adolescent smoking is quite persistent, and the majority of adolescent smokers continue their smoking into young adulthood (Miller, 2005).

In 2005, tobacco use at least once in the preceding month was reported among almost one-fourth of adolescents aged 16–17 (Substance Abuse and Mental Health Services Administration, 2006). The prevalence of tobacco use in adolescents peaked in the late 1990s at 36 percent and recently dipped to its lowest levels since the early 1990s (U.S. Department of Health and Human Services, 2004). Declines in adolescent smoking had been leveling off, but there is mixed information about a new decline in 2007 (Eaton et al., 2008; Johnston et al., 2008). In addition to the health risks faced by adolescents who smoke, it is estimated that in 2000, 18 million youths aged 12–19 were exposed to secondhand smoke (U.S. Department of Health and Human Services, 2006c).

American Indian and Alaskan Native adolescents are more likely to use tobacco than any other racial or ethnic group. Non-Hispanic white and Hispanic adolescents are more likely to use tobacco than non-Hispanic black or Asian adolescents (see Table 2-4). In 2005, 2 percent of high school students were reported to have used smokeless tobacco in the past month and 4 percent to have smoked cigars, a decrease since 1988 (National Institute on Drug Abuse, 1989; Substance Abuse and Mental Health Services Administration, 2006). Gender is not a major factor in the proportion of adolescents using tobacco; however, the prevalence of tobacco use increases with age (Centers for Disease Control and Prevention, 2005). A little over one-quarter of those aged 18–24 reported that they were current smokers (20 percent were daily smokers) (Lawrence et al., 2007).

Tobacco use produces health problems in both adolescence (e.g., less physical fitness, more respiratory illness) and young adulthood, including declines in lung function (U.S. Department of Health and Human Services, 2004). Moreover, adolescent tobacco use creates the risk for serious long-term health consequences in adulthood. Adolescent smoking often persists into adulthood, carrying with it the associated risk of serious adult morbidity and premature death (U.S. Department of Health and Human Services, 2004).

Alcohol Use

More than 60,000 people die annually in the United States from harmful drinking of alcohol (Rivara et al., 2004). These deaths occur because of heavy episodic or binge drinking or high levels of regular drinking. Binge drinking, which, as noted earlier, is especially likely to occur among adolescents, markedly raises the risk of injury, whether intentional or unintentional, and thus directly increases the risk of adolescent morbidity and mortality (Smith, Branas, and Miller, 1999). Most of the consequences of heavy regular drinking are seen during later adulthood and thus do not affect adolescents directly. The one exception is suicide, the risk of which is associated with both binge drinking and moderate to high levels of regular drinking (May et al., 2002).

There is a strong relationship between the age at onset of drinking and the risk of alcohol-related problems in both adolescence and adulthood. The median age of first alcohol use is 15 (DeWit et al., 2000). Alcohol use increases during the teen years, peaks in the early 20s, and decreases thereafter (Casswell, Pledger, and Hooper, 2003; Muthen and Muthen, 2000). The median age at onset for alcohol use disorder is 19–20 (Nelson, Heath, and Kessler, 1998). Early drinking has been associated with a variety of problems, and the risk of these problems increases as age at onset decreases (Hingson, Heeren, and Zakocs, 2001; Hingson et al., 2000, 2002, 2003). More than 40 percent of those who start drinking at age 14 or younger develop alcohol dependence, compared with 10 percent of those who begin drinking at age 20 or older (Hingson, Heeren, and Winter, 2006; Hingson et al., 2003).

In 2005, 28 percent of adolescents aged 12–20 reported drinking alcohol in the past month. Binge drinking was reported by 19 percent of adolescents and heavy alcohol use by 6 percent (Substance Abuse and Mental Health Services Administration, 2006). The prevalence of this behavior increased significantly between ages 12–13 and 18–20. In the late 1990s, the prevalence of current or heavy alcohol use peaked, and it has since decreased below the reported frequency in the early 1990s. Non-Hispanic white adolescents are more likely to binge drink than any other racial or ethnic group. American Indian and Alaskan Native and Hispanic adolescents also have a high prevalence of binge drinking compared with non-Hispanic black and Asian adolescents (aged 12–20). Alcohol use does not vary significantly by gender (see Table 2-4).

Marijuana and Other Illicit Drug Use

Use of drugs other than tobacco and alcohol is an important risky behavior among adolescents. Marijuana is the drug most commonly used by adolescents; according to the Youth Risk Behavior Survey, in 2007 one-fifth of students in high school reported using marijuana one or more times in the past month; almost 40 percent of the students reported having used it one or more times during their life (Eaton et al., 2008). Marijuana use increases with age. In 2005, almost 17 percent of those aged 18–25 reported using marijuana on at least 1 day in the past month, a stark contrast with young adolescents aged 12–17, at almost 7 percent (Substance Abuse and Mental Health Services Administration, 2006, see Table 2-4).

Illicit drug use among high school students has decreased from a peak in the last half of the 1990s (Johnston et al., 2006). This decline has paralleled a change in the attitudes of high school students toward the use of these substances. The majority of adolescents believe that regular use of illicit drugs carries great risk, a belief that extends to regular use of marijuana (Johnston et al., 2006). On the other hand, many fewer adolescents believe that occasional experimentation with illicit drugs poses a great risk of harm. In 2005, almost 8 percent of students in grades 9 to 12 reported using some form of cocaine during their lifetime; 6 percent reported using methamphetamines (Eaton et al., 2006). The prevalence of cocaine use peaked in 1999 and has remained steady, while in 1988, 4 percent of adolescents aged 12–17 reported using amphetamines during their lifetime (National Institute on Drug Abuse, 1989).

Finding: Use of alcohol, tobacco, and illicit drugs and carrying a weapon are adolescent behaviors that pose serious risk.

Pregnancy

In 2002 there were more than 750,000 pregnancies among adolescent girls aged 15–19 (Ventura et al., 2006). This rate represents a 35 percent decrease relative to that in 1990—a decline attributable mainly to a decrease in pregnancy among younger (aged 15–17) compared with older (aged 18–19) adolescents. In 2002 there were approximately 17,000 pregnancies among girls under age 15 (Guttmacher Institute, 2006), representing an even more dramatic decline of 50 percent in this age group between 1990 and 2002. Pregnancy rates in 2002 were more than twice as high among non-Hispanic black and Hispanic adolescents as among non-Hispanic white adolescents (see Table 2-4). Between 1990 and 2002, the pregnancy rate for Hispanic adolescents decreased less dramatically than that for black and non-Hispanic white adolescents; even so, black adolescents continue to have the highest pregnancy rate.

Adolescent childbearing is associated with a number of adverse consequences for adolescent mothers, fathers, and their children. For example, an adolescent mother is less likely than an older mother to complete high school or college, more likely to be a single mother, more likely to have more children sooner on a limited income, and more likely to abuse or neglect the child (Hoffman, 2006). Being the child of adolescent parents carries adverse health and social risks, including low birth weight and prematurity, poverty, school failure, and a greater likelihood of becoming involved in the juvenile justice system (for a boy) or becoming an adolescent mother (for a girl) (Hoffman, 2006).

Birth Rates Among Adolescents

Birth rates among adolescents declined during 1991–2005 to levels that represent a record low; preliminary data for 2005–2006, however, reveal an increased rate for the first time in more than a decade (Federal Interagency Forum on Child and Family Statistics, 2007; Hamilton, Martin, and Ventura, 2007; Ikramullah et al., 2007; Martin et al., 2006). As discussed in the next section, the decline in the teen birth rate has not been driven by more abortions, but by a decrease in the underlying pregnancy rate.

In 2004, the number of births among adolescents aged 10–19 was approximately 422,000 (Martin et al., 2006); births in this age group account for 10 percent of all births each year in the United States. Birth rates among adolescents increase with age. For example, adolescents aged 19 were nine times more likely to give birth than those aged 15. In 2004, there were more than 1 million births to mothers aged 20–24, approximately half of which were second- or higher-order births (Martin et al., 2006). There are substantial racial and ethnic differences in birth rates among adolescents aged 10–19. Hispanic and non-Hispanic black adolescents have the highest rates, followed by American Indian and Alaskan Native adolescents; Asian/Pacific Islander adolescents have the lowest rates (Federal Interagency Forum on Child and Family Statistics, 2007). The birth rate among those aged 20–24 also varies by race and ethnicity. Hispanics in this age group have the highest birth rate, followed by non-Hispanic blacks, American Indians and Alaskan Natives, whites, and Asian/Pacific Islanders (Martin et al., 2006).

Abortion Rates

Paralleling the decline in birth rates, rates of induced abortion among adolescents aged 15–19 declined during 1990–2002 (Ventura et al., 2006). In 2002 there were a reported 21.7 induced abortions per 1,000 adolescents aged 15–19, down approximately 50 percent from the rate in 1990 (Ventura et al., 2006). The rate of induced abortions among adolescents under age 15 decreased 51 percent between 1991 and 2002 (Guttmacher Institute, 2006).

Among adolescents aged 15–19, the reported proportion of pregnancies that ended in abortion was higher among non-Hispanic blacks than among either Hispanic or non-Hispanic whites (Ventura et al., 2006). Rates of induced abortion among adolescents increase with maternal age: 6 percent of all abortions in the United States are to those aged 15–17, while 12 percent are to those aged 18–19 (Jones, Darroch, and Henshaw, 2002).

Fetal Loss Rates

Rates of fetal loss among adolescents declined during 1990–2002 (Guttmacher Institute, 2006; Ventura et al., 2006). In 2002 there were a reported 11.8 losses per 1,000 female adolescents, down approximately 30 percent from the rate in 1990 (Ventura et al., 2006). Rates of fetal loss among adolescents increase with maternal age. Hispanic females aged 19 tend to have higher fetal loss rates than females of other ages and ethnicities.

Finding: Pregnancy rates among adolescents aged 13 19 have de creased since 1990; declines have been seen among all racial and ethnic groups, although the rate of pregnancy among Hispanic adolescents has been decreasing less dramatically. Pregnancy rates among Hispanic and non-Hispanic black adolescents continue to be twice as high as those among non-Hispanic white adolescents.

Unhealthful and Risky Eating Behavior

Eating behavior during adolescence has lifelong implications for health and well-being. Overweight and obese adolescents are more likely to be overweight and obese adults, who in turn are more likely to have diabetes and cardiovascular disease. In addition, overweight and obese adolescents are more likely to have decreased self-esteem and depression that persist into adulthood.

Overweight and Obesity

More than 10 million adolescents (31 percent) aged 12–19 were considered at risk of being overweight and overweight6 in 1999–2002 (Hedley et al., 2004, see Table 2-4). More than 17 percent of adolescents in this age group were considered overweight in 2004 (MacKay and Duran, 2007), a percentage that had more than tripled since 1980 (MacKay and Duran, 2007). Given that obesity is a condition that develops over time, it is relevant to note that in 2001, 22 percent of those aged 19–26 were considered obese.7 Among this group, the prevalence of extreme obesity—individuals with a body mass index ≥40—was more than 4 percent overall (Gordon-Larsen et al., 2004).

The percentage of adolescents who are overweight varies by race or ethnicity and gender. During 2001–2004, non-Hispanic black female adolescents and Mexican American adolescents (both genders) were more likely to be overweight than non-Hispanic white adolescents (both genders) aged 12–19. Information on other racial and ethnic groups, including Hispanics, Asians, and other populations, is unavailable. The proportion of overweight adolescents does not vary significantly according to economic status (MacKay and Duran, 2007).

Adolescents aged 10–17 in urban areas are somewhat less likely than those in rural areas to be overweight—14.2 percent versus more than 17 percent (Maternal and Child Health Bureau, 2005b). One of the most noticeable differences by location occurs among adolescents aged 12–14: 13.3 percent in this age group who live in urban areas are overweight, compared with 18.7 percent in rural areas (Maternal and Child Health Bureau, 2005b).

Overweight and obesity have serious health consequences for adolescents, increasing the risk of high cholesterol, hypertension, diabetes, and the metabolic syndrome (Dietz, 1998). There is substantial evidence from longitudinal studies that, as noted above, being overweight or obese during childhood and extending into adolescence is associated with a markedly higher probability of being overweight or obese as an adult (Deshmukh-Taskar et al., 2006; U.S. Department of Health and Human Services, 2007b; Whitaker et al., 1997). For example, in the Bogalusa Heart Study, 59 percent of males and 69 percent of females aged 15–17 who were at risk of being overweight (body mass index between the 85th and 94th percentiles) were overweight as adults. Among those who were overweight as adolescents, nearly 90 percent were obese as adults (Freedman et al., 2005b). Obesity in childhood and adolescence was more likely to lead to obesity in adulthood among blacks than among whites (Freedman et al., 2005a). Being overweight during childhood and adolescence also increases the likelihood of hypertension as an adult (Field, Cook, and Gillman, 2005).

Nutrition

According to the U.S. Department of Agriculture’s Nationwide Food Consumption Survey, in the 1970s the diet of U.S. adolescents was lower than recommended (National Research Council, 1989) in energy intake; vitamin B6; calcium; iron; dietary fiber; and sometimes vitamin C, folic acid, thiamin, and riboflavin (U.S. Congress and Office of Technology Assessment, 1991). Adolescents also were reported to consume excessive fat, cholesterol, sodium, and low-nutrient foods. More recent data indicate substantial increases in adolescent calorie (energy) and carbohydrate intake since the 1970s (Institute of Medicine, 2006b). For example, an increase of at least 100 calories per day has been noted for adolescents, who consume about double the suggested limit of added sugars in their diet (Enns, Mickle, and Goldman, 2003). Additionally, the data still show excessive intake of low-nutrient foods, total fat, saturated fat, and sodium relative to what is recommended (i.e., the Dietary Reference Intakes) (Institute of Medicine, 2006a,b). In 2003, 78 percent of adolescents participating in a national survey had not eaten five or more servings of fruits and vegetables a day during the 7 preceding days (Grunbaum et al., 2004). Adolescent females in particular are reported to consume inadequate amounts of iron.

Other Risky Eating Behavior

Risky eating behavior includes not eating for 24 hours or more and vomiting or taking laxatives. In 2007 the Youth Risk Behavior Survey found that 12 percent of high school students (9th through 12th grades) had not eaten for 24 hours or more in the 30 days prior to the survey—a steady prevalence since 1999 (Eaton et al., 2008; MacKay and Duran, 2007). More than 4 percent of students reported vomiting or taking a laxative; the prevalence of this behavior peaked in 2003 and subsequently decreased back to levels reported in 1997. Female students were more than twice as likely as males to report this risky eating behavior. This behavior does not vary by age or race or ethnicity.

Finding: The percentage of overweight adolescents has more than tripled since 1980, with more than 17 percent of adolescents aged 12–19 being considered overweight.

Physical Activity

Currently, only one-third of adults and two-thirds of children and younger adolescents engage in regular leisure-time physical activity (Barnes and Schoenborn, 2003; Duke, Huhman, and Heitzler, 2003). There is evidence that levels of physical activity during adolescence are directly related to those in adulthood, although this relationship is only moderately strong (Hallal et al., 2006). While the exercise patterns established during adolescence can carry over into adulthood, a myriad of other factors are influential as well.

Physical activity during adolescence is important for bone health in adulthood (Hallal et al., 2006). Moreover, physical inactivity is associated with an increased risk of death, as well as a host of diseases, including diabetes, obesity, cardiovascular disease, and other chronic illnesses.

Various national studies have quantified the amount of physical activity in which adolescents participate. However, the definitions used for physical activity have varied throughout the last two decades, making it difficult to compare results and describe trends accurately over time. For example, in 2007, 35 percent of adolescents in grades 9 through 12 reported meeting current recommendations for the level of physical activity (Eaton et al., 2008). In 1985, 59 percent of 5th through 12th graders reported engaging in appropriate physical activity (Ross and Gilbert, 1985). Although these data reveal a decrease in adequate physical activity over time, the two studies used different definitions of physical activity, and therefore no accurate conclusion can be drawn.8 On the other hand, a national survey that used the same definition (different from the above two) of physical activity from 1999 through 2005, a 6-year time frame, found that in 2005, 69 percent of students had participated in currently recommended levels (20 minutes of vigorous physical activity on 3 or more of the past 7 days and/or at least 30 minutes of moderate activity five or more times in the past week)—a percentage that had remained steady since 1999 (Centers for Disease Control and Prevention, 2007c; MacKay and Duran, 2007).

Although the prevalence and trend over time in participation in physical activity are difficult to describe accurately, studies reveal disparities among the adolescent population by gender and race or ethnicity. Participation in physical activity at the current recommended level was found to be substantially more likely among male than female students, but did not vary greatly by age. Non-Hispanic white students were more likely than non-Hispanic black students to have met the recommended level. Non-Hispanic white and Hispanic students were more likely than non-Hispanic black students to participate in moderate to vigorous physical activity (Centers for Disease Control and Prevention, 2007c; MacKay and Duran, 2007).

Adolescents aged 10–17 in rural areas are more likely than those in urban areas to participate in regular physical activity (3 or more days a week). Parents of girls aged 10–17 in urban areas report the lowest percentage of regular physical activity (Maternal and Child Health Bureau, 2005b).

HEALTH OF SPECIFIC SUBPOPULATIONS

The health status of adolescents can be characterized by the health conditions and behaviors discussed above. Not reflected in these data, however, is the fact that some groups of adolescents have particularly high rates of comorbid diseases, health conditions, or risky behaviors. As well, some groups of adolescents may face disparities or biases in the delivery of health services, as underscored by the Institute of Medicine (2003) report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. These adolescents face special challenges, and highlighting their health status underscores the complex services and settings that need to be encompassed by a health system that is responsive to all adolescents. As described in Losing Generations: Adolescents in High Risk Situations, a report of the National Research Council (1993), these at-risk populations have had to confront negative aspects of the social environment that decrease their opportunities for a successful transition through adolescence to adulthood.

Minority, Low-Income, and Rural Adolescents

Minority adolescents, those in low-income families, and those who live in rural areas experience particular disparities in health status and therefore face additional challenges in accessing needed health services:

  • The racial and ethnic makeup of adolescents in the United States is becoming more diverse (see Chapter 1). By 2050, it is estimated that more than 53 percent of adolescents aged 10–19 will be members of racial or ethnic minority groups (U.S. Census Bureau, 2007).
  • Adolescents who are in low-income families (income below $19,971 for a family of four in 2005) make up 16 percent of the adolescent population aged 10–17, while an additional 20 percent of adolescents live in near-poor families (income up to $37,619 for a family of four) (MacKay and Duran, 2007).
  • Of U.S. adolescents aged 12–17, 19 percent, or 4.6 million, live in rural areas (nonmetropolitan counties including no city with a population of greater than 10,000) (Fields, 2003). The population of rural adolescents increased from 1990 to 2002 (U.S. Census Bureau, 1992, 2003).

When available, information on the disparities in health status (i.e., mortality, morbidity, and health-related behavior) experienced by these specific groups of adolescents is presented throughout this chapter. It should be noted, however, that while some data exist on the health of low-income adolescents, these data are limited given that many of these adolescents are uninsured and not receiving consistent health services whereby their health status can be tracked. Additionally, it is often difficult to separate the effects of race and ethnicity from those of socioeconomic status. Without better data on these most vulnerable adolescents, understanding their specific health needs is problematic.

Adolescents in the Foster Care System 9

In 2005, there were 3.3 million complaints to child protection agencies alleging child abuse and neglect (child maltreatment), involving 6 million children and adolescents. As a result of the initial screening of those complaints, 3.6 million children and adolescents were referred for investigation by child protection authorities as the victims of child maltreatment. Those investigations substantiated that 900,000 children and adolescents were the victims of child maltreatment in 2005 (Children’s Bureau, Administration for Children and Families, and U.S. Department of Health and Human Services, 2007). On any given day in 2005, it is estimated that 514,000 children and adolescents lived in foster care to ensure their safety; approximately half were aged 8 or older (Children’s Bureau, Administration for Children and Families, and U.S. Department of Health and Human Services, 2007).

Children and adolescents in foster care have significantly more health problems than those in the general population (Hansen, Kagle, and Black, 2004). These problems include asthma, anemia, recurrent ear infections, and neurological abnormalities such as seizure disorders (Halfon, Mendonca, and Berkowitz, 1995). A significant number frequently experience upper respiratory infections, dermatological disorders, dental caries, and malnutrition (Silver, Haecker, and Forkey, 1999). In New York City, Chicago, Baltimore, and Canada, children in foster care have been found to have higher rates of vision, hearing, growth, and dental problems than other children (Barbell and Freundlich, 2001; Moffat et al., 1985; Swire and Kavaler, 1977; White, Benedict, and Jaffe, 1987). An estimated four in five also have a multitude of chronic health problems (Barton, 1999; Halfon, Mendonca, and Berkowitz, 1995; National Research Council and Institute of Medicine, 2004). Compared with other children and adolescents from the same socioeconomic background, those in foster care have much higher rates of serious emotional and behavioral problems, chronic physical disabilities, birth defects, and developmental delays (Committee on Early Childhood, Adoption, and Dependent Care and American Academy of Pediatrics, 2002).

Up to 80 percent of children and adolescents entering foster care have mental health problems (Simms, Dubowitz, and Szilagyi, 2000), as compared with 18–22 percent of children in the general population (Roberts, Attkisson, and Rosenblatt, 1998). One-third have at least one mental health diagnosis—most commonly post-traumatic stress disorder, alcohol abuse, substance abuse, or major depression. It has been reported that adolescents who have been in the foster care system have higher rates of illicit drug use than those who have never been in foster care (Substance Abuse and Mental Health Services Administration, 2005b). Males are more likely than females to be diagnosed with recent alcohol or substance abuse, while females are more likely to be diagnosed with recent depression (Leslie et al., 2000).

Approximately 60 percent of preschool-age children in foster care experience developmental delays (Inkeles and Halfon, 2002). In addition, it has been found that foster children tend to have more physical or mental health conditions that negatively impact school performance and psychosocial functioning (Kortenkamp and Ehrele, 2002).

Not only are these findings a concern as regards the immediate well-being of these children, but it has been reported that a disproportionate number of former foster children have mental disorders as adults (Casey Family Programs, 2005). Approximately half of adults who were placed in foster care as children have one or more mental health problems in adulthood, and 25 percent suffer from post-traumatic stress disorder (Pecora et al., 2005).

Homeless Adolescents

It has been estimated that there are between 1.3 million and 2 million homeless adolescents in the United States (Cauce et al., 1998; Hammer, Finkelhor, and Sedlak, 2002; Patel and Greydanus, 2002). This population is split almost evenly between males and females, and around 70 percent comprises adolescents aged 15–17 (Hammer, Finkelhor, and Sedlak, 2002). The precise number of homeless adolescents is difficult to determine, however, since homelessness is a dynamic status, with youths often migrating between staying with family and friends, in shelters, and on the street. Moreover, it is difficult to locate and count individuals who have no permanent address.

Collecting information on the health status of homeless adolescents is a particular challenge. With a population that is as transient and diverse as homeless adolescents, it is nearly impossible to find a large, randomly selected sample; collect data on these individuals over time; and develop a study with external and internal validity. Thus, much of the available literature in this area has serious limitations (Robertson and Toro, 1999). Nonetheless, the growing body of knowledge suggests that homeless adolescents are a sizable population, and that they face unique and significant health challenges.

Three major factors influence the physical and mental health of homeless adolescents: (1) homeless youths are more likely to come from troubled backgrounds (Cauce et al., 2000); (2) the challenges and stresses of living on the streets lead to high-risk behavior and a heightened danger of victimization; and (3) these individuals face multiple barriers to accessing health care.

Most homeless adolescents have already grappled with substantial health issues in their lives even before leaving home. They are more likely than other adolescents to have experienced sexual and physical abuse (Cauce et al., 2000; Haley et al., 2004; Rew, Taylor-Seehafer, and Fitzgerald, 2001), to come from homes where parents abuse alcohol or drugs (Cauce et al., 1998), and to suffer from mental health disorders (Rohde et al., 2001). Whether adolescents run away or are thrown out of their home, these issues are often a precipitating factor; self-reported reasons for becoming homeless include physical and sexual abuse, violence at home, drug use by a family member, and neglect (Cauce et al., 1998). In addition to triggering homelessness, these difficult life experiences can increase the chances that an individual will adopt risky behaviors, suffer from depression, and abuse drugs and alcohol (Rew, Taylor-Seehafer, and Fitzgerald, 2001; Stein, Leslie, and Nyamathi, 2002).

Abuse

The prevalence of physical and sexual abuse among homeless adolescents is significantly higher than is the case among the general population. It is estimated that 12.3 of every 1,000 children in the United States are victims of abuse (Childhelp, 2006), but studies of homeless adolescents indicate a much higher frequency: approximately half of homeless girls have been sexually abused (Haley et al., 2004; Rew, Fouladi, and Yockey, 2002; Wenzel et al., 2006) and around 20 percent of boys (Cauce et al., 1998, 2000), and physical abuse for both ranges up to 70 percent (Bao, Whitbeck, and Hoyt, 2000; Cauce et al., 2000). Physical and sexual abuse are among the most common reasons for leaving home (Andres-Lemay, Jamieson, and MacMillan, 2005; Cauce et al., 1998), and once on the streets, abused adolescents are at higher risk of further victimization (Craig and Hodson, 1998). Compared with other homeless adolescents, girls who have been abused are more likely to become pregnant (Haley et al., 2004), to contract an STI, and to experience psychological distress and depression (Stein, Leslie, and Nyamathi, 2002; Wenzel et al., 2006). Abused children of both genders are more likely to use alcohol and drugs, to consider or attempt suicide (Rew, Taylor-Seehafer, and Fitzgerald, 2001), to resort to violent and antisocial behavior (Moore, 2005), to participate in survival sex10 (Greene, Ennett, and Ringwalt, 1999), and to be sexually or physically assaulted on the streets (Cauce et al., 2000; MacLean, Embry, and Cauce, 1999).

Sexual Activity

For homeless adolescents, sexual activity starts early—their median age of first consensual sex is around 13 (Beech et al., 2003; Cauce et al., 1998), as opposed to approximately 17 for the general population (Guttmacher Institute, 2002). Sexual activity among homeless adolescents may be con sensual, or it may be manipulated, coerced, or forced. In addition to rape (Cauce et al., 1998) and involuntary sex while drunk or high (Rosenthal and Mallett, 2003), survival sex is a pervasive phenomenon in this population (Greene, Ennett, and Ringwalt, 1999; Van Leeuwen et al., 2004; Weber et al., 2004). One large, national study found that 27.5 percent of street youths and 9.5 percent of youths living in shelters had engaged in survival sex (Greene, Ennett, and Ringwalt, 1999). Other studies indicate similar numbers, ranging from 11 percent to more than 30 percent (Beech et al., 2003; Haley et al., 2004; Van Leeuwen et al., 2004). Although adolescents adopt this strategy to survive on the streets, the practice places them at higher risk of victimization, pregnancy, STIs, and sexual and physical assault.

Whether sex among homeless adolescents is voluntary or involuntary, it is likely to be unsafe. Although knowledge and attitudes about safe sex practices vary widely among different subpopulations of homeless adolescents, studies show inconsistent use of condoms both with clients and with casual or main sex partners (Haley et al., 2004; Wagner et al., 2001). Homeless adolescents may be less likely to practice safe sex because they lack access to condoms or are under the influence of alcohol or drugs, or because of the semicoercive nature of survival sex (Tyler et al., 2000). In addition, because most safe sex campaigns target school-based youths, street youths have less access to information about safe sex practices (Beech et al., 2003).

Unsafe sexual practices have serious consequences, including high rates of STIs and unintended pregnancy. Rates of STIs among homeless adolescents are far higher than among their nonhomeless peers (Boivin et al., 2005). Studies of homeless adolescents have found rates of HIV infection ranging as high as 16 percent among certain subpopulations (Beech et al., 2003; Lalota et al., 2005), with one study showing a median rate in four major cities of 2.3 percent (Robertson, 1996). It is estimated that the risk of contracting HIV is 6 to 12 times higher for a homeless than for a nonhomeless adolescent (Rotheram-Borus et al., 2003). The prevalence of other STIs is similarly troubling: rates of hepatitis B, hepatitis C, gonorrhea, syphilis, and chlamydia are all significantly higher than in the general adolescent population (Beech et al., 2003; Rew, Fouladi, and Yockey, 2002; Wagner et al., 2001); overall, between 17 and 28 percent of homeless adolescents have self-reported a history of STIs (Halcon and Lifson, 2004). There is even evidence to suggest a dose-response relationship between running away and STIs: a 2007 study showed that for every one unit increase in running away, there was a correlated 3 percent increase in the likelihood of having an STI (Tyler et al., 2007).

Homeless adolescent girls are at particular risk of the consequences of unsafe sexual practices. They are far more likely than homeless boys to be infected with an STI (Tyler et al., 2007), and are far more likely than their nonhomeless counterparts to become pregnant. More than half report having been pregnant at least once (Halcon and Lifson, 2004), although there is some question whether this number is accurate or is inflated because of malnourished girls mistaking amennorhea for pregnancy (Cauce et al., 1998). Many of these pregnancies end in miscarriage or abortion (Halcon and Lifson, 2004), and girls report knowing of friends who have tried drugs or abuse to self-induce abortion (Ensign, 2000). Homeless girls who are pregnant lack access to medical care and good nutrition and are more likely to use alcohol or drugs, resulting in poor health outcomes for both mother and child (Little et al., 2007).

Drug and Alcohol Use

The prevalence of drug and alcohol use among homeless adolescents is staggeringly high. In many cases, substance use starts before the adolescent leaves home (Rew, Taylor-Seehafer, and Fitzgerald, 2001); however, there exists a “continuum of risk” of substance use, with street youths using the most, nonhomeless youths the least, and shelter-based youths falling in between (Feldmann and Middleman, 2003). In addition to the health effects directly associated with drug and alcohol use, substance dependence can lead to secondary health risks, such as intravenous drug–related HIV and hepatitis exposure, the trading of unsafe sex for drugs, and a heightened danger of sexual or physical victimization (Rosenthal and Mallett, 2003).

Homeless adolescents start using substances early—one study indicates that a majority begin using alcohol, marijuana, and cocaine by age 12 (Rew, Taylor-Seehafer, and Fitzgerald, 2001). They use a wide variety of substances, including alcohol, marijuana, cocaine, methamphetamines, ecstasy, heroin, crack, hallucinogens, and ketamine. Exact rates of use are difficult to ascertain, but most studies suggest that homeless adolescents use at far higher rates than their nonhomeless peers (Thompson, 2004). More than 50 percent of homeless adolescents use alcohol, and more than a third consume in excess of 15 drinks a week (Lifson and Halcon, 2001; Van Leeuwen et al., 2004). Marijuana is one of the most frequently used drugs, at rates of up to 75 percent, and more than a third of homeless adolescents use marijuana at least three times a week (Lifson and Halcon, 2001; Van Leeuwen et al., 2004). Use of intravenous drugs, with its concomitant risk of HIV and hepatitis, is cause for serious concern. Rates of use of these drugs range from 15 percent to more than 30 percent (Feldmann and Middleman, 2003; Lifson and Halcon, 2001), and studies indicate that homelessness is associated with initiating and continuing the injection of drugs (Roy et al., 2003; Steensma et al., 2005).

Mental Health

The prevalence of mental health disorders in homeless adolescents is considerably higher than in the general adolescent population (Boivin et al., 2005; Unger et al., 1997). In this population, depression, dysthymia, internalizing and externalizing disorders, and dissociative symptoms are common diagnoses, and suicide is one of the leading causes of death (Boivin et al., 2005; Cauce et al., 2000; MacLean, Embry, and Cauce, 1999; Tyler, Cauce, and Whitbeck, 2004). Some of these mental health disorders exist before homelessness, and they may, in fact, play a role in an adolescent’s leaving or being kicked out of the home (Rohde et al., 2001). Other mental health problems, however, are the direct consequence of life on the streets. Many homeless adolescents are dealing with a history of abuse, substance abuse issues, a feeling of being trapped or helpless, and daily survival—all of which render mental health disorders practically inevitable (Kidd, 2006; Thompson et al., 2007; Tyler, Cauce, and Whitbeck, 2004).

Many studies note the link between stressful situations and the development of mental health disorders in homeless adolescents. Rew (2002) asserts that simply surviving in stressful environments makes homeless adolescents particularly vulnerable to psychological problems. Thompson and colleagues (2007) identify post-traumatic stress disorder as a consequence of exposure to street life. Tyler and Cauce (2002) observe that when homeless youths, who lack resources and support, experience stressors, they may turn to dissociative behavior in order to cope. Unger and colleagues (1998) find an association between stressful life events and depressive symptoms in homeless adolescents. Away from home, adolescents must deal with finding food and shelter, facing the risk of criminal and sexual victimization, and adapting to the culture of street life. These pressures are likely to contribute to emotional distress and mental health disorders, particularly when coupled with a lack of resources, support, and mental health care services.

In addition to the stress of living on the streets, two other factors commonly faced by homeless adolescents are highly correlated with mental health disorders: a history of physical, emotional, and sexual abuse, and current substance abuse issues. Youths with a history of abuse are far more likely to be depressed (Feldmann and Middleman, 2003; Stein, Leslie, Nyamathi, 2002), to display dissociative symptoms (Tyler, Cauce, and Whitbeck, 2004), to self-mutilate (Tyler et al., 2003), and to be suicidal (Unger et al., 1997). Among homeless adolescents, abuse of drugs and alcohol is associated with suicide (Rohde et al., 2001; Unger et al., 1997), self-injurious behavior, depression, and low self-esteem (Unger et al., 1997).

Regardless of when or how mental health disorders arise, it is evident that they are widespread in this population and that they have serious consequences for the affected individuals. One study found that two-thirds of its sample had symptoms that matched the criteria listed in the Diagnostic and Statistical Manual, Third Edition Revised (DSM III-R),11 for such a disorder (Cauce et al., 2000). Highly prevalent disorders included depression, mania, post-traumatic stress disorder, and schizophrenia (Cauce et al., 2000). Another study found that 12.2 percent of its sample had a DSM, Fourth Edition (DSM-IV), diagnosis of major depression, and 6.5 percent had been diagnosed with dysthymia. Homeless adolescents themselves report high rates of mental health disorders: 44 percent in one study reported feeling “depressed or sad often” (Feldmann and Middleman, 2003), and in another study, 32 percent “perceived a need for help with mental health problems” (Solorio et al., 2006). Unfortunately, these adolescents often resort to hurting themselves. Self-injurious behavior and self-mutilation are widespread among homeless adolescents (Tyler et al., 2003; Unger et al., 1997). As noted, suicide is among the leading causes of death for homeless adolescents (Boivin et al., 2005; Roy et al., 2004); moreover, studies have found suicide attempt rates ranging from 18 to 53 percent, and suicide ideation rates of 28 to 62 percent (Yoder et al., 2008).

In sum, homeless adolescents are at acute risk of developing mental health disorders because of both their family history and their everyday life. With a lack of resources, support, and mental health care, these disorders can have life-or-death consequences.

Homeless Adolescents Who Are Lesbian, Gay, Bisexual, or Transgender

Within the population of homeless adolescents, those who are lesbian, gay, bisexual, or transgender (LGBT)12 are at an even greater risk of poor physical and mental health and more likely to engage in risky behaviors. (The health risks faced by LGBT adolescents generally are discussed in detail in a later section.) LGBT youths make up a sizable proportion of homeless adolescents. Numbers vary widely, but an analysis of the available literature performed by the National Gay and Lesbian Task Force suggests that between 20 and 40 percent of homeless youths are LGBT (Ray, 2006). Being LGBT increases the likelihood of becoming homeless: “coming out” can be a trigger for leaving home, whether because of verbal or physical disputes with parents or parents kicking the youths out (Ray, 2006; Rew, Fouladi, and Yockey, 2002). Once homeless, LGBT youths are more likely than other homeless youths to engage in a multitude of practices associated with health problems, including substance abuse, survival sex, and risky sex.

Multiple factors are involved in LGBT youths’ increased health risks. Homeless LGBT youths are more likely to have been abused as children, more likely to abuse substances, and more likely to have mental health disorders relative to other homeless youths (Noell and Ochs, 2001; Rew et al., 2005; Whitbeck et al., 2004). When these factors are compounded by a lack of familial support, the increased threat of victimization, and the social stigma and discrimination faced by all LGBT youths, homeless LGBT adolescents are at a profound risk for poor mental and physical health outcomes. LGBT homeless adolescents are far more likely than their heterosexual counterparts to engage in survival sex (Gaetz, 2004; Weber et al., 2004); they are more likely to engage in risky sexual behavior (Cochran et al., 2002); and their higher incidence of STIs, including HIV, reflects this difference (Rew et al., 2005). LGBT homeless adolescents abuse alcohol and drugs at greater rates than their heterosexual peers (Noell and Ochs, 2001; Van Leeuwen et al., 2004), putting them at greater risk of associated comorbidities, including mental health disorders and disease related to the use of intravenous drugs. LGBT status among homeless adolescents is correlated with higher rates of depression (Noell and Ochs, 2001) and other mental health disorders (Cochran et al., 2002; Whitbeck et al., 2004), increasing the chances of considered or attempted suicide (Gibson, 1989). Finally, LGBT homeless adolescents are at greater risk of victimization on the streets: according to one study, they “reported an average of 7.4 more perpetrators of sexual victimization than did heterosexual youths” (Cochran et al., 2002, p. 774). LGBT homeless adolescents must contend with both the unique issues of being a sexual minority and the stresses of street life, and these multiple factors amplify and exacerbate their risk of poor mental and physical health.

Adolescents in Families That Have Recently Immigrated

The dramatic change in the racial and ethnic makeup of the United States since the decennial census in 1990 has been fueled by immigration at levels unseen since the early 1900s (Schmidley, 2001), as well as by high birth rates among immigrant women, largely of Hispanic origin (Sutton and Mathews, 2006). Over the 10-year period from 1990 to 2000, the proportion of children in the United States living in immigrant families rose from 15 to 20 percent (Hernandez, 2004). Children living in immigrant households may themselves be foreign born, or may be U.S. citizens with one or two foreign-born parents. Of all children under age 18 living in households in 2005, 20 percent were of Hispanic origin, 4 percent were Asian, and a total of 4 percent were foreign born. Four of five children of immigrants are U.S. citizens, and three of five children of immigrants have at least one parent who is a noncitizen (Capps et al., 2004). However, citizenship status decreases with increasing age. Nearly 2.5 million adolescents aged 10–19 are not U.S. citizens, compared with fewer than 1 million children aged 0–9 (U.S. Census Bureau, 2005). As will be described, the mere fact that a child or adolescent lives in an immigrant family has an impact on his or her health and health care.

Children and adolescents in immigrant families may be located along the three traditional migrant streams in the United States or in major urban centers, but they increasingly reside in nontraditional immigrant centers, described as “new Latino destinations … from Wilmington to West Palm Beach, from Little Rock to Las Vegas” and marked by rapid population change from 1990 to 2000 (Suro and Singer, 2002, p. 5). The likelihood that these children are foreign born, being either legalized residents or undocumented immigrants, rises with their age, recognizing that most immigrant families are of mixed status, with one or two noncitizen parents and younger children that are likely to be U.S. citizens (Capps et al., 2004). In addition to a higher likelihood of living in poverty, overcrowded housing, and linguistic and social isolation, these adolescents are less likely to have graduated from high school at age 19 (with Mexican, Central American, Dominican, Indochinese, and Haitian immigrant children being least likely among all racial and ethnic groups) (Hernandez, 2004). They are also less likely to have access to family supports through federal benefits such as the Temporary Assistance for Needy Families program or food stamps because of ineligibility due to their immigration status (Capps et al., 2004).

A subset of the children in immigrant families live in the families of migrant or seasonal workers, where the very nature of that work and the situation in which they live place their health at additional risk. In the 2001–2002 school year, nearly 875,000 students aged 3–21 were eligible for services in the Migrant Education Program. Although the vast majority of these students were Hispanic (89 percent), there were white, black, Asian, and American Indian/Alaskan Native children in migrant families as well. In 2001–2002, more than 190,000 of these students were in grades 7–12 (U.S. Department of Education, 2006). Knowledge of health risks to the children of migrant and seasonal agricultural workers has existed for more than 30 years. These risks range from environmental factors such as increased exposure to lead (Osband and Tobin, 1972) and nutritional deficiencies (Berman, 2003), to infectious hazards related to close living quarters and poor sanitation (Gwyther and Jenkins, 1998), to injuries associated with the agricultural milieu (Wilk, 1993) in which these children live. Higher infant mortality rates (Slesinger, Christenson, and Cautley, 1986) and poor oral health (Castiglia, 1997; Flores et al., 2002) have also been seen in these families, and agricultural workers continue to have the highest worker fatality rates in the nation (U.S. Bureau of Labor Statistics, 2007).

Unfortunately, results of more recent research using participatory methods show that this burden of risk is compounded by the fact that children of agricultural workers have high levels of unmet health needs—far above, for instance, those of their nonmigrant Hispanic or Mexican American contemporaries (Weathers et al., 2003). Although this research and a subsequent study by the same group did not focus specifically on adolescents, a lack of transportation and not knowing where to go for health services were the two main reasons identified for the most recent unmet medical need (Weathers et al., 2003), factors that would presumably apply to adolescents either within a migrant family or, even more so, on their own in the agricultural environment.

The health status of immigrant children and adolescents has received increased emphasis in the literature recently as more attention has been paid to the overall health status of racial and ethnic minority children, particularly Latinos, in the United States. However, much remains to be learned. What has been and continues to be well described is the “healthy immigrant effect,” which denotes direct relationships between lower acculturation (by a variety of surrogate measures) and lower rates of obesity and mental disorders in adults and better neonatal outcomes (Flores and Brotanek, 2005). Concerning risky and health-protective behaviors among adolescents, lower acculturation has been found to be associated with both later onset and lower rate of sexual intercourse (Adam et al., 2005), less alcohol use, less cigarette use, and increased likelihood of eating breakfast (Ebin et al., 2001). It appears, however, that this protective effect on health status and health behaviors wanes with the amount of time an adolescent lives in the United States and is nearly gone by the third generation (National Research Council and Institute of Medicine, 1998). Furthermore, there is much heterogeneity among immigrant adolescents, including within racial and ethnic subgroups. Factors such as country of origin and language spoken, as well as length of time in the United States, have a significant impact in research seeking to tease out the best measure of acculturation and its most accurate correlation with health status and health risk (Yu et al., 2003). Tremendous public health gains would be realized with enhanced understanding of this link between acculturation and health (Flores and Brotanek, 2005).

Lesbian, Gay, Bisexual, and Transgender Adolescents

LGBT adolescents face the typical issues that all adolescents encounter as they transition to adulthood; however, they have unique needs due to the social stigma that results from the minority status of their sexual orientation and gender identity (Perrin, 2002). Many of these adolescents endure rejection, ridicule, harassment, social isolation, and discrimination; some fail to find support within their families or communities to help them cope with these challenges. For some adolescents, this stigma may induce psychosocial stress that can lead to increased risky behavior and possibly poorer health outcomes due to a lack of access to appropriate health services.

Researchers face numerous challenges in estimating the prevalence of homosexuality in the general population of adolescents or adults, including difficulties in identifying representative sample populations and measuring sexual minority status. Most prevalence estimates are likely underestimates, in part because of the societal stigmatization of homosexual orientation (Stronski Huwiler and Remafedi, 1998). The use of differing methods for measuring sexual orientation (self-identified sexual orientation, romantic attraction, or sexual activity) has made comparisons among studies problematic at best (Friedman and Downey, 1994). As well, existing data may disproportionately reflect the experience of LGBT adolescents who are participating in more risky behavior, since those adolescents who participate less in such behavior may not have health issues that result in their appearing in health settings where the data are collected, or may be less public about their sexual orientation. Although the prevalence data discussed below are limited by these methodological issues, they nonetheless represent a starting point for understanding the impact of the healthy development of LGBT adolescents on the health of the overall U.S. adult population.

In a national population-based survey of junior high and high school students, 7 percent reported having same-sex romantic attractions or relationships (Russell and Joyner, 2001). In another national study, adolescent children of participants in the Nurses Health Study II were asked to identify themselves on a spectrum of sexuality, from completely heterosexual to completely homosexual.13 One percent of the adolescents described themselves as homosexual or bisexual, 5 percent as mostly heterosexual, and 2 percent as unsure (Austin et al., 2004a). Finally, in a statewide representative sample of 7th through 12th graders in Minnesota,14 1.1 percent of students identified themselves as homosexual or bisexual, while 4.5 percent reported same-sex sexual attractions. The proportion of students reporting that they were unsure of their sexual orientation declined with age: 25 percent of 12-year-olds compared with 5 percent of 18-year-olds (Remafedi et al., 1992). Among the adult population, estimates of homosexuality range from 3 to 10 percent, although a larger proportion report ever having same-sex attractions or behavior (Fay et al., 1989; Friedman and Downey, 1994; Seidman and Rieder, 1994; Sell, Wells, and Wypij, 1995; Stronski Huwiler and Remafedi, 1998).

A plethora of studies have examined health-related behavior and outcomes for LGB15 adolescents (Kourany, 1987; Lemp et al., 1994; Noell and Ochs, 2001; Safren and Heimberg, 1999). However, many of these studies are based on nonrepresentative, convenience, or community samples (Russell, 2003). Several statewide school-based surveys and two large national surveys provide limited data on the differences between LGB and heterosexual adolescents with respect to a variety of health-related behaviors and outcomes (Austin et al., 2004b; Garofalo et al., 1998; Robin et al., 2002; Saewyc et al., 1998; Udry and Chantala, 2002). The rest of this section details these data in the areas of suicide, substance abuse and smoking, eating disorders, sexual activity and STIs, violence, and psychosocial stressors. This is followed by a discussion of special issues for transgender teens.

Suicide

State and national random samples of high school students demonstrate a higher rate of suicide attempts among LGB compared with heterosexual adolescents. In a study using representative data from the Vermont and Massachusetts Youth Risk Behavior Survey (YRBS),16 students who reported sexual experiences with members of both sexes were five times more likely to report serious suicide attempts (controlling for age, gender, and incidence of forced sex) than those who reported sexual experiences with members of the same sex only. This difference in risk did not exist for students with same-sex sexual experiences compared with those with opposite-sex sexual experiences (Robin et al., 2002). In a representative sample from the Minnesota Adolescent Health Survey, after controlling for demographic factors, those boys identifying themselves as homosexual or bisexual were seven times more likely to attempt suicide than heterosexual males (Remafedi et al., 1998; Robin et al., 2002). In data from both the U.S. National Longitudinal Study of Adolescent Health (Add Health)17 and the Massachusetts YRBS, sexual orientation was an independent predictor of suicide attempts; LGB adolescents were twice as likely to attempt suicide, after controlling for such mediating factors as substance abuse, violence, victimization, and depression (Russell and Joyner, 2001; Udry and Chantala, 2002).

Substance Abuse and Smoking

Adolescents who report having sexual contact with, attractions to, or relationships with individuals of both sexes are at higher risk for substance use than their peers reporting sexual contact with, attractions to, and relationships with the opposite sex only. State and national data indicate that these adolescents are more likely to report marijuana use, binge drinking, getting drunk, drinking alone, and illicit drug use than their heterosexual peers (Robin et al., 2002; Russell, Driscoll, and Truong, 2002). Rates of substance use for adolescents reporting same-sex sexual attractions and behavior are comparable to the rates for their heterosexual peers. A similar pattern exists for tobacco use. In Add Health, although there were no differences in tobacco use between adolescents with same-sex and opposite-sex attractions, adolescents reporting attractions to both sexes smoked more cigarettes than those reporting attractions only to the opposite sex. In the Massachusetts YRBS, adolescents describing themselves as LGB were more likely to smoke cigarettes than heterosexual adolescents; however, this study did not analyze smoking rates for homosexual and bisexual adolescents separately (Garofalo et al., 1998; Russell, Driscoll, and Truong, 2002).

Eating Disorders

Data from the Growing Up Today Study show that health risk behaviors related to eating and body image disorders are less likely among self-identified lesbian girls than among heterosexual girls, while the opposite is true for self-identified gay versus heterosexual boys. Lesbian and bisexual girls are happier with their bodies and less likely to report trying to look like images of women in the media, whereas gay and bisexual boys are more concerned with trying to look like images of men in the media and more likely to binge eat (Austin et al., 2004b).

Sexual Activity and Sexually Transmitted Infections

Risky sexual behavior puts all adolescents at risk for STIs, including HIV/AIDS. LGB adolescents report more unprotected sex, earlier age at initiation of sexual intercourse, and more sexual partners than heterosexual adolescents (Garofalo et al., 1998). Anal intercourse without a condom puts gay and bisexual male adolescents at high risk for HIV/AIDS, hepatitis B, and HPV anal carcinoma, as well as other STIs (Makadon, 2006). In addition, unprotected anal or oral sex increases the risk for transmission of hepatitis A (Garofalo and Harper, 2003). Lesbian adolescents are also more likely to engage in risky sexual behavior and may experience higher rates of negative health outcomes compared with heterosexual girls. In the Massachusetts YRBS, self-identified lesbian and bisexual girls who had had sexual intercourse were more likely to report unprotected sex with a male and had more pregnancies than heterosexual girls who had had sexual intercourse (Carlson et al., 1995). This behavior poses an increased risk for STIs, HIV/AIDS, and unintended pregnancy. In working to improve these sexual health outcomes for LGB adolescents, it is important to recognize that it is sexual activity, not sexual orientation, that puts adolescents at increased risk of these outcomes (Garofalo and Katz, 2001; Perrin, 2002).

Violence

LGB adolescents face a disproportionate risk for violence as a result of their sexual minority status. Those who report same-sex attractions have higher rates of being threatened with a weapon, being in a physical fight in the previous 12 months, being forced to have sex in the previous 12 months, and missing school because of fear for their own safety (Robin et al., 2002; Russell, Franz, and Driscoll, 2001).

Psychosocial Stressors

LGB adolescents must endure the emotional stress related to social isolation and fear of discovery, which itself can lead to peer rejection, loss of friends, school failure, and discrimination (Kreiss and Patterson, 1997). They must decide whether to disclose their sexual orientation or even questions about their sexual orientation to others. Disclosure can result in family conflict and rejection, which in some cases can lead to homelessness (Kreiss and Patterson, 1997; Perrin, 2002). As discussed above, homeless teens face a number of other risks, including survival sex, poverty, poor access to health services, and victimization (Kruks, 1991).

Special Issues for Transgender Teens

The term transgender denotes individuals who have persistent and distressing discomfort with their biological sex (White, 1998). In DSM-IV, these individuals are considered to have gender identity disorder, a diagnosis that requires evidence of a strong and persistent cross-gender identification (the desire to be or the insistence that one is of the other sex) and persistent discomfort about one’s phenotypic sex. There must be evidence of clinically significant distress or impairment in functioning without a concurrent intersex condition (American Psychiatric Association, 2000). Transgender adolescents may be romantically attracted to males, females, or members of both sexes; gender identity does not confer or assume any particular sexual orientation.

While there are no U.S. national or state-based representative data on transgenderism in adolescents, convenience and other nonrepresentative samples have revealed that these adolescents often suffer from depression, suicide attempts, risky sexual behavior, violence, HIV infection, and homelessness (Clements-Nolle et al., 2001; Garofalo et al., 2006; Lombardi et al., 2001). Transgender individuals frequently encounter extreme social prejudice because of their gender-atypical behavior, causing them even greater psychological and emotional distress (Lombardi, 2001).

Adolescents in the Juvenile Justice System

According to the then acting U.S. Surgeon General, Rear Admiral Kenneth Moritsugu:

On an average day, approximately 100,000 young people are housed in juvenile justice residential facilities and about one-half million are on court-ordered community supervision. An additional 100,000 young people are on informal probation supervision. These young people are medically underserved in the community; they are underinsured and are less likely to have a medical home. (Office of Juvenile Justice and Delinquency Prevention, 2007b)

In 2005, there were 2.1 million juvenile (adolescents under age 18) arrests, a substantial decline from the number in 1996 (Office of Juvenile Justice and Delinquency Prevention, 2007a). Approximately 16 percent of these arrests were for substance use–related crimes (including drug abuse and liquor law violations, driving under the influence, and drunkenness). In 2005, females accounted for 29 percent of all juvenile arrests; this percentage increased in the 1990s. There are more racial and ethnic minority than white adolescents in juvenile justice residential settings (American Academy of Pediatrics Committee on Adolescence, 2001). Further analysis of the adolescent population in residential settings reveals that 62 percent are minorities, 85 percent are males, and a majority lack adequate health insurance (Sickmund, Sladky, and Kang, 2004). Of those arrested, however, most do not end up at trial, and of those whose cases are adjudicated, two-thirds are sentenced to probation (National Center for Juvenile Justice, 2007), allowing for community-based interventions.

Adolescents who come in contact with the justice system and are detained or incarcerated in correctional facilities have a variety of medical and emotional disorders and, as noted, are generally medically underserved (American Academy of Pediatrics Committee on Adolescence, 2001). According to the American Academy of Pediatrics Committee on Adolescence (2001), these youths not only enter the system with preexisting health problems, but also develop acute problems linked to their arrest and their stay in the detention or correctional facility. Thus they show greater rates of physical and emotional problems such as substance abuse, STIs, unplanned pregnancies, and psychiatric disorders upon entry (American Academy of Pediatrics Committee on Adolescence, 2001); an elevated risk of suicide during their incarceration (Gallagher and Dobrin, 2006; Roberts and Bender, 2006); and post-traumatic stress disorder upon both entry and release (Mahoney et al., 2004; National Center for Mental Health and Juvenile Justice, 2007) (see the discussion below). This is particularly true for juvenile offenders transferred into the adult criminal justice system and held in adult jails or correctional facilities (Woolard et al., 2005). Moreover, within facilities, girls are more likely than boys to be sexually victimized and to die while incarcerated (Physicians for Human Rights, 2007).

Mental Health and Substance Abuse Problems

Most adolescents held in custody meet diagnostic criteria for some mental or substance abuse disorder, and a substantial percentage meet criteria for both. It is estimated, for example, that 65–70 percent of adolescents in the juvenile justice system have a mental disorder, and for approximately 20 percent, this disorder is serious (Skowyra and Cocozza, 2006; Teplin et al., 2002). The National Center for Addiction and Substance Abuse found that a majority of the juvenile justice population was affected by addiction and substance abuse disorders. The center’s 2004 report concluded that four of every five, or 1.9 million out of 2.4 million, juvenile arrests involved offenders who were under the influence of alcohol or drugs at the time of the offense, tested positive for drugs, were arrested for an alcohol- or drug-related offense, or were admitted for substance abuse. In addition to use of alcohol and illegal drugs, there are high rates of cigarette smoking among this population, necessitating smoking cessation interventions. One study also found that 63 percent of detained juveniles assessed as having a substance abuse disorder also had at least one comorbid mental health diagnosis (Hussey et al., 2005), including ADHD, conduct disorder, post-traumatic stress disorder, depression, and oppositional defiant disorder (Clark and Gehshan, 2006).

Oral Health

Although mental health, substance abuse, and other medical conditions within this population have received significant attention, much less consideration has been given to oral health concerns. Although there are no national prevalence data on this issue for the juvenile justice system, a survey in Washington State found that 65.9 percent of adolescents in its juvenile justice system reported dental problems (Anderson and Farrow, 1998).

Sexually Transmitted Infections

Adolescents in the juvenile justice system have particularly elevated rates of STIs. A recent review (Golzari, Hunt, and Anoshiravani, 2006) found prevalence rates of up to 18–22 percent, depending on whether a specific individual disease or a general category of “any” STI was considered.

Other Medical Problems

Feinstein and colleagues (1998) report that 10 percent of adolescents admitted to detention had significant medical problems other than substance abuse or STIs. Common among these problems were asthma, orthopedic problems, and otolaryngologic conditions. Yet only one-third of adolescents in detention had a regular provider of medical care, and just 20 percent had a private physician. With growing numbers of females in the justice system, gynecological and prenatal care is also required (American Academy of Pediatrics Committee on Adolescence, 2001).

Risk of Victimization Within Facilities

The National Commission on Correctional Health Care (1998) noted that juveniles in adult correctional facilities are particularly vulnerable to victimization, and stated that the incarceration of adolescents in adult facilities is “detrimental to [their] health and developmental well-being.” This conclusion is further supported by Woolard and colleagues (2005) and other researchers (Bishop et al., 1996; Committee on Adolescence, 2001; Forst, Fagan, and Scott, 1989; Steinberg, Chung, and Little, 2004), who have found that adolescents in adult prisons are a particularly vulnerable population, at risk for physical and emotional abuse, suicide, and death.

Finding: Certain subpopulations of adolescents defined by selected demographic characteristics and other circumstances—such as those who are poor or members of a racial or ethnic minority; in the foster care system; homeless; in a family that has recently immigrated to the United States; lesbian, gay, bisexual, or transgender; or in the juve nile justice system—have higher rates of chronic health problems and may engage in more risky behavior relative to the overall adolescent population.

SUMMARY

Most adolescents are healthy as defined by traditional measures of mortality, morbidity, and use of health services. Even though these traditional indicators give reason for optimism, behavioral indicators of health status continue to show little improvement in the overall well-being of adolescents. The health problems of adolescents are primarily behavioral and environmental in origin, dominated by interpersonal violence, motor vehicle crashes, substance (including tobacco and alcohol) use and abuse, problems associated with risky sexual behavior, risky eating behavior, inadequate physical activity, and mental disorders. These behaviors not only affect adolescents’ immediate health, but also have a significant impact on their health as adults. It is important as well to provide health services that are attentive and responsive to the needs of specific subpopulations of adolescents with certain characteristics, such as being low-income, a racial/ethnic minority, in the foster care system, homeless, living in an immigrant family, LGBT, or in the juvenile justice system, since evidence shows that these young people often have higher rates of chronic health problems, may engage in more risky behavior, and may live in social environments that place them at greater risk relative to the overall adolescent population. Looking at these data, the committee is struck by the need for a focus on prevention; on behavioral health issues; on mental health issues; on oral health issues; and on disparities in health status that derive from income, race, and special circumstances. Available health services for adolescents and the extent to which they respond to these needs are explored in subsequent chapters.

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Footnotes

1

Adolescents with special health care needs are defined by McPherson and colleagues (1998, p. 138) as “those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”

2

Dental caries is a disease that damages the structure of the teeth. Dental cavities and tooth decay are a consequence of dental caries. These three terms are generally used interchangeably.

3

The NHANES reported information on Mexican American and non-Hispanic black and white populations. Information on other racial and ethnic groups (e.g., Hispanics, Asians) was not reported.

4

This is because dentists employ a lower threshold for counting teeth as having caries relative to the national survey methodology. Thus, dentists may fill teeth that the national survey would not consider as having decay. The filled tooth is counted in the survey as evidence of its having had a cavity.

5

These findings come from animal data and have not yet been conclusively established for humans.

6

At risk of being overweight is defined as having a body mass index (kg/m2) between the 85th and 94th percentiles, while overweight is defined as having a body mass index greater than or equal to the 95th percentile, based on gender and age, from the 2000 CDC growth charts.

7

Obesity is defined in adults over age 18 as having a body mass index (in kg/m2) of ≥30.

8

Appropriate or currently recommended physical activity was defined in 2007 as being physically active for a total of 60 minutes or more per day on 5 or more of the past 7 days, and in 1985 was defined as engaging in activity requiring 60 percent or greater of an individual’s cardiovascular capacity at least three times per week for at least 20 minutes.

9

The available literature included in this section encompasses both children and adolescents (ages 8 and older, usually up to age 17) and thus is not specific to the adolescent population only; the text therefore refers to “children and adolescents” in discussing these data.

10

Survival sex can be defined as the “selling of sex to meet subsistence needs,” including “shelter, food, drugs, or money” (Greene, Ennett, and Ringwalt, 1999, p. 1406).

11

The Diagnostic and Statistical Manual of Mental Disorders is the U.S. standard diagnostic tool for mental disorders of the American Psychiatric Association (http://www​.psychiatryonline.com/).

12

The group referred to as “lesbian, gay, bisexual, and transgender” sometimes also encompasses the term “questioning” and is commonly referred to by the acronym LGBT (or GLBT) or LGBTQ (or GLBTQ). For the purposes of this report, the identifier “lesbian, gay, bisexual, and transgender” or LGBT is used.

13

The Growing Up Today Study surveyed 16,882 children of women from the ongoing Nurses Health Study II. Youths were asked to identify themselves as completely heterosexual, mostly heterosexual, bisexual, mostly homosexual, completely homosexual, or not sure. Those reporting mostly homosexual, completely homosexual, and bisexual were combined to create an LGB category.

14

The 1987 Minnesota Adolescent Health Survey included 34,706 students. It asked about sexual orientation and about the sex of individuals involved in their sexual fantasies, attractions, and experiences.

15

In most cases, the data presented do not include an explicit focus on transgender adolescents, and therefore the acronym LGB is used. A separate discussion of transgender adolescents follows this section.

16

The 1995 and 1997 YRBS from Massachusetts (n = 4,159 and n = 3,982, respectively) and Vermont (n = 5,987 and n = 8,636, respectively) surveyed 9th- through 12th-grade students. In Massachusetts, the surveys asked students about the sex of individuals with whom they had had sexual contact and their own sexual orientation (heterosexual, gay/lesbian, bisexual, not sure). In Vermont, students were asked only the sex of those with whom they had had sexual contact (male, female, both).

17

This study surveyed 11,940 students using an audio computer-aided interview and asked about the sex of the individuals to whom they had been attracted or with whom they had had sexual relationships.

Copyright 2009 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK215414

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