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PAPER CONTRIBUTION E

Preadolescent and Adolescent Influences on Health

Cheryl L.Perry, Ph.D.

Adolescence, the stage of development between childhood and adulthood, and approximately the second decade of the life cycle, was first presented as a subject for scientific inquiry only a century ago by G.Stanley Hall (1904) and was characterized as the developmental stage of “storm and stress.” Manifestations of storm and stress included adolescents ' tendencies to contradict their parents, experience mood changes, and engage in antisocial behaviors (Arnett, 1999). After nearly 100 years of research, this picture of adolescence seems both limited in scope and too broad a generalization (even if the tendencies are still familiar and relevant). In particular, as we enter the twenty-first century, adolescence is viewed as part of life span development, with continuities from childhood, unique developmental challenges and tasks, and implications for adulthood. Adolescence is also examined within context, so that adolescence is seen as a dynamic developmental process that is influenced by proximal and distal social environments. The manifestation of this developmental process can be seen in adolescents ' behaviors, behaviors that cause considerable concern in American society. Thus, this paper attempts to provide a snapshot of the dynamics of adolescence and adolescent behavior, what factors influence the adoption or maintenance of behavior, examples of how changes in behavior

Dr. Perry is professor, Division of Epidemiology, School of Public Health, University of Minnesota. This paper was prepared for the symposium, “Capitalizing on Social Science and Behavioral Research to Improve the Public's Health,” the Institute of Medicine, and the Commission on Behavioral and Social Sciences and Education of the National Research Council, Atlanta, Georgia, February 2–3, 2000.



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Promoting Health: Intervention Strategies from Social and Behavioral Research PAPER CONTRIBUTION E Preadolescent and Adolescent Influences on Health Cheryl L.Perry, Ph.D. Adolescence, the stage of development between childhood and adulthood, and approximately the second decade of the life cycle, was first presented as a subject for scientific inquiry only a century ago by G.Stanley Hall (1904) and was characterized as the developmental stage of “storm and stress.” Manifestations of storm and stress included adolescents ' tendencies to contradict their parents, experience mood changes, and engage in antisocial behaviors (Arnett, 1999). After nearly 100 years of research, this picture of adolescence seems both limited in scope and too broad a generalization (even if the tendencies are still familiar and relevant). In particular, as we enter the twenty-first century, adolescence is viewed as part of life span development, with continuities from childhood, unique developmental challenges and tasks, and implications for adulthood. Adolescence is also examined within context, so that adolescence is seen as a dynamic developmental process that is influenced by proximal and distal social environments. The manifestation of this developmental process can be seen in adolescents ' behaviors, behaviors that cause considerable concern in American society. Thus, this paper attempts to provide a snapshot of the dynamics of adolescence and adolescent behavior, what factors influence the adoption or maintenance of behavior, examples of how changes in behavior Dr. Perry is professor, Division of Epidemiology, School of Public Health, University of Minnesota. This paper was prepared for the symposium, “Capitalizing on Social Science and Behavioral Research to Improve the Public's Health,” the Institute of Medicine, and the Commission on Behavioral and Social Sciences and Education of the National Research Council, Atlanta, Georgia, February 2–3, 2000.

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Promoting Health: Intervention Strategies from Social and Behavioral Research have been achieved, and the implications of this research for healthful adolescent development in the twenty-first century. DEVELOPMENTAL INFLUENCES DURING ADOLESCENCE The Dynamics of Adolescence Adolescence is a time of metamorphosis. Some changes are biologically —and others socioculturally—determined. The latter are often referred to as the “developmental tasks” of adolescence and are discussed in the next section. From a biological viewpoint, during adolescence, children become adults. They experience puberty, acquire reproductive capabilities, and secondary sexual characteristics, and grow to reach full adult height (Susman, 1997). Hormones are primarily responsible for the biological changes in adolescence (Hopwood et al., 1990; Buchanan et al., 1992). The primary hormones begin to differ by gender at about age 11 (Susman, 1997), with the most dramatic biological changes occurring during early adolescence, between the ages of 12 and 16 (Tanner, 1978). The timing of biological changes differs by gender and racial or ethnic group (Money, 1980; Susman, 1997). On average, females mature 1–2 years ahead of males, and reach their full adult height by age 14 (Marshall and Tanner, 1970); African American females mature even earlier than white females (Kaplowitz and Oberfield, 1999). Interestingly, the age of pubertal onset, as measured by menarche in females, has become younger throughout the past century, most likely due to improved nutritional intake (Wyshak and Frisch, 1982; Hopwood et al., 1990; Herman-Giddens et al., 1997; Kaplowitz and Oberfield, 1999). Hormonal changes have been “blamed” for their influence on adolescent mood and behavior. Recent provocative research suggests that hormones do influence behavior; the direct effects are small but stable and may be mediated by the social environment (Buchanan et al., 1992; Brooks-Gunn et al., 1994; Susman, 1997). For example, Olweus et al. (1988) found that boys with relatively higher testosterone levels were more likely to become aggressive if they were provoked. Thus, some boys might never exhibit aggressive behavior in a social environment without provocation. Similarly, Udry (1988) found that testosterone levels were a strong predictor of sexual involvement among young adolescent girls. This relationship was attenuated or eliminated by their involvement in sports or having a father in the home. Again, the hormone-behavior relationship existed, but did not manifest in particular environments. Substantial research has been done on the timing of puberty relative to peers (Silbereisen et al., 1989). Early maturers are differentiated from on-time and late maturers in terms of the development of secondary sexual characteristics, height velocity, and menarche (Silbereisen and Kracke, 1993). Most studies in the United States have found that early maturation among boys is positive for them, with early maturers reporting more confidence, less dependence, and greater popularity than their peers (Nottelmann et al., 1990; Petersen and Taylor, 1980).

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Promoting Health: Intervention Strategies from Social and Behavioral Research For girls, the picture is more mixed, with studies showing more negative affect, lower self-esteem, and greater contact with deviant peers among early-maturing females (Brooks-Gunn, 1988; Brooks-Gunn and Warren, 1989; Silbereisen and Kracke, 1993). However, these associations with early maturation may be mediated by social, cultural, and socioeconomic factors (Clausen, 1975; Silbereisen and Kracke, 1993). For example, in homes where the father was absent, females matured at significantly younger ages (Surbey, 1990). Also, closeness of mothers to their daughters was associated with slower maturational development among girls (Steinberg, 1989; Silbereisen and Kracke, 1993). Thus, even for biological changes that are examined relative to age-mates or peers, the rate of maturation may be mediated by the social context of the adolescent. Changes in cognitive processes also occur during preadolescence and adolescence. These changes may be the result of continued brain growth during adolescence and more efficient neural processing (Crockett and Petersen, 1993; Brownlee, 1999). Pre- and young adolescents are concrete thinkers (Blum and Stark, 1985). To experience something, concrete thinkers need to see, feel, touch, smell, or hear it, rather than being able to rely on abstract descriptions. By middle or late adolescence, formal operational or abstract thinking is possible (Blum and Stark, 1985; Crockett and Petersen, 1993). Rather than strictly relying on experience, abstract thinkers can generate hypotheses, possible solutions, rules, and ideals using symbols and abstractions. Adolescents can learn to arrange pieces of information into multiple combinations, understand words that are not reflecting real life, think about thinking, and conceptualize ideals. However, many adolescents may not attain formal operational thinking levels (Flavell, 1985) or may revert to concrete thinking in unfamiliar or emotionally charged situations (Hamburg, 1986). The level and sophistication of thinking has important implications for adolescents' behavior. As concrete thinkers, young adolescents cannot truly comprehend abstract concepts such as “health” or project the outcomes of their current behavior into the future (Blum and Stark, 1985). Even as adolescents learn to think abstractly, this occurs through trial, error, and experimentation. Messages about health behaviors, therefore, that rely on long-term consequences or fail to provide relevant and concrete examples will have little meaning to many adolescents. Likewise, adolescents may misperceive that others are preoccupied with them, confusing their own thoughts with the thoughts of others (Arnett, 1992). This can lead to a sense of invulnerability and participation in reckless behavior (Elkind, 1967; Arnett, 1992). The lack of rational and abstract thinking abilities leaves adolescents particularly vulnerable to messages from the social environment that portray some behaviors, such as smoking, drinking, and sexual behavior, as potentially functional and rewarding (Perry, 1999a), even though the longer-term consequences may be dire for them. In terms of biology, then, adolescents are maturing earlier than in previous times; so physically, they become adults at a younger age, yet do not have the cognitive capabilities to cope with a complex social environment as adults. Ad-

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Promoting Health: Intervention Strategies from Social and Behavioral Research ditionally, the changes within and between adolescents are not synchronous — there are enormous differences in the rate and timing of these changes. This sets the stage for a kind of “prolonged” adolescence, during which young people are expected to become prepared to become adults in our society, mentally and socially, yet with physical bodies that are already mature. This tension may contribute to some of the problems associated with adolescents, such as precocious or unprotected sexual behavior, which have a biological as well as a social etiology (Hine, 1999). The “Tasks” of Adolescence Puberty and the associated physical and cognitive changes are perhaps the only parts of adolescence that are culture-free; that is, adolescents worldwide experience these metamorphoses. Yet, as the examples above indicate, even biological changes interact with social environmental factors to influence adolescent behavior. Still, from within specific cultures and subcultures come the answers to the question, What are adolescents supposed to achieve during this developmental stage? These achievements are considered the psychosocial tasks of adolescence (Havighurst, 1972; Hill, 1980; Hill and Holmbeck, 1986; Masten et al., 1995). For adolescents in the United States, the specific tasks have been described in psychological and social terms, and include accomplishments related to autonomy, sexuality, attachment, intimacy, achievement, and identity (Havighurst, 1972; Hill and Holmbeck, 1986). Adolescents strive to accomplish these tasks (1) to become independent and able to make their own decisions, (2) to understand their changing social-sexual roles and sexual identity, (3) to change their relationships with their parents, (4) to transform acquaintances into deeper friendships, (5) to focus their ambitions on their futures, and (6) to transform their images of themselves to accommodate their physical and psychosocial changes. These tasks have been characterized as the driving forces in adolescent behavior (Havighurst, 1972). Adolescents are more likely to think of themselves as being adults when these psychosocial tasks, rather than particular events, such as high school graduation, are achieved (Scheer et al., 1996). However, these tasks may also be changing in scope and interpretation as greater cultural and ethnic diversity is found throughout the United States. Recent research has examined the continuity and coherence of developmental tasks in childhood and adulthood, using sophisticated methodologies. Masten et al. (1995) defined developmental tasks as “broad dimensions of effective behavior evaluated in comparison to normative expectations for people of a given age” (p. 1636). They observed three areas of competence in late childhood and adolescence (academic achievement, rule-abiding conduct, and getting along with peers) and two additional areas that emerge in adolescence (holding a job for pay and romantic relationships). Using structural equation modeling techniques, they examined the coherence of these areas of competence and demonstrated the continuity of the three childhood areas into late adoles-

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Promoting Health: Intervention Strategies from Social and Behavioral Research cence. Notably, rule-abiding or rule-breaking conduct in late childhood strongly predicted such conduct in adolescence, thus “demonstrating the stability of anti-social behavior by late childhood” (Masten et al., 1995, p. 1654). Adolescent conduct problems in adolescence were also associated with lower academic achievement and being able to hold a job. This suggests that focusing attention on early conduct problems and competencies in childhood should be beneficial for academic and job achievements, as well as reducing conduct problems, in adolescence (Moffitt, 1993; Masten et al., 1995). Additionally, this study strongly underlines the need to examine early precursors to some adolescent behaviors as an avenue to early prevention and intervention. The promotion of positive youth development is complementary to the goal of healthfully achieving the developmental tasks of childhood or adolescence (Catalano et al., 1999). As Bronfenbrenner and Morris (1998, p. 996) note: Especially in its early phases, but also throughout the life course, human development takes place through progressively more complex reciprocal interactions between an active, evolving, biopsychological human organism and the person, objects, and symbols in its immediate external environment. To be effective, the interaction must occur on a fairly regular basis over extended periods of time. The authors then describe the developmental process for adolescents as a series of interactions within particular social contexts—families, schools, neighborhoods, and communities—that progressively shape young people and their behavior (lessor, 1993). These interactions, and resulting behavior, are also determined by the time in history and the culture of the young person (Elder, 1974; Hine, 1999; Vega and Gil, 1998). Thus, the way in which youth develop, and whether they have the resources and environmental supports to achieve developmental tasks, serve as the background against which healthful or unhealthful behavior in the United States should be examined. Threats to Health Among Preadolescents and Adolescents Adolescence is the developmental period that has been characterized as the physically healthiest in the life cycle: adolescents have outgrown most of the childhood infectious diseases and are not yet old enough to suffer from the chronic diseases that plague adults (Ozer, Brindis et al., 1998). Yet, even a brief review of adolescent health issues suggests otherwise. Adolescents engage in a range of behaviors that impact their current and future risk of injury or premature death; many of these behaviors have their onset during this developmental stage (Blum, 1998; Perry, 1999b). The United States continues to lead the developed world in adolescent mortality rates, even though there has been a significant decline in these rates in the past 10 years (Blum, 1998). Unintentional injuries, homicide, and suicide are the primary causes of adolescent mortality, accounting for four out of five deaths (Ozer et al., 1998). Among these deaths, more than half are due to motor vehicle collisions (CDC, 1993), and a third of those are related to alcohol use.

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Promoting Health: Intervention Strategies from Social and Behavioral Research Fortunately, the fatal collision rate has been declining since 1980, primarily due to environmental and policy changes such as improved highway construction, safer cars, and a uniform 21-year-old drinking age (Blum, 1998). Of recent concern is the startling increase in the young adolescent suicide rate, which has risen 35% since 1990 among those 10 to 14 years old (Blum, 1998). The mortality rates among adolescents show notable differences by ethnic or racial group and gender. Although there has been a 14% decline overall in mortality rates over the past decade, there has been a 17% decline among white males, and an 11% increase among African American males (Blum, 1998). Also among African American males, death from homicide is nine times higher than among white males, reaching epidemic proportions (Ozer et al., 1998). Suicide rates, however, are higher among white adolescents. In general, males are more likely than females to die from any type of injury (although females are more likely to attempt suicide, males are more likely to commit suicide). Among those 15–19 years old, males are about two times more likely to die of any unintentional injury and five times more likely to die of homicide or suicide than females (Ozer et al., 1998). The major causes of adolescent morbidity are also behavioral, with differences in subgroups of adolescents who engage in particular risk-related behaviors, as shown in Table 1. The behaviors of most concern are tobacco, alcohol, and drug use; precocious and unprotected sexual behavior; unhealthful eating practices; sedentariness; violence; and deviant, risky behaviors. Although these are being reviewed separately, there is significant covariation among these health behaviors, making some adolescents at increased risk for a range of short-term and long-term health problems (Jessor and Jessor, 1977; U.S. DHHS, 1994; Lytle et al., 1995). Drug Use The gateway drugs—tobacco, alcohol, and marijuana—require particular attention during adolescence because they are initiated during this period; cause injury, illness, and death during adolescence and in adulthood; and are precursors to “heavier” drugs such as cocaine, hallucinogens, and heroin (U.S. DHHS, 1994). In addition, the majority of adolescents in the United States engages in each of these behaviors before they graduate from high school—74% have tried a cigarette, 84% have had an alcoholic drink, and 52% have used marijuana (CDC, 1998). Clearly, societal and personal decisions concerning tobacco, alcohol, and marijuana use are an integral part of examining adolescence in the United States, as the entire population can be considered “at risk.” There are important differences in tobacco, alcohol, and marijuana use by ethnic or racial group and gender. These differences are particularly important to note as the United States continues to become increasingly multicultural (Vega and Gil, 1998). Overall, African American adolescents smoke, drink, and use illegal drugs at significantly lower rates than white and Hispanic adolescents

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Promoting Health: Intervention Strategies from Social and Behavioral Research TABLE 1 Adolescent Health Risk Behaviors: Prevalence and Risk Status by Racial or Ethnic Group and Gender   Prevalence (%) Greatest Risk by Race or Ethnicitya By Genderb Behavior 9th–12th Grades Whites Blacks Hispanics Asians American Indians Female Male Smoking (past month) 36.4% X   X X X Alcohol use (past month) 50.8% X   X   X   X Marijuana use (past month) 26.2% X   X   X   X Sexual intercourse (ever) 48.4%   X X   X   X Pregnant or made pregnant (ever) 6.5%   X X   X   High fat intake (past day) 37.7%   X   X Insufficient fruits and vegetables (past day) 70.7%   X   Dieting (past month) 39.7% X   X   X   Insufficient vigorous activity (3 times in past week) 36.2%   X X   X   Fighting (past year) 36.6%   X X X   X Carried weapon (past month) 18.3%   X   X Carried gun (past month) 5.9%   X X   X Riding with a drinking driver (past month) 36.6%   X   Drove after drinking (past month) 16.9% X * X   X aDoes not take into account subcategories of racial or ethnic groups or acculturation. Data are from the 1997 Youth Risk Behavior Surveillance System for white, black, and Hispanic high school students (CDC, 1998). Data for American Indians and Asians come from the Monitoring the Future Study and other non-nationally representative studies (U.S. DHHS, 1998) for drug use, sexual behavior, and fighting only. bMales were significantly more likely than females to report smokeless tobacco use and episodic heavy drinking, and to initiate sexual intercourse at a younger age.

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Promoting Health: Intervention Strategies from Social and Behavioral Research CDC, 1998). White students are more likely to smoke cigarettes than Hispanic students (U.S. DHHS, 1998). National data from American Indian and Asian students have only recently become available from the Monitoring the Future study (Johnston et al., 1998; U.S. DHHS, 1998), and rates of tobacco, alcohol, and marijuana use among American Indians are consistently as high or higher than among white students, while Asian students' use was similar to African Americans and lower than other racial or ethnic groups (Beauvais, 1992; Gruber et al., 1996; Neumark-Sztainer et al., 1996; Epstein et al., 1998; U.S. DHHS, 1998; Chen et al., 1999). Several authors make note, and this is relevant across all behaviors, that the classification of ethnic or racial groups masks significant differences within groups, such as differences between American Indian tribal groups and whether they live on or off reservation lands, and subcategories of Asians (Chinese, Japanese, Korean, etc.) and Hispanics (Gruber et al., 1996; Epstein et al., 1998; Bell et al., 1999). The classifications also do not account for levels of acculturation among recent immigrant groups and differences in drug use based on level of acculturation (Vega et al., 1993; Chen et al., 1999). Gender differences in drug use among adolescents are also noted. Males are more likely than females to use smokeless tobacco, engage in episodic heavy drinking, and use marijuana (CDC, 1998), but females now are equally as likely as males to use other substances. Finally, rates of tobacco and marijuana use increased substantially in the 1990s, although that increase may now have leveled off; the increases occurred across all ethnic or racial and gender groups (Johnston et al., 1998). Sexual Behavior Sexual behavior also has its debut in adolescence, with two out of three adolescents reporting having had sexual intercourse prior to high school graduation (CDC, 1998). This sexual activity incurs the risk of pregnancy and infectious diseases, which have significant social, economic, and physical health ramifications (Ozer et al., 1998). Overall, males are more likely to initiate sexual activity earlier than females (Ozer et al., 1998; Upchurch et al., 1998). Black adolescents are more likely than Hispanics and whites to have initiated sexual intercourse, to have had more sexual partners, and to have had begun sexual activity at a younger age (Ozer et al., 1998). Asian adolescents appear to begin sexual activity later (Upchurch et al., 1998; Bell et al., 1999) and American Indian adolescents earlier, than do whites (Gruber et al., 1996; Neumark-Sztainer et al., 1996), but these were not nationally representative samples. In contrast with drug use behavior, sexual behaviors have declined in prevalence since the early 1990s. This decline occurred after a steady two-decade increase in the percentage of adolescents engaging in sexual activity. The decline is associated with changes in related sexual behaviors. About 75% of teens report using contraceptives at first intercourse (up from 62% in 1988) and 54% report using condoms (Ozer et al., 1998). Condom use is more prevalent

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Promoting Health: Intervention Strategies from Social and Behavioral Research among younger adolescents, while the use of birth control pills increases with age (Kann et al., 1996). Whites are more likely than blacks or Hispanics to use contraception at first intercourse (Ozer et al., 1998). Similarly, rates of pregnancy also appear to be declining after dramatic increases since the 1970s. Still, 12% of all females ages 15–19 become pregnant each year—19% of black females, 13% of Hispanic females, and 8% of white females. Notably, of the 1 million adolescents who become pregnant each year, most (85%) report that their pregnancy was unintended (Ozer et al., 1998). More than half of these pregnancies result in births and more than a third result in abortion (Ozer et al., 1998). The birth and abortion rates among black and Hispanic adolescent females is about double that of white females. About 70% of these births occur out of wedlock. And, unfortunately, for the children of teenage mothers, there are also consequences—lower birth weight, lower cognitive and socioemotional functioning, and greater likelihood of death during the first year of life. These outcomes are linked to lower socioeconomic status, which is both a predictive factor for teenage pregnancy and an outcome of the limited opportunities and instability that are associated with being a teenage mother (Irwin and Shafer, 1992). Sexual behavior may also result in sexually transmitted diseases, with adolescents at greater risk for these infectious diseases than any other age group (Irwin and Shafer, 1992). Chlamydia is most prevalent, affecting about 2% of female adolescents ages 15–19 (CDC, 1997). Gonorrhea and syphilis decreased in the 1990s; both of these infectious diseases are most prevalent among black adolescents (Ozer et al., 1998). Finally, although AIDS cases among adolescents are rare because of the 10-year incubation period, many adolescents become infected with HIV that will become manifest when they are in their 20s. Young adults, ages 20–29, comprise nearly one-fifth of the AIDS cases in the United States. Thus, teenage sexual behavior, while now appearing to decline, has increased dramatically in the past 25 years. The outcomes—teenage pregnancy, abortion, out-of-wedlock births, sexually transmitted diseases, and HIV—have significant implications for the future for these young people as well as for the next generation of young people in the United States. Eating Behaviors and Physical Activity In comparison with drug use, violence, and sexual behavior, eating and exercise may seem like relatively benign behavioral areas for adolescents. Yet eating behaviors significantly affect growth during adolescence (Story, 1992), are the second leading cause of cancer (World Cancer Research Fund, 1997), and track from adolescence to adulthood (Perry et al., 1997). Sedentary behavior contributes to obesity and chronic diseases, with activity patterns forming and tracking in childhood and adolescence (Kelder et al., 1994; U.S. DHHS, 1996; Troiano and Flegal, 1998). The primary diet-related concerns among adolescents involve overconsumption of fat, overweight and obesity, unsafe weight-loss methods, eating

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Promoting Health: Intervention Strategies from Social and Behavioral Research disorders, and insufficient intake of fruits, vegetables, and calcium. Most adolescents do not eat a diet that meets the U.S. Department of Agriculture's (1995) Guidelines for Americans (Perry et al., 1997). National data show that children and adolescents, more than any other age group, are more likely to exceed the recommendations for fat and saturated fat, with more than 90% of adolescent males consuming more than 30% of their calories from fat (Kennedy and Goldberg, 1995). Black adolescents are more likely than Hispanic and white adolescents to eat more servings of high-fat food per day (CDC, 1998). On the other hand, adolescents are not eating sufficient fruits and vegetables—only 29% eat the recommended five servings per day. Males are more likely to eat five or more servings per day than females (32% vs. 26%). In addition, the low intake of calcium is of special concern to female adolescents. Females ages 12–19 consume only 68% of the recommended amount of calcium, making it unlikely that many adolescent females will reach their full biological potential for bone mass development and making it more likely they will experience osteoporosis later in life (Kennedy and Goldberg, 1995). Obesity is now considered the most prevalent nutrition-related health problem of children and adolescents in the United States. (Dietz, 1998). The current generation of children and adolescents will grow up to be the most obese adults in American history (Hill and Trowbridge, 1998). Although many of the outcomes of being obese or overweight during adolescence are social, such as discrimination and more negative self-images, there is now evidence that being obese contributes to earlier physical maturation, increased blood lipid levels, and diabetes among adolescents (Dietz, 1998). The Third National Health and Nutrition Examination Survey (NHANES III) data indicate that about 11% of children and adolescents ages 6–17 are overweight, compared with a 5% expected prevalence (Troiano et al., 1995; Troiano and Flegal, 1998). In other words, the prevalence of overweight children and adolescents has doubled in the past 20 years. About one-quarter of children and adolescents are in the upper 85th percentile for weight, compared with the expected prevalence of 15%, placing them at risk for continued overweight and obesity into adulthood. Black and Hispanic females were more likely to be overweight than white females (Troiano and Flegal, 1998). However, females were not more likely to be overweight than males, except among African Americans (Troiano and Flegal, 1998). In the 1997 Youth Risk Behavior Survey, 27% of high school students reported they were overweight (CDC, 1998). Females were more likely to report being overweight than males; and Hispanic students were more likely than black students to report being overweight (CDC, 1998). Notably, perceptions of being overweight did not necessarily correspond with objective measures, particularly between the genders. Correspondingly, about 40% of high school students report trying to lose weight in the past month—60% of females and 23% of males. Healthy weight loss behaviors (such as moderate exercise, decrease in snacks, decrease in fat intake) are more prevalent than unhealthy practices (such as fasting, diet pills, laxatives, vomiting; French et al., 1995). Still, nearly 5% of students reported taking laxatives or vomiting, and 5% had taken diet pills, to control weight in

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Promoting Health: Intervention Strategies from Social and Behavioral Research the month prior to the survey (CDC, 1998); 30% of students dieted and 52% exercised to control their weight. Females were significantly more likely to use all forms of dieting methods than males. Hispanic and white students were more likely than black students to diet or exercise to lose weight; Hispanic students were more likely than white students to use laxatives or vomiting to control weight (CDC, 1998). In one study, American Indian females were more likely to engage in unhealthy weight loss practices than whites, while Asians were less likely (Neumark-Sztainer et al., 1996) Despite some evidence that African American females are heavier than Hispanic and white females, they are more likely to be satisfied with their weight and body image, and have a lower prevalence of eating disorders (Resnicow et al., 1997). The prevalence of eating disorders ranges from 1 to 5% among adolescent females and is associated with serious outcomes (Perry et al., 1997). Physical activity significantly declines during adolescence for both males and females, despite the benefits of regular exercise for weight control, mental health, and the prevention of osteoporosis, cardiovascular diseases, and cancer (Kelder et al., 1995; U.S. DHHS, 1996; CDC, 1998; Kohl and Hobbs, 1998). Overall, 64% of high school students participate in vigorous physical activities on three or more days each week, with male students (72%) more likely to exercise than female students (54%), and white students (67%) more likely than Hispanic (60%) or black (54%) students to participate in vigorous physical activity (CDC, 1998). Still, 14% of young people reported no recent physical activity. Violence and Other Risky Behaviors Violent behavior by adolescents both on school property and in the community has been a topic of national discussion and debate for the past few years, prompted by several tragic school shootings. In fact, adolescents in the United States have relatively easy access to weapons and guns (Komro, 1999); overall, 18% of high school students reported having carried a weapon during the month prior to the survey and 6% reported having carried a gun (CDC, 1998). Males (28%) were more likely than females (7%) to have carried a weapon and a gun; black (9%) and Hispanic (10%) students were more likely than white (4%) students to have carried a gun (CDC, 1998). Nearly half of male students and one-fourth of female students had been in a physical fight during the year prior to the survey. Black, Hispanic, and Asian students were more likely than white students to have been in a physical fight on school property (Hill and Drolet, 1999). Reported physical fighting decreases as students get older (CDC, 1998). Still, among older males ages 18–21, about one-third reported carrying a gun in the month prior to the survey (Ozer et al., 1998). Adolescents engage in other behaviors that put them at risk for unintentional injury, including driving after drinking, driving at high speeds, riding with a driver who has been drinking, and not using seat belts, motorcycle helmets, or bicycle helmets. Since motor vehicle collisions are the primary cause of death for adolescents, these behaviors are of considerable concern during

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Promoting Health: Intervention Strategies from Social and Behavioral Research portant to continue to guide this process. First, there needs to be more research on interventions with varied cultural and ethnic groups, and by gender, specifically concerning behaviors where they are at greater risk. This has already been forthcoming from various funding agencies, but needs to be underscored, given the high rates of some risk behaviors in these groups. Second, there needs to be research on timing of interventions. For example, long-term outcomes were observed for an eating pattern intervention that was implemented with third through fifth graders, but such outcomes have not been observed with drug use interventions (Nader et al., 1999). There may be targeted programs that will be most efficacious at particular times in a young person's life. Third, the types of competencies, skills, or opportunities for adolescents that might influence their behavior need to be more fully explored and expanded and included in intervention research, and might include self-management, communication, academic planning, character building, community organizing, and even spiritual skills. For example, in Project Northland, students ' self-evaluation of their own wisdom (including harmony and warmth, intelligence, and spirituality scales) was significantly predictive of their alcohol, tobacco, and marijuana use and their violence at 12th grade (Jason et al., in press). These new areas may be alternative avenues or skills for adolescents, with multiple potential outcomes. Fourth, we must have greater knowledge of the needed competencies for schools, neighborhoods, families, clinics, and communities that work with and serve adolescents, and importantly, how these competencies can be taught, promoted, or disseminated. This is particularly critical for communities with varied ethnic or racial groups or with recent immigrants. Fifth, dissemination research should be supported, since outcomes found in controlled trials often cannot be replicated when more broadly implemented (DiClemente and Wingood, 1998; Perry, 1999b). Finally, policy research, where changing public policy is the goal, should be encouraged, to learn about the process and outcomes of policy changes that affect adolescents. It is clear that we need much more than competent adolescents—we need to create and provide a social environment for them that is competent and compassionate as well. The American experiment has had some side effects in the latter part of the twentieth century. While countries such as India, China, Japan, and Singapore have relatively few problems with their adolescents, the United States continues to have significant and, in some cases, growing problems among its youth. While turning the clock back a century, or adopting social policies from Asia, are not feasible solutions to these concerns, it might be useful to examine social contexts in which the overwhelming majority of youth are healthful, productive, and content. How many hours do they spend in school? Do they spend significant time unsupervised? Are they involved in food preparation? Are there safe places to walk or bicycle to be with friends? Is academic achievement rewarded throughout the community? And so forth. This might lead to broader societal changes, alternative solutions, or creative options that may have salutary effects on adolescents and their health behaviors in the twenty-first century.

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