Addressing Challenges and Promoting the Healthy Development of Adolescents
There is an interesting contradiction with respect to adolescent health. While adolescence is one of the healthiest periods in the life span—characterized by relatively low incidence of disabling or chronic illnesses, low rates of morbidity and mortality associated with illness or disease, fewer short-term hospital stays, and fewer days away from school because of illness—adolescence is a time when young people are at high risk for engaging in behaviors that can result in poor health outcomes. As mentioned earlier, the U.S. Centers for Disease Control and Prevention has noted that six categories of behavior are responsible for 70 percent of adolescent mortality and morbidity: unintentional and intentional injuries, drug and alcohol abuse, sexually transmitted diseases and unintended pregnancies, diseases associated with tobacco use, illnesses resulting from inadequate physical activity, and health problems due to inadequate dietary patterns.
Fifty years ago, the majority of deaths among adolescents were attributed to natural causes, but there has been a steady decrease in adolescent deaths from cancer, heart disease, and cardiovascular disease. Those declines have been offset in part by steady increases in other leading causes of death and injury. Since the early 1980s, for example, adolescent deaths from homicide, suicide, and the complications of HIV infection have increased. Furthermore, the rates of teenage pregnancy, sexually transmitted diseases, and drug use have either increased or remained at high levels relative to those observed in other countries. Indeed, mortality rates for adolescents have increased since the mid-1980s. Teenage deaths by violence
are directly related to economic and social conditions in low-income neighborhoods and to the availability of guns in American society. The rise in teenage homicide and suicide also suggests increasingly high levels of hopelessness, grief, and anger among adolescents. Because of high injury and violence rates, young people in the United States are far more likely to die during adolescence than teenagers in other industrialized countries. Perhaps most important is the fact that the most salient causes of adolescent mortality and morbidity are entirely preventable.
Adolescence is characterized by exploration and experimentation, behaviors that to some extent are developmentally appropriate and socially adaptive, even if they involve a certain amount of risk-taking. Risk-taking involves, among other things, exploration, imagination, developing new and more intimate relationships with peers, testing new levels of independence, establishing a new identity, developing values, unleashing creativity, trying on different hats to see what fits. Carried to extremes, however, risky behaviors may impair mental and physical health. And health risks, such as pregnancy and substance use, may be problems not just when they happen; the consequences of these acts can reach far into the future, and their antecedents are very likely to emerge even before adolescence. But just as adolescence is a time when damaging patterns of behavior can begin to take hold, it also represents an excellent opportunity for the formation of healthful practices.
SEXUAL RISK, UNINTENDED PREGNANCY, AND SEXUALLY TRANSMITTED DISEASES
A large proportion of adolescents in the United States are engaging in sexual activity and at earlier ages than before, often without the knowledge or skills required to protect themselves from unintended pregnancies and infection with sexually transmitted diseases, including HIV. Studies show that by the 12th grade, nearly 70 percent of adolescents have had sexual intercourse, and approximately a quarter of all students have had sex with four or more partners. This puts many adolescents at high risk for unintended pregnancy, increased incidence of sexually transmitted diseases, and a host of emotional problems associated with a lack of preparation for sex.
For teenagers of different ages, at different stages of cognitive and emotional development, and living under different social, economic, and cultural circumstances, choices concerning sexual behavior reflect very different degrees of rational thinking and conscious decision making. A
substantial body of research exists on the variety of individual, family, and social factors associated with adolescent sexual activity. Indeed, research suggests that a number of factors are strongly associated with the initiation of sexual activity before marriage. Among the most important of these are individual characteristics, such as puberty and other developmental characteristics, age, race and socioeconomic status, religiousness, intelligence and academic achievement, and dating behavior; family characteristics, such as family background and parental support and controls; and the influence of peer groups. Thus, although there appears to be a strong relationship between pubertal development, hormone levels, and sexual activity, social factors do intervene in determining when and how both boys and girls initiate sexual intercourse, given maturation.
A substantial body of literature emphasizes the importance of parents and other family members. A number of studies have found that the nature of teenagers' relationship with their parents affects their sexual behavior. As previously discussed, there is growing consensus that adolescents with parents who provide guidance, discipline, and close supervision are significantly less likely to engage in the kinds of behaviors that put them at risk for poor health outcomes—unintended pregnancy, infection with sexually transmitted diseases, involvement in antisocial behaviors, use of drugs—and they are more likely to experience success with their peers and at school. There is also a large body of evidence to suggest that if teenage girls have good lines of communication with their mothers and use their mothers as a source of information about birth control, they are significantly more likely to use contraception. This evidence further emphasizes the importance of parents during the adolescent years and the need for connectedness between adolescents and their parents.
Peers are often cited as the single most important factor affecting the initiation of intercourse by adolescents. It appears, however, that peer influence may have been overrated, particularly for males. However, same-gender peers do appear to be a major source of information about sex. Peer pressure can take several forms (e.g., challenges and dares, coercion, social acceptability), and its influence seems to vary among young people of different ages and genders. Because adolescence in general is a period in which children's orientation shifts away from parents toward peers, it seems likely that peer influence varies according to age. As teens get older, peers become more influential. Although existing research is not conclusive, it also seems likely that the relative influence of peers and parents may also vary depending on the issue. For example, parents may be more important in
teenagers' establishing life goals and developing aspirations, whereas peers and sexual partners may be more important in forming attitudes about sexual activity. With respect to infection with sexually transmitted diseases, peers also play a role in limiting or increasing a teenager's risk of exposure to infectious agents. Through social diffusion, sexually transmitted diseases including HIV are transmitted within the social and sexual networks of infected people. The characteristics of these networks, including how often and with whom adolescents engage in unprotected sexual intercourse within them, appear to determine the rate and extent of spread both within and between local networks. Networks are placed at risk because individual members of one network may have connections to other networks.
Increasingly, adolescents are also believed to be at increasing risk for early initiation of sexual intercourse, unprotected sexual intercourse, unintended pregnancy, and infection with sexually transmitted diseases, because they are exposed to mixed and inconsistent messages from their families, their peers, the community, and the mass media regarding what is expected, appropriate, and socially desirable behavior. Moreover, as the sheer volume of violent images and themes on television increases, there is growing concern that children are becoming "numb" or desensitized to this violence. As a result, there has been growing concern about the role the media plays in encouraging a wide range of harmful or negative behaviors among children and adolescents.
Since the 1960s, television has been a significant vehicle for transmitting information, communicating ideas, and influencing culture. For adolescents growing up in the 1960s, the 1970s, and the 1980s, television was a dominant aspect of their lives. Now, in the 1990s, as much as 40 percent of adolescents' time is spent watching television, listening to the radio or compact discs (CDs), watching music videos, playing on the Internet, and playing video games—all of which send unbalanced and often confusing messages about sexuality, sexual behavior, and sexual responsibility. Pre-marital sex, cohabitation, and nonmarital relationships are often depicted as the norm for adults. And little frank or informed advice is offered about sexually transmitted diseases, sexuality, contraception, or the harsh realities of early pregnancy and parenting.
Throughout the 1980s and 1990s, television was the most significant mass media influence on adolescents. On average, about a third of Americans' recreational time is spent watching television. That is more time than is spent on the next 10 most popular leisure activities combined; children spend more hours watching television than they spend in school each day.
Television is an important source of information regarding sexual behavior: 37 percent of men and 41 percent of women surveyed cite television talk shows as a primary source of information regarding sexually transmitted diseases.
In addition to serving as a source of information, mass media may influence social attitudes and sometimes social behavior. For example, violence depicted in the mass media has been shown to be a significant factor in real-life violence. The degree to which sexual content in mass media directly affects sexual behavior is unclear because appropriate longitudinal studies have not been conducted, but such content has been shown to influence adolescents' attitudes and beliefs regarding sex. One study found an association between frequent viewing of television programs with strong sexual content and the early onset of sexual intercourse among adolescents, but it was not possible to determine the direction of causation. Another study that examined the influence of mass media on eight potentially risky behaviors, including sexual intercourse, found that adolescents who had engaged in more risky behaviors listened to radio and watched music videos and movies on television more frequently than those who had engaged in fewer risky behaviors, independent of demographic factors.
As of 1993, one-quarter of the 12 million new cases of sexually transmitted diseases each year occurred among adolescents. There is clear evidence that rates of infection are highest among adolescents and young adults (up to age 24) compared with older adults. Adolescents' increased risk for infections with sexually transmitted diseases has been found to be associated with high rates of unprotected sexual intercourse and the fact that adolescent girls and young women are biologically more susceptible to infection. Lack of accurate information about their risk is certainly one barrier to preventing these infections among teenagers. However, there are a number of other barriers as well, including but not limited to the fact that many adolescents do not have access to free condoms, and they lack the confidence and behavioral skills to use them properly.
Increasingly, school-and community-based education and prevention programs, as well as public service announcements, are alerting adolescents to the fact that they are at risk for infection with sexually transmitted diseases. The programs work with teenagers to provide them with the information and skills they need to protect themselves from sexually transmitted diseases and unintended pregnancy. They also help to include them in decision making, develop assertiveness and communication skills required
to delay initiation of sexual intercourse, avoid unwanted intercourse, and effectively negotiate "safe sex" practices and effective condom use.
Mass media could also play an important role in helping teens protect themselves by airing messages that discourage them from prematurely engaging in sexual behaviors (i.e., before they are emotionally ready or feel comfortable doing so) and encourage them to protect themselves through condom use. Indeed, comprehensive public health messages regarding sexually transmitted diseases, including HIV infection, sexual abuse, and unintended pregnancy, have already shown promise for reducing these risks among adolescents and young adults. Opinion polls show that most Americans support making information regarding sexually transmitted diseases and contraceptives available in the mass media, including the advertising of condoms on television.
For their part, television networks have traditionally banned advertisements for contraceptives until very recently. Condom advertisements on television have been controversial ever since the first such advertisement in 1975. It was not until 1986 that the word "condom" was first used on prime-time television. Recently, the U.S. Centers for Disease Control and Prevention had to fight to use the word "condom" in its public service announcements on HIV prevention. Despite agreeing to air recent announcements about HIV prevention promoting condoms, the networks have restricted the messages to non-prime-time hours. Primarily as a result of the HIV epidemic, in 1991 the Fox Broadcasting Company became the first national television network to run a condom commercial, and some network-owned stations recently have begun to accept condom advertisements, with certain restrictions and so long as they are in "good taste." Some networks, such as Fox and MTV, have been less restrictive in accepting condom advertisements.
Condom use has increased in the past decade, reaching especially high levels among adolescents in part because of these advertisements. Other factors likely to have influenced adolescents' use of condoms include school-based education campaigns and community-based outreach programs. However, condom use tends to decrease as men get older. Although the measures are not completely comparable across the two datasets used, there is clearly a negative association between condom use and age. Even among adolescents ages 15 to 19, there appears to be a decrease in condom use by age, reflecting movement to female methods after initial sexual experiences, during which condoms are often used. One study reports that 16-year-old males who are sexually active use condoms more than 19-year-olds.
Condom use also varies by racial and ethnic affiliation. Black men are the most likely to report using condoms at all ages. Among adolescents, black males use condoms at higher rates than either Hispanic or white males. Although condom use among black adolescent males is higher at last intercourse than among white adolescents, condom use at first intercourse is lower. Since black males, on average, initiate sex about one year earlier than white males, and since earlier ages of first intercourse are associated with less use of contraception, some of the racial difference in condom use at first intercourse is attributable to differences in age at initiation. However, after age at initiation is controlled along with other confounding variables, being a young black man continues to be associated with lower condom use at first intercourse.
Adolescents may face particular barriers in obtaining the more effective methods of contraception. Circumstances vary under which family planning providers will make services available to adolescents, especially if there is no parental involvement. One federal program was designed in part to increase access to contraception among adolescents, but the limited financing and reach of the program means that barriers to access continue to exist for this age group in some circumstances.
Of the many risks associated with early sexual activity, unintended pregnancy and infection with sexually transmitted diseases is perhaps the most widespread. Numerous studies of adolescents have clearly shown that many also have very limited and often faulty information about when fertility begins, the timing of fertility within the menstrual cycle, and the probability of conception. Such misinformation can lead to poor contraceptive use and therefore unintended pregnancy and sexually transmitted diseases.
The proportion of births to unmarried women, including adolescent females, continues to rise. These birth rates, which had declined steadily since World War II, began rising again in 1985, and by 1989 were higher than they had been since the early 1970s. Births to unmarried women represented 15 percent of all births to adolescents in 1960 and 30 percent in 1970; in 1989 over 67 percent of teenage mothers were unmarried, including 92 percent of black teenage mothers.
Because teenage mothers tend to be economically disadvantaged prior to giving birth, it has been difficult to disentangle the consequences of giving birth as a teenager from those of prior disadvantage. Consequences fall both on the young mothers themselves, and on their children. There is evidence to suggest that children of adolescents are at high risk for a wide
range of poor outcomes, including health, developmental, and academic problems. As adolescents, children of adolescent mothers are far more likely than those of older mothers to do poorly in school and to engage in high-risk behaviors, including early sexual intercourse and adolescent pregnancy.
Cultural differences may influence the ways that young parents respond to the responsibilities of childrearing: for example, white mothers appear more likely to marry to legitimize their child; blacks are more likely to incorporate the mother and her infant into an extended household, with other adults—usually the adolescent's mother or maternal grandmother or both—assisting with child care. Living with other adults appears to benefit adolescent mothers, who are more likely to complete high school and be employed than those who marry and live in a separate household. Among adolescent mothers receiving Aid to Families with Dependent Children (prior to 1996), blacks were more likely than whites to remain in their parents' home after giving birth, continuing schooling, and delaying marriage; they stayed longer on welfare but were more likely to graduate from high school.
Although much public attention has been given to the growing number of births to unmarried women and to teenage pregnancies, it is only recently that attention has focused on adolescent fathers. Teenage fathers are more likely to come from an economically disadvantaged family and to have completed fewer years of schooling than their childless peers. Although teenage fathers earn more money than their childless counterparts up to age 20, by age 29, those who deferred fatherhood earn roughly 74 percent more than teenage fathers. Teenage fathers are also more likely than their childless peers to commit and be convicted of illegal activity, and their offenses are of a more serious nature. Given their low educational attainment and low earnings, it is not surprising that absent teenage fathers are less likely to pay child support than those who father children in their 20s.
Few men who father children outside marriage subsequently marry the mothers of those children and live with them. But not living in the same household does not necessarily mean lack of involvement with their children. As reported in one study, nearly 80 percent of unmarried fathers who lived near their children visited them every day or several times a week. Ethnographic work also suggests that inner-city young black males usually acknowledged their paternity and that the community supported the young father's participation in informal child support arrangements.
It is often the case that teenage fathers want to spend time with their children, and there is good reason to believe that it is in the best interest of
the mother and child to have the father involved. When fathers spend time with their children, research has found them as nurturing as mothers, but in slightly different ways. For example, fathers engaged in more physical play with their children than do mothers. Thus, fathers appear to make a significant and perhaps unique contribution to children's emotional and social development.
A number of programs aimed at encouraging the involvement of young fathers with their children have been developed in recent years. Some of these programs are aimed primarily at improving the educational, parenting, and job skills of young fathers to allow them to better support and interact with their children. Some programs try to capitalize on the desire for involvement, dealing with individual responsibility and self-improvement rather than job training. Few programs, however, have been rigorously evaluated.
TOBACCO, ALCOHOL, AND ILLICIT DRUGS
Cigarette smoking is the leading cause of avoidable death in the United States. Most smokers begin smoking during childhood and adolescence, with nicotine addiction beginning during the first few years of tobacco use. Decades of research show that, if people do not begin to use tobacco as youngsters, they are highly unlikely to initiate use as adults. Minors consume at least 516 million packs of cigarettes per year, and at least half of those are sold to them illegally. The average age of beginning smoking is 14.5 years; the average age when people become a daily smoker is 17.7 years; of those who have ever smoked daily, 71 percent have done so by age 18.
Many young people are erroneously led to believe that tobacco consumption is widespread among adults, is a social norm among attractive people, and is widespread among vital, successful people who seek to express their individuality, enjoy life, and are socially secure. This message is driven home to children and adolescents by their near-constant exposure to pro-tobacco messages and images (e.g., neighborhood billboards). They also attend cultural and sporting events either sponsored by the tobacco industry or where tobacco logos are prominently displayed.
Research has begun to document the fact that adolescents have a heightened sensitivity to image advertising and promotion, since they are often struggling to define their own identities. Cigarette advertisements are often evocative, play off teenage anxieties, and are positioned to appeal
to specific groups defined by social class and ethnic identity. Early adolescence (ages 10 to 14) in particular may be a time of increased susceptibility to the appeal of advertising that promotes certain images attractive to young teenagers.
Clearly, adolescents who choose to use tobacco perceive greater benefits relative to risks. What is most striking, however, is the nature of the trade-off. When children and adolescents begin to use tobacco, they tend to do so for reasons that are transient in nature and closely linked to specific developmental tasks—for example, to assert independence and achieve perceived adult status, or to identify with and establish social bonds with peers who use tobacco. Adolescents who smoke tend to be heavily influenced by their perception of potential social benefits.
With regard to alcohol use, young people of junior high school age drink to a greater extent than was true a generation ago: a larger percentage of them drink, they have their first drinking experience earlier, they drink larger quantities, and they report more frequent intoxication. Furthermore, the generational shift is greater for adolescent girls than for adolescent boys; although girls still do, by and large, drink less than boys, the percentage who drink and who report intoxication experiences has increased more rapidly for girls than for boys.
Marijuana use is often referred to as a gateway drug to other illicit drug use—i.e., other than alcohol, it is often the drug used first, before other drugs such as cocaine, amphetamines, hallucinogenics, and heroin. Throughout the 1980s, national surveys of high school seniors reported a dramatic decline in marijuana use and a general decline in use of other illicit drugs. However, there was a reversal in this trend in the 1990s, particularly among younger students, for the use of various types of illicit drugs, marijuana being most notable.
Adolescents who use alcohol and other drugs recreationally are at greater risk for developing significant health problems resulting from abuse and dependence. Although the patterns, prevalence, and consequences of alcohol, tobacco, and illicit drug abuse in youth populations are not fully understood, a number of individual personality characteristics have been found to be associated with the onset of drinking and illicit drug use among adolescents. They include positive attitudes toward alcohol and other drug use, rebelliousness, tolerance of deviant behavior, low school achievement, lower expectations about academic achievement, and greater opposition to authority. It has also been found that alcohol and other drug abuse and mental health problems often occur simultaneously. Mental health prob-
lems that have been found to be associated with increased risk of alcohol and other drug abuse include conduct disorders, attention deficit disorder, and anxiety disorders, particularly phobias and depression. Research has also shown a high degree of overlap between disruptive behavior and drug use in older adolescents, particularly those with a cooccurring conduct disorder.
A number of family factors have also been found to be associated with drug use and abuse among adolescents, including poor quality of the child-parent relationship, family disruption (e.g., divorce and acute or chronic stress), poor parenting, parent or sibling drug use, parental attitudes that are sympathetic to drug use, and neglect.
The peer environment can also make a substantial contribution to alcohol and other drug use. Among older adolescents, peers have a greater effect than parents on alcohol and other drug use and abuse. Typically, adolescent alcohol and other drug use takes place in the company of peers. Peer influence on drug use and abuse may occur in a mutually reinforcing pattern based on the tendency for drug-using adolescents to select similar peers. Studies have not yet demonstrated, however, the influence of peers in the transition from experimental use of alcohol and other drugs to actual abuse (i.e., increased frequency of use, sustained use, and symptoms associated with tolerance and withdrawal).
The sociocultural factors that can have an impact on drug use or abuse include community patterns of drug use. Living in a community with high rates of crime, ready availability of drugs, association with delinquent peers, and acceptance of drug use and abuse are all associated with drug abuse. The larger sociocultural environment also plays a part: alcohol, tobacco, and illicit drugs are frequently reported by news media as having been used by sports and entertainment figures. In addition, social and legal policies (taxes, restrictions on conditions of purchase and use, legal status, and enforcement) can have important effects on access to substances, and consequently abuse.
Ethnographic research designed to explore various risk factors for drug use and abuse, as well as the impact of drug abuse on the community, suggests that the degree of acculturation and assimilation of individuals who are recent immigrants to the United States has been found to be of some importance as a contextual factor, particularly among Mexican Americans. Specifically, children in families who have recently immigrated to the United States or who are first-generation immigrants are at significantly less risk for a wide range of problems, including alcohol, tobacco, and drug use, compared with children in families who are second-and third-genera-
tion immigrants. Children in families who are second-and third-generation immigrants—i.e., more assimilated and acculturated—are in turn more likely to resemble U.S.-born children.
In many communities of color, individuals may lack access to broader educational, employment, and consequently economic opportunities, which may also be associated with alcohol and other drug use and abuse. For example, white adolescents typically stop using drugs in their mid-20s, when adult roles of employment and marriage are adopted. In contrast, a significant proportion of black young adults continue drug use well into their adulthood and consequently develop substance abuse disorders.
In American Indian communities, unemployment rates are high, resulting in circumstances in which drug use can flourish. Research has shown that alcoholism is a particular health problem on American Indian reservations. Among American Indian adolescents, school failure and high drop-out rates are a serious problem. Also, delinquency and crime are strongly linked to drug use, and gang activity is on the rise among adolescents living on reservations.
Nevertheless, environment—such as communities and neighborhoods—can reinforce a protective sense of self-worth, identity, safety, and environmental mastery. These environmental factors may also serve to protect individuals from drug use and abuse.
Currently more is known about the initiation of drug use than about the transition from use to abuse and dependence. It is clear, however, that adolescents are also vulnerable to the consequences of drug abuse, including health effects, accidents and injuries, violence resulting from illegal activities, and HIV transmission. Adolescent drug abusers differ from adult drug abusers in several ways that are significant for treatment. Of course, adolescent abusers usually have a shorter history of drug abuse; have less severe symptoms of tolerance, craving, and withdrawal; and usually do not have the long-term physical effects of drug abuse. They are, however, at great risk for developing lifelong patterns of drug abuse, which could in turn result in a constellation of negative physical, psychological, and social consequences.
Moreover, the state of knowledge about adolescent treatment is, at best, incomplete. The number of useful studies on adolescents is small, and most of the work that has been conducted in this area is based on studies of treatment outcomes with adults. There are major obstacles to the treatment research with adolescents, such as inconsistent terminology used to refer to adolescent treatment approaches and service components, the use of adult treatment modalities with adolescents, the lack of health care
benefits or coverage for alcohol or drug treatment, and a requirement to obtain parental consent for treatment services.
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