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CHAPTER 10

Adolescent Health

Historical Changes in Adolescence (1 of 3)

Referred to as “youth” (before 1904), which had a connotation of semi-independent participation in economic activities

The term “adolescent: was not in common use until G. Stanley Hall’s publication (1904).

Presently seen as a protected transition time (though may not be universally accepted)

Historical Changes in Adolescence (2 of 3)

Pre-Industrial Revolution

Adolescents and children treated as economic assets

Sometimes fostered out to other families as workers or apprentices

Industrial Revolution (18th and 19th centuries)

Decline in demand for child labor

Increased emphasis on education

Cultural view shift from children as economic assets to beings to be protected

Historical Changes in Adolescence (3 of 3)

Industrial Revolution (18th and 19th centuries)

Extended period of adolescence and dependency

Opportunity for self-exploration of identity, goals, and personal experimentation

Dependent on socioeconomic status, race, and the legacy of slavery

20th century

Markers of the transition to adulthood pushed to older ages

Separation from adults and greater focus on school and peers

Development of a distinct youth culture

Adolescence viewed as a turbulent period of storm, stress, and risk-taking

Demographics: What is Adolescence Today?

Age-based definition: usually refers to those who are in the second decade of life

Definition using biological markers such as the beginning and completion of puberty

Social definitions: leaving family of origin, becoming economically independent, or becoming a legally responsible adult

Demographics: Who Are Adolescents? (1 of 2)

Total adolescent population (10–19 years) increased from 34 million (1990) to ~42 million (2009)

13% of the United States population; 16% of the global population

Becoming increasingly heterogeneous, with the percentage of those who do not consider their heritage primarily European going from 18.5% (1980) to 45% (2025)

87.1% of all young people <18 years lived with two parents in 1970, 67% in 2000

Demographics: Who Are Adolescents? (2 of 2)

Nearly one in five adolescents lived in poverty (2017)

Most adolescents live in suburbs (54%), followed by central cities (27%), rural areas (19%)

Large racial differences

46% of African-American adolescents living with two parents, compared with two-thirds of all adolescents

More than 50% of all African-American youth living in low income or poverty, compared to 1 in 5 for all adolescents

Globally, road injuries, AIDS-related conditions, suicide, lower respiratory infections, and interpersonal violence continue to be leading causes of death for adolescents.

Adolescent Health Status

Generally healthy; exceptions include disparities and unhealthy behaviors

Some health problems of adolescents are preventable.

Certain subpopulations have poorer health status than others.

Several health-related behaviors result in significant adult morbidity and mortality.

The health of adolescents will affect the health of succeeding generations, and the economy.

Data Sources for Adolescent Health

CDC’s Youth Risk Behavior Surveillance System (YRBSS)

National Health Interview Survey

Others: National Survey of Family Growth, The National Survey of Drug Use and Health, University of Michigan’s Monitoring the Future project, National Longitudinal Survey of Youth, National Longitudinal Study of Adolescent to Adult Health

Population-based surveys provide the best estimates of adolescent health status.

Most funded and fielded by federal agencies

Concerns remain about the comprehensiveness of data collected and the validity and reliability of self-reported data

Limitations of Data Sources

Differing age categories

Some do not include nonstudents and higher risk teens, socioeconomic status, indicators of most at risk, gender identity, or sexual orientation

Some require active parental consent.

Inconsistency in reporting behaviors (e.g., weight control activities)

Concerns remain about the comprehensiveness of data collected and the validity and reliability of self-reported data

Data on Well-Being of Adolescents

Positive factors about adolescents prevent and lessen harm from risky behavior

Indicators: rates of high school graduation, volunteering, attending religious services

Parental connectedness and school engagement as positive markers of adolescent well-being

What Influences Adolescent Health

Social determinants of health are the “conditions in the environments in which people are born, live, learn, work, play, worship, and age” that can have profound effects on the health benefits and risks they experience, and on their overall health outcomes. (HealthyPeople.gov, 2020)

The social-ecological model contextualizes factors that contribute to an individual’s health at the interpersonal, organizational/institutional, community, and policy levels.

Morbidity and Mortality

Death higher among males and certain ethnic groups

Disparities result from differences in injury mortality

Injuries, intentional and unintentional, are the major cause of mortality and morbidity among adolescents.

Followed by suicide and homicide

Estimated that for every fatal injury, there are 41 adolescents hospitalized for a nonfatal injury

Unintentional Injuries

Motor vehicle injuries are the leading cause of death (62% of all unintentional injuries).

Of fatal crashes in 2017:

47% of teen drivers were not wearing a seat belt

31% male and 18% female drivers were speeding

24% of teen drivers were drinking alcohol

9% of teen drivers were engaged in distracted driving

Teen male drivers more likely to be involved in a fatal crashes than teen female drivers.

Intentional Injuries and Violence

Since 1999, homicide has been the leading cause of death among Black/African-American adolescents

Since 2016, suicide has been the leading cause of death among Asian/Pacific Islanders

Males are much more likely to be victims of homicide and suicide; racial disparity exists

Adolescents who identify as lesbian, gay, bisexual, transgender, or gender nonconforming have a much greater risk of suicide than their heterosexual or gender-conforming counterparts.

Violence

Bullying and missing school due to safety concerns

In 2017, among high school students:

15% were electronically bullied

19% were bullied at school

7% reported missing school because of safety concerns

Higher percentages of White students report being bullied

Higher percentages of Hispanic and Black/African-American students report missing school due to safety concerns

More females than males report instances of bullying or electronic bullying

School Shooting Incidents

School shooting incidence was slightly cyclical between 1970 and 2020.

2018 and 2019 saw school shootings (116 and 112 incidents) nearly double the next highest year, 2006 (59 incidents)

Active shooter casualties from 2000 to 2017

153 in elementary and secondary schools

147 in post-secondary institutions

Between 1999 and 2018 fatal school shootings were more likely at locations which were:

Predominately White

Rural or suburban

Taught students of elementary-age

School Discipline, Juvenile Justice Contact, and Police Arrests and Shootings

Black students, boys, and students with disabilities are disciplined in K–12 public schools at much higher rates relative to their presence in the population.

Black students are more likely to experience in- and out-of-school suspensions, referrals to law enforcement, expulsions, corporal punishment, and school-related arrests than other races.

Teens of color are more likely to be stopped by police, arrested, and incarcerated than White teens.

Over the lifespan, chances of being killed by police use of force increase 2.5x for Black men and 1.4x for Black women compared to their White counterparts.

Police-related deaths peak at age 20 for Black/African-American males and American Indian/Alaska Native males and females.

Forced Sex and Physical and Sexual Dating Violence

Between 2007 and 2017, approximately 7% of high school students report having been forced to have sex.

Reports of physical and sexual dating violence victimization trended downward between 2013 and 2017.

Black/African-American students are more likely to report physical dating violence than White and Hispanic students.

White and Hispanic students are more likely to report sexual dating violence than Black/African-American students.

Females are more likely than males to report instances of physical and sexual dating violence.

Commercial Sexual Exploitation of Children/Domestic Minor Sex Trafficking (1 of 2)

Commercial sexual exploitation of children (CSEC) encompasses all forms of sexual involvement of minors in underground economies, including sex trafficking, pornography, prostitution, stripping, and other sexual activities for profit.

Domestic minor sex trafficking (DMST) involves “the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act in which a commercial sex act is induced by force, fraud, coercion, or in which the person forced to perform such an act is young than age 18.” (Clawson, Dutch, Solomon, and Grace, 2009, p. 3)

Commercial Sexual Exploitation of Children/Domestic Minor Sex Trafficking (2 of 2)

Disparities exist by race, gender, gender identity, sexual orientation, and levels of physical and cognitive ableness.

Black LGBTQ+ adolescents are more affected by CESC/DMST than White cisgender, heterosexual adolescents.

Risk factors also include child abuse and maltreatment, poverty, caregiver strain, running away or being thrown away, poor mental health, early substance use, involvement in Child Protective Services or juvenile detention, difficulty in school, conflict with parents, and prior rape or sexual victimization.

Violence Toward Lesbian, Gay, and Bisexual Students

In 2018, significantly more lesbian, gay, bisexual, and sexual identity questioning students than heterosexual students reported that they:

Were threatened or injured with a weapon at school

Did not go to school over safety concerns

Were bullied or electronically bullied

Were forced to have sex

Experienced physical or sexual dating violence

Students having sexual contact with only the same sex or with both sexes were more likely to report all these forms of violence than their heterosexual peers.

Substance Use (1 of 2)

Tobacco

In 2019, 31% of high school students and 13% of middle school students reported smoking cigarettes in the past 30 days.

Rates of adolescents who have tried cigarette smoking or actively smoke at any level have declined over the past three decades.

Electronic vapor product use has increased the rate of overall tobacco use.

Alcohol

Similarly, rates of adolescents who drink alcohol have declined over the past three decades.

Racial disparities in use exist.

14% of high school students report instances of binge drinking in the previous 30 days.

Sexual minority youth are much more likely to report ever having consumed alcohol, drinking before age 13, and being active drinkers than heterosexual youth.

Substance Use (2 of 2)

Cannabis

Despite trending toward increasing use over the last three decades, current rates of use have been in decline since 1999.

20% of high school students report having used cannabis within 30 days of being asked.

Prescription drug/opioid misuse

14% of high school students have reported misuse of prescription drugs.

Higher rates in sexual minority students

Stimulant use (Ritalin and Adderall) among college students has risen sharply.

Prevalence of use for cannabis and prescription drugs/opioids is similar among females and males, stimulant use is higher among males.

Sexuality, Contraception, Fertility, and Sexually Transmitted Infections

Small decrease in sexual intercourse and improvements in safer sexual behavior

Sexual minority adolescents are more likely than heterosexual adolescents to have ever had sex, be sexually active, or had sex with four or more persons.

Condom use is more prevalent among heterosexual adolescents than sexual minority adolescents.

Overall, condom use is slightly down but holding steady from 2003 estimates.

Use of hormonal contraceptive methods has increased among adolescents since 2013.

Teen Pregnancies and Teen Births

Improvements in contraception and reduction in rates of intercourse have led to a drop in teen pregnancies

118 pregnancies per 1,000 females ages 15–19 (1990)

43 pregnancies per 1,000 females ages 15–19 (2013)

Pregnancy rates for Black/African-American and Hispanic teens remain 2x the rates of their White counterparts.

Pregnancy rates are higher for older teens (18–19) than younger teens (15–17).

Birth rates for Black /African-American, Hispanic, American Indian or Alaska Native, and Native Hawaiian or other Pacific Islander teens are 2x those of non-Hispanic White teens.

Birth rates for Asian teens are low.

Teen Abortions

Teen abortion rates have decreased by 56% between 2007 and 2016

2016 reported abortion statistics show:

Age Range	% Of All Abortions	Abortion Rate
<15	0.3%	0.4/1,000 adolescent females
15–19	9.4%	6.2/1,000 adolescent females

Sexually Transmitted Infections

Almost half of all sexually transmitted infections (STIs) are incurred by individuals between the ages of 15 and 24 years.

Biological factors make females more susceptible to STIs.

Contextual factors (access to care, prevention, treatment, incarceration, poverty, discrimination, etc.) result in Black/African-American adolescents being more likely to contract STIs than other adolescents.

Most common STIs:

Human papillomavirus (HPV)

Chlamydia

Gonorrhea

HPV vaccination can prevent the spread of HPV and reduce the chance of HPV-related cancers.

Human Immunodeficiency Virus

Young people ages 13–24 account for one in five of all new human immunodeficiency virus (HIV) diagnoses.

Gay and bisexual, as well as Black/African-American and Hispanic youth, are disproportionately affected.

Stigma related to sexual and racial minorities creates barriers to HIV prevention and care.

Racism and stigma limit partnering options for same-gender-loving Black and Hispanic men, leading to sexual relationships in higher-risk sexual networks.

Same-gender-loving Black/African-American and Hispanic men are

More likely to be exposed to a partner that has HIV that is not virally suppressed

Less likely to be protected if exposed to HIV

Less likely to know their HIV status

Less likely to receive care

Mental Health and Suicide: Considered Suicide, and Suicide Attempts, Plans, and Injuries

Trends in adolescent mental health have been inconsistent

Considering suicide and making a suicide plan higher in 1991 than 2017

More suicide-related injuries reported in 2017 than 1991

Black/African-American adolescents report more suicide attempts and suicide-related injury than White adolescents.

Female adolescents fare worse than males on all suicide metrics.

Lesbian, gay, and bisexual adolescents are disproportionately likely to plan, attempt, and be injured in a suicide attempt.

Anxiety and Depression

11% of 12- to 17-year-olds report having anxiety problems.

70% of 13- to 17- year-olds report that anxiety and depression are a “major problem” and for 26% they are a “minor problem.”

Hopelessness and sadness among high school students increased between 1991 and 2017.

Female, non-heterosexual, sexual-identity questioning students, and students with sexual contact with the same-sex or both sexes were more significantly more likely to report persistent feelings of sadness or hopelessness.

Major Depressive Episode

In 2018, 14% of 12- to 17-year-olds reported having a major depressive episode (MDE) in the past year.

Females 3x more likely than males

More Whites, Hispanics, and American Indian/Alaskan Native teens (~15%) report depressive episodes than Asian teens (13.6%) and Black/African-American teens (10.3%).

Among teens reporting MDE, 10% reported severe impairment with the episode.

Females 3x more likely than males

Black/African-American teens less likely than other races

Receipt of Mental Health Services

In 2018, 16% of 12- to 17-year-olds reported receiving mental health services in the past year.

Reasons for receiving services:

Felt depressed (57%)

Felt like or attempted committing suicide (32%)

Felt very afraid and tense (30%)

Home/family problems (24%) and school problems (19%)

Broke rules and “acted out” (17%)

Anger control issues (15%)

42% reported receiving treatment

Females more likely than male

White teens more likely than Hispanic and Black/African-American teens

Obesity, Nutrition, and Physical Activity

Today, more than 40% of adolescents aged 16–19 are overweight or obese, up from 30% in 1999–2000

Being overweight/obese is linked to poor nutrition and low levels of physical activity which are often the result of historic and structural racism.

Almost half of high school students report being physically active for at least 60 minutes on 5 or more days in the last 7 days

Males more likely than females

White teens more likely than Black/African-American and Hispanic teens

Nutrition and physical activity are closely related to the social determinants of health at the family level and beyond.

More Likely to be Overweight or Obese	Less likely to be Overweight or Obese
Black/African-American, Hispanic	Whites, Asian Americans
Sexual minority women	Heterosexual women

Chronic Conditions and Disabilities

Prevalence low among adolescents

Exceptions:

Asthma

23% of adolescents as of 2017

ADHD

7.6% of 10- to 17-year-olds between 1997 and 1999

13.0% of 10- to 17-year-olds between 2015 and 2017

Increase most likely due to increased testing

Males more likely than females

White and Black/African-American adolescents more likely than Hispanic, American Indian/Alaskan Native, or Asian youth

Lower socioeconomic status linked to higher rates

Puberty and Biological Development

Puberty is lengthy and multifaceted, changing virtually every aspect of the body.

Adrenarche: 6–9 years of age; contributes to the development of pubic hair, axillary hair, and body odor

Earlier in girls than boys

Gonadarche: 9–11 years of age; hypothalamus stimulates the production of sex steroids prompting the development of secondary sex characteristics

Biological changes: implicated in many issues related to adolescent development

Significant historical, environmental, and racial variations in the timing of puberty

Changes in the brain during adolescence are complex, with increase in cognitive activity and emotional maturation

Cognitive Development and Decision Making

Why do adolescents appear to “choose” to engage in more risky behaviors?

Adolescents process information in irrational, incomplete, or fundamentally different ways; perceive risks differently; or are less risk averse.

Not found to be linked to underdeveloped cognitive skills

Sensation seeking and impulsivity peak in adolescence

Peaks earlier in girls than boys

Racial disparities exist

Correlated with:

Sexual risk-taking, substance use, and self-harm

Operationalization, self-reported data, measurement, and data collection methods make relationship between risk-taking, sensation seeking, and impulsivity unclear.

The Neurological Basis of Changes in Adolescent Decision Making

Dual systems model of adolescent brain development

Two parts develop on different timetables

Socioemotional system develops early

Governs how we seek out and respond to reward and motivation

Cognitive control system develops more slowly over time

Regulates emotions, thoughts, and behaviors

Not fully mature until mid-20s

Now thought to be too overly simplistic

Modern integrated models

Adolescent brain works as a dynamic and interactive whole.

Changes in connectivity across different neural systems in the brain account for changes in behavior and decision-making.

Development responsive to experience and environmental inputs

Social Development (1 of 3)

Key developmental tasks: identity development and agency in good decision-making

Parents and peers exert powerful influences on social development

Parents

Socioeconomic resources, time and emotional support

Parenting characteristics are linked to developmental outcomes

Parenting styles

Authoritative (high warmth, appropriate monitoring)

Most likely to facilitate better physical, behavioral, and psychosocial outcomes

Authoritarian (low warmth, high monitoring)

Permissive (high warmth, low monitoring)

Disengaged (low warmth, low monitoring)

Social Development (2 of 3)

Peers

As the developmental salience of individuation, identity, and autonomy increases, so the importance of peer acceptance and status.

Reflected appraisal: self-assessment based on the approval or disapproval of peers

Identity and values are influenced by affiliation with peers.

Adolescents are more motivated to behave in ways consistent with valued peer-groups.

Popularity

High status and likeability have large implications during adolescence and beyond.

Social media acts as a “super peer,” providing information on how to look and act

May be most influential among early-maturing adolescents

Social Development (3 of 3)

Socialization

Selection vs. socialization

Adolescents seek out others who have similar behavior and attitudes to their own

Peers influence and change the behavior of others

Both?

Most likely multiple mechanisms, including:

Peer pressure

Observational learning

Social comparison

Perceived social norms

Peer influence

Historically linked to problematic behaviors (aggression or substance use)

Prosocial behavior by friends may promote prosocial behavior in others.

Close social relationships may buffer against adverse experiences, and support mental health and well-being.

Environmental and Contextual Influences on Adolescent Health and Development: Schools

American high schools are the dominant social institution in adolescents’ lives.

Major site for public health interventions

Poor school adaptation has been associated with pregnancy, delinquency, substance use, etc.

School structure and environment have been associated with poorer adaptation and engagement.

Neighborhood and Community

Neighborhoods and community directly influence health and development.

“What surrounds us, shapes us.”

Examples:

Higher rates of alcohol use in communities with wider alcohol availability and advertising

Lower body mass index in communities with richer physical activity resources

Indirect effects

Peer groups and families are influenced by social cohesion, social capital, institutional resources, neighborhood norms, residential instability, collective efficacy, social disorganization, neighborhood socioeconomic disadvantage, and neighborhood disorder.

Example:

Neighborhood poverty may indirectly influence adolescent outcomes via parenting behaviors and family well-being

Legal Systems

From 12 to 21, adolescents gradually gain legal rights and responsibilities.

Regulatory steps designed to reduce risky behavior.

Age of various legal rights/autonomy differ by states.

Confidential health care is a concern among adolescents with many issues:

Decision-making capacity has ramifications for criminal culpability.

Minority youth remain disproportionately represented across all areas of the criminal justice system due primarily to discriminatory practices.

Immigrant youth face additional challenges in the legal system.

Driving	Financial decision-making
Alcohol and tobacco use	Medical and sexual consent
Civic participation

Parental notification	Consent for abortion/judicial bypass process
Sexual and reproductive health	Confidential contraception

The Media and Technology

Major influence on adolescent development

Increasing time spent on the internet, mobile phones, television, music and video games

Health impacts: academic performance, weight, increased risk behavior, including substance use and earlier sexual activity

Improving Adolescent Health

Adolescence is a “sensitive period”

Social and environmental factors can optimize or impair development.

Multi-system improvements across education, neighborhoods, health care, and the juvenile justice system need to be made to improve outcomes.

Enhancing family resources

Strengthening schools and neighborhoods

Providing high-quality physical and mental healthcare

Establishing adolescent-friendly healthcare services

Education

Existing heterogeneity in experience and skill level combine with disparities related to race, ethnicity, and socioeconomic status lead to disparities in:

Educational achievement

Occupational success

Racial disparities persist in graduation rates

Changing schools to address adolescent needs includes:

Recognizing developmental needs

Increasing cultural competency

Providing skills to better match today’s world

Educational experiences should leverage modernization and the plasticity of adolescence to enhance creativity, critical thinking, and decision-making.

Paths to both college and vocational training should be provided.

Neighborhoods

Living in a high poverty-concentration neighborhood has adverse consequences.

Rural/urban differences

Community assets: policies and practices that support families, facilitate positive interactions with youth, and endorse prosocial values

Legal Systems

Juvenile justice systems should incorporate developmental considerations in providing treatment and services.

Progress on recognition of developmental needs varies among states

What should be considered?

Developmental maturity

A focus on individualized programs to prevent re-offense

Avoiding youth confinement except when necessary for safety reasons

Assurance of fair legal proceedings

Avoiding disparate treatment based on race or socioeconomic factors

Maternal and Child Health Bureau

Federal agency that administers Title V of the Social Security Act, which funds most public health services for adolescents

Includes the Division of Child, Adolescent, and Family Health

Funds programs at schools of public health, programs to increase interdisciplinary training, and several organizations related to adolescent health

Division of Adolescent and School Health

Within the CDC’s National Center for Chronic Disease Prevention and Health Promotion

Supports a variety of initiatives to monitor adolescent health, synthesize and apply research, enable health interventions by various agencies, and to evaluate program effectiveness

YRBSS —One of the main tools of DASH

Teen Pregnancy Prevention Programs

Office of Adolescent Health

Established within HRSA in 2008 with the primary purpose of supporting evidence-based pregnancy prevention

In 2010, $75 million was allocated to replicate evidence-based programs, and $25 million to research the effectiveness of promising program methods.

Database of effective programs available

Future Directions

Realizing the IOM’s “promise of adolescence” will take increasing effort to manage existing and existential issues in adolescent health and development

Injuries, violence, substance use

Vaping and e-cigarettes

New media and technologies

Longitudinal data needed

Need to better represent the increasingly diverse adolescent population in research

Public and political will and collaboration will be necessary to improve adolescent health.

Recognition that adolescent health is a distinct and important pursuit to ensure positive health and well-being outcomes

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