The purpose of this course is to assist the healthcare provider in understanding the growth and development of the adolescent, cognitive development, relationship development, and mental health, and how this period can influence the ability to effectively respond to treatments, health education and health promotion. Changes in our society are reflected in the responses adolescents have toward their own health care. Meeting their needs is a challenge to all healthcare providers.
After completing the course, the participant will be able to:
Adolescence is the transition from childhood to adulthood. It is a stressful developmental period filled with major changes in physical maturity, sexuality, cognitive processes, emotional feelings, and relationships with others. The age of adolescence is generally regarded as 11-19 years of age; however, some individuals function as adolescents well into their 20’s or more! Adolescence is the time for formulating a sense of personal identity, emancipation from the family unit, and for challenging parental authority.
As adolescents gain independence and take more responsibility for their own health, preventative healthcare and education become vital to ensure understanding and compliance. Prevention includes, but is not limited to, knowledge about sexually transmitted diseases, pregnancy prevention, and the effects of drugs, substance abuse and smoking. The Society of Adolescent Medicine identifies seven criteria for providing healthcare to adolescents:
Adolescence is a time of many transitions that do not follow the same time line for everyone. It is important to understand the physical changes that are occurring in both sexes. There are growth spurts with rapid gains in height and weight. Weight gains are due to increased muscle development in males and body fat in females. During a one-year growth spurt, boys average at least 4.1 inches and girls 3.5 inches in height. Typically girls are two years ahead of the boys.
Puberty, which is the beginning of adolescences, is a time when hormonal levels change and secondary sex characteristics blossom. This is the point when reproduction is possible. Secondary sex characteristics include:
A normal child’s brain will grow the most during the first five years of life. It reaches 90 percent of its final size by age one. Recent studies suggest that this process is not completed until late adolescence and that the connections between neurons affecting emotional, physical, and mental abilities are incomplete. This may be the reason some teens cannot control their emotions, and seem to have no common sense. Growth of a child’s body is complete between the ages of 16 and 18, when the growing ends of bones fuse. Reproductive maturity and gametogenesis is usually delayed for one to two years after external changes are exhibited.
These physical changes cause teens to sleep longer. It is not unusual for teens to sleep over nine hours a night. They tend to be sleepy at getting up times. Teens are curious about what they will look like and are confused by the changes. Suddenly, they show a personal interest in appearance and height, weight, penis size, and bra size becomes important.
Girls focus on loosing weight and some develop eating disorders such as anorexia nervosa (starvation) or bulimia (binge eating and vomiting). In contrast, boys, tend to be constantly hungry and companionship at meals and at after-school snacks becomes important.
Adolescence is the time when teens want to fit in with their peers, but may not be physically developing at the same rate as their peers. Some develop early and some later than others. Teens who mature early tend to be placed in leadership positions because adults assume early maturing teens are also cognitively mature. Teens who mature early tend to be more popular with their peers. Younger girls who mature early tend to be pressured into developing dating relationships with older boys because of their new physical endowments, before they are emotionally ready. These girls tend to suffer from anxiety, eating disorders, and depression.
The growth spurts that teens experience causes them to be clumsier and to appear uncoordinated. Self-image is challenged during this phase of development. Now is the time when teens feel awkward and shy about demonstrating affection to the opposite sex, parent or guardian.
Direct questions about sex are asked as sexual values are being established. Teens tend to equate intimacy with sex and engage in the physical act, assuming the emotional attachment will follow. They want to know how to abstain from sex and when it is the right time to have sex. Questions about birth control and sexually transmitted diseases are common during this stage of their growth and development.
Teens have better thinking skills than they did at a younger age. A process called Concrete Operations occurs when the youth is seven to eleven years old. She/he is able to deal with properties of the present world in solving new problems. At this time the youth cannot yet deduce or reason hypothetically. Thus reasoning is inductive because decisions are based on the influence of others. Developing advanced reasoning skills starts at approximately twelve to fifteen years of age. This is called the development of Formal Operations. The adolescent learns to attack problems from the angle of all possible combinations of relations. Free use of hypothetical reasoning occurs. Variables are systematically isolated and manipulated. The youth becomes introspective.
Formal operation is the ability to foresee the consequences of his /her actions and to detect the logical consistency within a statement. Finally, the adolescent is able to think realistically about self, others, and their world, without egocentrism. This means the teen thinks about the whole not just the self. Developing abstract thinking skills by thinking about things that cannot be seen, heard, or touched is also part of this cognitive process.
Teens develop the ability to think using a process called meta-cognition. This process allows individuals to think about how they feel and what they are thinking. This process is the ability to think realistically about self, others, and their world. Logical strategies are created to meet a need. One device is the creation of mnemonic devices to help in memory retainment.
All of these Cognitive Changes cause adolescents to demonstrate the following actions:
Changes in adolescent physical and cognitive development are also accompanied by major changes in adolescent’s relationships with others, including family and friends. The following are five recognized psychosocial issues: establishing an identity; establishing autonomy, independence, and a self-governance; establishing intimacy; establishing self-esteem and comfort with one’s sexuality; and achievement.
Establishing an identity or self-knowledge about one’s characteristics, or personality is vital. This is one of the most important tasks of adolescents. At this stage he/she begins to integrate the opinions of influential others into their own likes and dislikes. Values and beliefs, occupational goals, and relationship expectations emerge. Difficulty in developing a clear concept of self or identity occurs when adolescents are unable to resolve struggles about who they are as physical, independent, sexual persons.
Establishing autonomy, independence, and a self-governance within relationships is a necessary achievement for adolescents to become self-sufficient within society. The adolescent learns to independently work out his/her own problems, and live by his/her own set of principles of right and wrong while becoming less emotionally dependent on parents or guardians.
Establishing intimacy is of primary importance. Now is the time to develop close relationships in which people are open, honest, trusting, and caring. Adolescents report feeling more understood and accepted by their peers and spend less and less time with their parents and other family members. Close friendships tend to develop with adolescents that are more similar in social class, ethnic backgrounds, and interests. It is within these groups that adolescents explore their sexuality, and feelings about it. Girls are more intimate with self-disclosure; whereas boys form relationships with groups of friends who validate each other’s worth with their deeds and actions.
Establishing self-esteem and comfort with one’s sexuality also occurs during this time. Due to the many body changes during adolescence, teens become more concerned about who they are and who they want to be. The key question raised is “how much do I like myself?” Adolescents tend to place more importance on their appearance. As teens move into the late adolescent stages he/she develops a more secure sense of who they are. The teen at this stage is physically mature enough to reproduce and becomes actively conscious of the opposite sex. How teens are educated in attitude and deed will greatly determine whether they develop a healthy sexual identity. This is the time when teens become sexually active. Teen pregnancies and sexually transmitted diseases/AIDS start to appear within this population.
Several predictors of sexual intercourse during the early adolescent years, including early pubertal development, a history of sexual abuse, poverty, lack of attentive and nurturing parents, cultural and family patterns of early sexual experience, lack of school or career goals, substance abuse, and poor school performance or dropping out of school (Klein, 2005). Factors associated with a delay in the initiation of sexual intercourse include living with both parents in a stable family environment, regular attendance at places of worship, and higher family income (Klein). Recently, parental supervision, setting expectations, and parent/child connectedness have been recognized as clearly associated with decreasing risky sexual behavior and other risky behaviors among adolescents (Klein).
Achievement is pushed and valued within our society. Teens now begin to see the relationship between their current abilities, need for more knowledge and experience in order to improve their chances to reach their future goals.
All of these psychosocial changes cause teens to change how they interact with family and friends. Teens spend more time with their friends and less with their family. Acceptable and not acceptable social skills and practices are developed and reinforced through peer pressure. When it comes to decisions about education, values and long-term plans, the teen still tends to conform to parental influences. More questions about sexuality and when it is the right time to experience sex arise. Teens become curious about what their parents did as teenagers and how they handled sex. Some teens begin to keep a journal to help establish their feelings and individual identities. Privacy and having their own space is vital to being independent and to being considered equal in their parents’ eyes. Teens become more argumentative and start to question adults’ values and judgments. They tend to feel they know best! Teens when asked where they are going or who they will be with are elusive and answer in generalities. Teens become involved with many activities in order to determine what they are good at, what’s thought of as cool, and what they enjoy. They are quick to change their interests. Many teens do not want to be seen with their parents even though the parent may now be more of a friend/equal!
Adolescents can be broken down into three stages. These are Early Adolescence, Middle Adolescence, and Late Adolescence.
Puberty is also considered Early Adolescence. Each sex has special characteristics during this period of growth and development. Both sexes vacillate between maturity and babyishness. Moodiness, sloppiness, and disorder become the norm. They rebel against home and rules/curfews. Same sex close friendships develop and questions about erotic feelings or behaviors toward the same sex arise. Some special characteristics of girls include, but are not limited to the following:
Some special characteristics of boys include, but are not limited to the following:
Middle Adolescence is the phase of development when there is a limited concept of cause and effect and the teen feels omnipotent. Often times the adolescent is between 12-16 years of age. During this phase, the greatest experimental risk taking happens. This is evidenced by drinking and driving, drinking while pregnant, and having unprotected sex. Sexually transmitted diseases now start to rise among this population. Thus drinking, drugs, smoking, and sexual experimentation are of primary importance to the Middle Adolescence. This is the time when first intercourse, first drink, or first pregnancy occurs. The major pre-occupation of Middle Adolescent is sex.
Testosterone increases are found in both sexes; however, higher levels are found in boys causing greater sexual aggressiveness and more physical drives and gratifications. Girls tend to view sexual gratification as secondary to fulfillment of other needs such as love, affection, reassurance, and self-esteem. They are less likely to abstain from sex in a relationship they sense brings closeness to someone and/or a means to act out against authority. The adolescent transition to male-female and sexual relationships are influenced by sexual interest and by cultural and social norms and expectations.
During Middle Adolescence parental conflicts occur often on a daily basis as the teenager strives for independence and thinks he/she knows all. This behavior is normal and confrontation and resolution are needed. Adolescent males and females tend to have more disagreements with their mothers than with their fathers. Teenagers now seek more advice from their friends than their parents.
Late Adolescence is a time when there are fewer conflicts and disagreements with parents/guardians. The Adolescent now seeks parental respect for opinions and acceptance of maturity. Now the teenager wants to be accepted by society, at college and in the workplace. Late Adolescence brings on questions related to career choices. Adolescents explore different work areas by volunteering or taking on part time jobs to assist them in making decisions related to their future vocations. Once a decision is reached, the adolescent’s self-concept and sense of self-worth help establish a positive identity.
However, indecisions regarding vocational choices are common. Much of this is caused by family influences: mother or dad’s professional aspirations for their children based on what they did or had hopes of doing when they were younger. The adolescent’s interests may conflict with the parent’s choices. If the adolescent is talented in a specific area and/or has varied interests this too makes choosing a vocation extremely difficult and can lead to conflicts with his/her parents. Other factors influencing vocational choices are:
Some special characteristics demonstrated by girls during Late Adolescence include, but are not limited to:
Some special characteristics demonstrated by boys during Late Adolescence include, but are not limited to:
During Late Adolescence both sexes tend to demonstrate the following:
Non-optimal negative identity, often occur as the adolescent tries to become more independent. These adjustments delay the growth process. Peer groups highly influence the adolescent and he/she ends up conforming to the groups’ expectations. This makes it very difficult for the adolescent who may have to move. Social isolation could result as he/she attempts to fit in, or once accepted the adolescent might over identify with a peer or assume many traits of his/her parents. This can lead to identity crisis. Teens in conflict are confused, often in conflict with everyone, and do crazy things, like dating people a lot older than themselves.
Communication barriers are common during adolescence. The adolescent does not want to appear vulnerable and distrusts adults. Many feel adults do not listen to them and therefore cannot understand their feelings and behaviors. Adolescents now distrust adults and authority figures.
The adolescent years are filled with turmoil for both the adolescent and the family. Adolescent developmental issues can complicate the teenager’s ability to cope with illness, injury, medical treatments, hospitalization, surgery, and the required treatments, because their physical appearance, desire to be independent, and accepted by their peers is of primary importance. Presently about 10% of adolescents under the age of 17 years suffer from a chronic disability or illness.
Common adolescent conditions are:
A substantial number of morbidity and social problems resulted from the approximately 870,000 pregnancies that occurred each year among women 15-19 years of age. An estimated three million cases of sexually transmitted diseases (STDs) occurred among those 10-19 years of age (CDC, 2002).
50% of adolescent pregnancies occur within the first six months of initial sexual intercourse despite the increasing use of contraceptive devices and medications (Klein, 2005). The HIV epidemic and the public health education efforts have made an impact and more adolescents use barrier contraceptives. However, in 2003, among high school students who reported they had sexual intercourse only 63% reported having used a condom the last time they had intercourse (Klein). Even with the education provided on HIV prevention once prescription contraceptives are started, the use of condoms decreases. Many adolescents have already been sexually active a year before a prescription contraceptive is used (Klein). Currently there is decreased use of the pill and increased use of an injectable contraceptive.
Using information from 33 states with confidential name-based HIV infection reporting The Center of Disease Control reported that by the end of 2004 that there were 187,093 males and 61,726 females who had acquired AIDS. There were 528 teens with AIDS who were 13-14 years of age and 4,559 individuals 15-24 years of age with AIDS.
Impact of Sexual Behaviors
The Youth Risk Behavior Surveillance System (YRBSS, 2005)
Leading causes of mortality and morbidity among adolescents were related to the following categories of health behavior:
Behaviors That Contribute to the Leading Causes of Morbidity and Mortality
The Youth Risk Behavior Surveillance System (YRBSS, 2005)
These behaviors are frequently interrelated and often are established during youth and extend into adulthood.
Behaviors that contribute to Unintentional Injuries are related to:
Behaviors that contribute to Violence:
Physicians and other healthcare providers who are knowledgeable in adolescent medicine help adolescents and their families/guardians develop workable strategies to deal with developmental issues, conflicts, and complications that could occur between illness, treatment and specific developmental needs. These professionals help to improve communication between all parties to help adolescents deal with peer pressure and the desire to experiment with sex, drugs, poor nutrition, and fads.
Young people can have mental, emotional, and behavioral problems that are real, painful, and costly. These problems, often called disorders, are sources of stress for children and their families, schools, and communities. The number of young people and their families who are affected by mental, emotional, and behavioral disorders is significant. It is estimated that as many as one in five children and adolescents may have a mental health disorder that can be identified and require treatment.
Mental health disorders in children and adolescents are caused by biology, environment, or a combination of the two. Examples of biological factors are genetics, chemical imbalances in the body, and damage to the central nervous system, such as a head injury. Many environmental factors also can affect mental health, including exposure to violence, extreme stress, and the loss of an important person.
Families and communities, working together, can help children and adolescents with mental disorders. A broad range of services is often necessary to meet the needs of these young people and their families. Most adolescents who experience mental health problems can return to their activities of daily living, if they receive appropriate treatment. Physicians and other healthcare providers dealing with mental health issues are available in many communities. There are also professionals available for low to no-income families.
The National Institute of Mental Health (NIMH), part of the National Institutes of Health (NIH), reported the following:
Young people, who experience excessive fear, worry, or uneasiness may have an anxiety disorder. According to one study of 9- to 17-year-olds, as many as 13 of every 100 young people have an anxiety disorder. Anxiety disorders include the following.
Depression is a strong feeling of sadness in response to a loss or sad event. When this feeling is out of proportion to the stimulating event and the length of time lasts from months to years a problem exists. Adolescents, just like adults, can become depressed regardless of race, sex or socioeconomic status. Depression is more common in adolescents who have family members who have a history of depression.
Studies of the brain have found that there is a complex system of neurotransmitters that produce chemicals that transfer signals from nerve cell to nerve cell. Serotonin is one of these chemicals, which is responsible for giving person feelings of euphoria and well-being. There are drugs, which correct neurotransmitter imbalances. Causes or factors contributing to depression are the following:
Some signs of depression a child may experience are:
Chronic depression exists when a person is depressed for at least a year or more. When there are periods of euphoria with periods of deep sadness, this is called bipolar or maniac-depressive disorder. Adolescents who demonstrate exaggerated mood swings that range from extreme highs to extreme lows may have bipolar disorder. Periods of moderate mood occur among the extreme highs and lows. During manic phases, adolescents may talk nonstop, need very little sleep, and show unusually poor judgment. At the low end of the mood swing, adolescents experience severe depression. Bipolar mood swings can recur throughout life. Adults with bipolar disorder often experienced their first symptoms during their teenage years
Adolescents often have thoughts of suicide when they are severely depressed. During this time they display no interest in anything, including eating and basic personal hygiene. In many instances of severe depression the adolescent may attempt suicide.
The key to preventing severe mental health problems later in life is early diagnosis. This is very difficult when dealing with the adolescent because of the emotional and physical barriers they put up to become independent and accepted by peers. Signs of depression are signals to find a doctor or healthcare provider who specializes in mental health problems. Special evaluation tools such as the Child Depression Inventory (CDI) questionnaire are utilized to help diagnose depression. Professionals also ask about the possibility of drug or alcohol abuse or physical abuse, which could cause or contribute to severe depression.
Treatment is available in the form of drugs and psychotherapy. Antidepressants, which are selective serotonin reuptake inhibitors (SSRIs), are usually started. Two of these drugs are fluoxetine (Prozac) and sertraline (Zoloft). These drugs increase the serotonin levels, which contribute to a feeling of well-being. Side effects are anxiety, diarrhea, headache, sweating, nausea, difficulty sleeping, difficulty concentrating, and nausea.
Other age-dependent and severity-based antidepressants are also used. These include tricyclic antidepressants (TCAs), such as imipramine, amitriptyline, nortriptyline, and monoamine oxidase inhibitors (MAOs), which include phenelzine and anylcypromine. MAOs block and inhibit the action of the enzyme monoamine ozidase in the central nervous system. However, these drugs should not be taken with certain foods or drinks because they can cause life-threatening side effects. These include foods that are high in tyramine (ie soy sauce, red wines, beer on tap, certain meats and aged cheeses), some over-the-counter cough medications, and both trycyclic and SSRI antidepressants. These combinations can cause sudden and severe hypertension.
Another category of antidepressant is the heterocyclics. These include bupropion, and trazodone. Bupropion should not be given to patients with seizure disorders. Trazodone is also given to adolescents with insomnia since it causes sedation.
These drugs may take from two to six weeks to be effective and must be taken around the same time of day. Antidepressants are not addictive and should not be stopped without a doctor’s permission. Antidepressants need to be reduced gradually to prevent side effects. Hospitalization is recommended for those who are suicidal.
Psychotherapy is also recommended and must be designed to meet the individual needs of the patient. All types of therapy focus on the cause of the depression and therapeutic ways to cope with each situation. Therapy can be individualized or be a combination of individual, group, and family therapy. Family support is a key to a successful outcome.
Young people with attention deficit/hyperactivity disorder (ADHD) are unable to focus their attention and are often impulsive and easily distracted. ADHD occurs in up to five of every 100 children. Most children with this disorder have great difficulty remaining still, taking turns, and keeping quiet. Symptoms must be evident in at least two settings, such as home and school, in order for ADHD to be diagnosed.
Difficulties that make it harder for children and adolescents to receive or express information could be a sign of learning disorders. Learning disorders can show up as problems with spoken and written language, coordination, attention, or self-control.
Young people with conduct disorder usually have little concern for others and repeatedly violate the basic rights of others and the rules of society. Conduct disorder causes children and adolescents to act out their feelings or impulses in destructive ways. The offenses these children and adolescents commit often grow more serious over time. Such offenses may include lying, theft, aggression, truancy, the setting of fires, and vandalism.
Children or adolescents who are intensely afraid of gaining weight and do not believe that they are underweight may have eating disorders. Eating disorders can be life threatening. Young people with anorexia nervosa, for example, have difficulty maintaining a minimum healthy body weight. Anorexia affects one in every 100 to 200 adolescent girls and a much smaller number of boys.
Youngsters with bulimia nervosa feel compelled to binge, eating huge amounts of food in one sitting. After a binge, in order to prevent weight gain, they rid their bodies of the food by vomiting, abusing laxatives, taking enemas, or exercising obsessively. Reported rates of bulimia vary from one to three of every 100 young people.
Children with autism, also called autistic disorder, have problems interacting and communicating with others. Autism appears before the third birthday, causing children to act inappropriately, often repeating behaviors over long periods of time. For example, some children bang their heads, rock, or spin objects. Symptoms of autism range from mild to severe. Children with autism may have a very limited awareness of others and are at increased risk for other mental disorders. Studies suggest that autism affects 10 to 12 of every 10,000 children.
Young people with schizophrenia have psychotic periods that may involve hallucinations, withdrawal from others, and loss of contact with reality. Other symptoms include delusional or disordered thoughts and an inability to experience pleasure. Schizophrenia occurs in about five of every 1,000 children.
Now, more than ever before, there is hope for young people with mental, emotional, and behavioral disorders. Most of the symptoms and distress associated with adolescent mental, emotional, and behavioral disorders can be alleviated with timely and appropriate treatment and supports.
In addition, researchers are working to gain new scientific insights that will lead to better treatments and cures for mental, emotional, and behavioral disorders. Innovative studies also are exploring new ways of delivering services to prevent and treat these disorders. Research efforts are expected to lead to more effective use of existing treatments so children and their families can live happier, healthier, and more fulfilling lives. Many of these research studies are funded by Federal agencies within the Department of Health and Human Services, including the:
Related activities are taking place within the:
Adolescent Mortality and Risky Behaviors
Compared with younger children, adolescents ages 15 to 19 have much higher mortality rates. Adolescents display risky behavior and are much more likely to die from injuries sustained from motor vehicle traffic accidents or firearms. This difference illustrates the importance of looking separately at mortality rates and causes of death among teenagers ages 15 to 19.
An injury is defined as unintentional or intentional damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat or oxygen (SAMHSA, 2002). Injuries include unintentional injuries such as those caused by motor vehicle crashes and fires as well as intentional injuries such as violence and suicide. Violence is the threatened or actual use of physical force or power against another person, against oneself, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, or deprivation.
Injuries requiring medical attention, or resulting in restricted activity, affect more than 20 million children and adolescents (250 per 1,000 persons) and cost $17 billion annually for medical treatment (Grunbaum, Kann, Kinchen, Williams, Ross, Lowry, et al., 2002). In the United States, injuries are the leading cause of death and disability for people aged 1 to 34 years. Approximately 70% of all deaths among adolescents aged 10-24 years are attributed to injuries from only four causes: motor vehicle crashes (31%), all other unintentional injuries (12%), homicide (15%), and suicide (12%). Highly associated with these injuries are adolescent behaviors such as physical fights, carrying weapons, and not using seatbelts. In 2001, 14% of high school students never or rarely wore a seat belt when riding in a car, 17% had carried a weapon in the past 30 days, and 33% had been in a fight in the past 30 days. Changing the environment, individual behavior, products, social norms, legislation, and governmental and institutional policy can prevent injuries. Up to 90% of unintentional injuries can be prevented.
Adolescents are more likely than older drivers to underestimate the dangers in hazardous situations, and they have less experience coping with such situations. Adolescents are more likely than older drivers to speed, run red lights, make illegal turns, ride with an intoxicated driver, and drive after using alcohol or drugs.
An estimated 302,100 women and 92,700 men are forcibly raped each year in the United States. More than half of the female rape victims were less than 18 years of age when they were first raped (SAMHSA, 2001).
The use of alcohol and other drugs has an enormous impact on the physical, mental and social health of the nation's youth. Alcohol use is a factor in approximately half of all deaths from motor vehicle accidents and from intentional injuries. Alcohol use has also been linked to physical fights, academic and occupational problems, and illegal behavior. Long-term alcohol misuse is associated with liver disease, cancer, cardiovascular disease, and neurological damage. Dependence on alcohol and other drugs is also associated with psychiatric problems such as depression, anxiety and antisocial personality disorder. Drug use contributes directly and indirectly to the HIV epidemic, and alcohol and drug use contribute markedly to infant morbidity and mortality.
Unfortunately, substance use among high school students is high. Since 1991, current use of alcohol has remained steady at about half of all high school students with 30% of all 9th-12th grade students reporting episodic heavy drinking.
Source: Youth Risk Behavior Survey (YRBS). Centers for Disease Control and Prevention. The YRBS is an in-school survey of students in grades 9 through 12. Students completed self-administered questionnaires in their classrooms. In 2005, the national sample consisted of 13,917 responses from 159 schools. In 1991, the national sample consisted of 12,272 responses from schools.
Current marijuana use increased from 15% in 1991 to 24% in 2001. At all levels of blood alcohol concentration, the risk of being involved in a motor vehicle crash is greater for adolescents than for drivers who are older (IIHS 2000). In 2002, 29% of drivers ages 15 to 20 who died in motor vehicle crashes had been drinking alcohol (NHTSA 2003). Analysis of data from 1991–1997 found that, consistently, more than one in three teens reported they had ridden with a driver who had been drinking alcohol in the past month. One in six reported having driven after drinking alcohol within the same one-month time period (Everett 2001). In 2002, among adolescent drivers who were killed in motor vehicle crashes after drinking and driving, 77% were unrestrained (NHTSA 2003).
In 2000, the death rate for adolescents ages 15 to 19 was 67 deaths per 100,000. Overall, the rate has declined substantially since 1980, despite a period of increase between 1986 and 1991. Injury, which includes homicide, suicide, and unintentional injuries, continues to account for more than 3 of 4 deaths among adolescents. After injuries, additional leading causes of death for adolescents include cancer, heart disease, and birth defects.
Five Leading Causes of Death
Five Leading Causes of Injury Death
Among children and adolescents aged 5 to 19 years, 70% of unintentional injury deaths are due to motor vehicle accidents. Traffic-related injuries also include those sustained while walking, riding a bicycle, or riding a motorcycle. Among bicycle-related deaths, 83% are caused by collisions with motor vehicles. In 2000, motor vehicle traffic-related injuries accounted for 25 of the 67 deaths per 100,000 youth ages 15 to 19 (37 percent).
Motor vehicle injuries were the leading cause of death among adolescents for each year between 1980 and 2000, but the motor vehicle death rate declined by more than one-third during the time period. In 1980, motor vehicle traffic-related deaths among adolescents ages 15 to 19 occurred almost three times as often as firearm injuries (intentional and unintentional). By 2000, the rate of motor vehicle traffic-related deaths was less than double that of firearm injuries. Motor vehicle and firearm injury deaths are both more common among male than among female adolescents. In 2000, the motor vehicle traffic death rate for males was nearly twice the rate for females; and the firearm death rate among males was eight times that for females. In 2001, 43% of the teen motor vehicle deaths occurred between 9 pm and 6 am (IIHS 2003).
In 2000, firearm injuries accounted for 13 of the 67 deaths per 100,000 youth ages 15 to 19 (19 percent). Most of the increase in firearm injury deaths between 1983 and 1993 resulted from an increase in homicides. The firearm homicide rate among youth ages 15 to 19 more than tripled from 5 to 18 per 100,000 between 1983 and 1993. At the same time, the firearm suicide rate rose from 5 to 7 per 100,000.
Deaths from firearm injuries among adolescents declined between 1994 and 2000, particularly among Black and Hispanic males. From 1994 to 2000, the firearm homicide rates for Black and Hispanic adolescent males declined substantially; from 126 to 52 per 100,000 for Black males, and from 49 to 22 per 100,000 for Hispanic males.
Firearm injuries were the most common cause of death among Black males. Black males were more than twice as likely to die from a firearm injury as from a motor vehicle traffic injury. Deaths from firearm suicides were more common than deaths from firearm homicides among White, non-Hispanic adolescents, while the reverse is found for Black and Hispanic adolescent males.
In the United States, minority males bear most of the burden of homicide victimization. In 2001, among males aged 15 to 19 years, the homicide rate was 3.9 per 100,000 among whites; 6.9 per 100,000 among Asian/Pacific Islanders; 15.8 per 100,000 among American Indian/Alaskan Natives; 23.8 per 100,000 among Hispanics; and 59.9 per 100,000 among Blacks. The United States child homicide rate, 2.6 per 100,000 for children less than 15 years of age, is five times greater than the combined rate of 25 other industrialized countries (CDC, 2000).
During one study, done by SHPPS (2001).60.4% of states and 50.6% of districts provided model policies on accident or unintentional injury prevention. 58.3% of states and 77.1% of districts have policies on the inspection or maintenance of playground facilities and equipment.
Percentage of States and Districts with Policies on Wearing Appropriate Protective Gear, and Percentage of Schools Requiring Students to Wear Appropriate Protective Gear When Engaged in Selected Activities (SHPPS, 2001)
States with policies
Districts with policies
Lab activities (photography, chemistry, biology, or other science classes)
Physical activities during physical education
Wood shop or metal shop
School requiring protective gear
Middle/junior high schools
Senior high schools
Lab activities (photography, chemistry, biology, or other science classes)
Physical activities during physical education
Wood shop or metal shop
Among teachers of required health education, elementary school teachers who provided accident and injury prevention education spent a median of 5 hours per school year teaching the topic, middle/junior high school teachers spent a median of 4 hours, and senior high school teachers spent a median of 5 hours.
During the two years preceding the study (SHPPS, 2001):
Percentage of Schools Teaching Topics and Skills Related to Accident or Unintentional Injury Prevention in at Least One Required Class or Course, by Topic and Skill (SHPPS, 2001)
First aid or CPR
Road or transportation safety
Use of protective equipment for biking, skating, or other sports
Communication skills to avoid accidents
Decision-making skills to avoid accidents
Goal-setting skills to protect oneself from accidents
Resisting peer pressure that would increase risk of accidents
Tobacco use, including cigarette smoking, cigar smoking, and smokeless tobacco use, is the single leading preventable cause of death in the United States. Each year smoking causes more than 400,000 premature deaths and 5 million years of potential life lost. The estimated direct and indirect costs associated with smoking in the United States exceed $68 billion annually. Approximately 80% of tobacco use occurs for the first time among young people less than 18 years of age.
In 2001, 29% of high schools students reported current cigarette use and 15% reported current cigar use. In addition, 8% of high school students and 19% of white male high school students reported current smokeless tobacco use.
Each day in the United States, approximately 4,400 youths aged 12-17 try their first cigarette (SAMHSA, 2002). If current patterns of smoking behaviors continue, an estimated 6.4 million of today’s children can be expected to die prematurely from a smoking-related disease. Although the percentage of high school students who smoke has declined in recent years, rates remain high: 29% of high school students report current cigarette usage (smoked cigarettes ≥ 1 of the preceding 30 days) (Grunbaum, et al., 2002).
Non-Hispanic white and Hispanic students (32% and 27%, respectively) are significantly more likely than black students (15%) to report current cigarette use (Grunbaum, et al., 2002). Nationwide, 64% of students have tried cigarette smoking. Male students (66%) are significantly more likely than female students (62%) to have tried cigarette smoking (Grunbaum, et al., 2002). 22% of high school students have smoked a whole cigarette before age 13 (Grunbaum, et al., 2002). 15% of students report having smoked cigars, cigarillos, or little cigars in the past month. 8% of high school students use smokeless tobacco (15% males and 2% females). Adolescents who use smokeless tobacco (snuff, chewing tobacco) are more likely than nonusers to become cigarette smokers.
Cigarette smoking by young people leads to serious health problems, including cough and phlegm production, and increase in the number and severity of respiratory illnesses, decreased physical fitness (both performance and endurance), adverse changes in blood cholesterol levels, and reduced rates of lung growth and function. Cigarette smoking causes heart disease; stroke; chronic lung disease; and cancers of the lung, mouth, pharynx, esophagus, and bladder. Use of smokeless tobacco causes cancers of the mouth, pharynx, and esophagus; gum recession; and an increased risk for heart disease and stroke. Smoking cigars increases the risk of oral, laryngeal, esophageal, and lung cancers.
The younger people begin smoking cigarettes, the more likely they are to become strongly addicted to nicotine. Several studies have found nicotine to be addictive in ways similar to heroin, cocaine, and alcohol. Because the typical tobacco user receives daily and repeated doses of nicotine, addiction is more common among tobacco users than among other drug users. Of all addictive behaviors, cigarette smoking is the one most likely to become established during adolescence. Of high school students who are current smokers, 57% have tried to quit in the past month (Grunbaum, et al., 2002).
All states have laws making it illegal to sell cigarettes to anyone under the age of 18, yet among students who report current cigarette use, 19% purchase their cigarettes in a store or gas station. Approximately two thirds of students (67%) who purchased or attempted to purchase cigarettes in a store or gas station were not asked to show proof of age (Grunbaum, et al., 2002). Cigarette companies spend more than $9.5 billion each year to promote their products, and in 1998 tobacco companies spent nearly $7 billion to advertise and promote cigarettes (FTC, 2000). Children and teenagers constitute the majority of all new smokers, and the industry’s advertising and promotion campaigns often have special appeal to these young people (CDC, 2000). 88% of young smokers (ages 12-17) choose the three most heavily advertised brands: Marlboro, Camel, and Newport (SAMHSA, 2001).
More than 6 million youth are exposed to secondhand smoke daily, and more than 10 million youth ages 12-18 live in a household with at least one smoker. Twenty-two percent of middle school students and 24% of high school students are exposed to secondhand smoke in the home (Farrelly, Chen, Thomas & Healton, 2001). Those most affected by secondhand smoke are children. Because their bodies are still developing, exposure to the poisons in secondhand smoke puts children in danger of severe respiratory diseases and can hinder the growth of their lungs (CDC, 2003). Secondhand smoke exposure during childhood and adolescence may increase lung cancer risk as adult, increase new cases of asthma or worsen existing asthma.
Healthy eating is associated with reduced risk for many diseases. Healthy eating in childhood and adolescence is important for proper growth and development and can prevent health problems such as obesity, dental caries, and iron deficiency anemia. Most young people are not following Dietary Guidelines for Americans recommendations.
Unhealthy diet and physical activity patterns together account for at least 300,000 deaths among adults in the United States each year; only tobacco use contributes to more deaths (HHS, 2001). Diet is a known risk factor for the three leading causes of death heart disease, cancer, and stroke; as well as for obesity, diabetes, high blood pressure, and osteoporosis. In 2000, the cost of obesity in the United States was over $117 billion, of which $61 billion was for direct medical costs and $56 billion was for indirect costs (HHS, 2001).
Type 2 diabetes, formerly known as adult onset diabetes, has become increasingly prevalent among children and adolescents as rates of overweight and obesity rise. A CDC study estimated that one in three American children born in 2000 will develop diabetes in their lifetime (Venkat, Boyle, Thompson, Sorensen, & Williamson, 2003).
Early indicators of atherosclerosis, the most common cause of heart disease, begin during childhood and adolescence. Atherosclerosis is related to blood cholesterol levels, which are associated with dietary habits (Kavey, Daniels, Lauer, Atkins, Hayman, & Taubert, 2003). Osteoporosis, a disease where bones become fragile and can break easily, is associated with inadequate intake of calcium. Children and adolescents who consume adequate amounts of calcium through dairy products and other calcium rich foods will have stronger bones and may have reduced risk of developing osteoporosis later in life.
Research suggests that not having breakfast can affect children’s intellectual performance (Kleinman, Hall, Green, Korzec-Ramirez, Patton, Pagano & Murphy, 2002). The percentage of young people who eat breakfast decreases with age; while 92% of children ages 6–11 eat breakfast, only 75–78% of adolescents ages 12–19 report eating breakfast. A study among inner city children at nutritional risk showed that participants in a school breakfast program increased their nutrient intake and were more likely to improve their academic and psychosocial functioning than their counterparts who did not participate in the program (Kleinman, et al., 2002).
Overweight is defined as a body mass index (BMI) at the 95th percentile or higher. Almost 9 million children and adolescents in the United States aged 6–19 years are overweight (CDC, 2001). The prevalence of overweight among children aged 6–11 has more than doubled in the past 20 years, increasing from 7% in 1980 to 15% in 2000. Overweight among adolescents aged 12–19 has tripled in the same time period, rising from 5% to 15% (CDC, 2001). Overweight children and adolescents are more likely to become overweight or obese adults ;( Micic, 2001) (Ferraro, Thorpe & Wilkinson, 2003) one study showed that children who became overweight by age 8 were more severely obese as adults (Freedman, Kahn, Dietz, Srinivasan, & Berenson, 2001).
While the prevalence of overweight and obesity has increased in all segments of the U.S. population, disparities exist based on race and ethnicity, sex, and socioeconomic status. For example, overweight is particularly common among minority groups and those with a lower family income (HHS, 2001).
Prevalence of Overweight
Children (Ages 6 to 11)
Adolescents (Ages 12 to 19)
Less than 40% of children and adolescents in the United States meet the U.S. dietary guidelines for saturated fat, fruit, and vegetable intake. Of U.S. youth aged 6-19, 67% exceed dietary guidelines recommendations for fat intake, and 72% exceed recommendations for saturated fat intake. Only 21% of high school students eat the recommended five daily servings of fruits and vegetables (when fried potatoes and potato chips are excluded).
Percent of Children and Adolescents Who Meet Dietary Guidelines, 1994–1996
Children (Ages 6 to 11)
Adolescents (Ages 12 to 19)
Only 39% of children ages 2–17 meet the USDA’s dietary recommendation for fiber (found primarily in dried beans and peas, fruits, vegetables, and whole grains) (Lin, Guthrie & Frazao, 2001). Eighty-five percent of adolescent females do not consume enough calcium. During the last 25 years, consumption of milk, the largest source of calcium, has decreased 36% among adolescent females (Cavadini, Siega-Riz & Popkin, 2000). Additionally, from 1978 to 1998, average daily soft drink consumption almost doubled among adolescent girls, increasing from 6 oz to 11 oz, and almost tripled among adolescent boys, from 7 oz to 19 oz (USDA, 2003).
A large number of high school students use unsafe methods to lose or maintain weight. A nationwide survey found that during the 30 days preceding the survey 13.5% of students went without eating for one or more days; 5.4% had vomited or taken laxatives; and 9.2% had taken diet pills, powders, or liquids without the advice of their physicians (Grunbaum, Kann, Kinchen, Williams, Ross, Lowry & Kolbe, 2001).
Unprotected sexual intercourse and multiple sex partners place young people at risk for HIV infection, other sexually transmitted diseases (STDs), and pregnancy. Each year, approximately three million cases of STDs occur among teenagers and approximately 860,000 teenagers become pregnant. In 2001, 46% of high school students had ever had sexual intercourse, 14% of high school students had four or more sex partners during their lifetime, and 42% of sexually active high school students did not use a condom at last sexual intercourse (The Youth Risk Behavior Surveillance System (YRBSS):
Among teachers of required health education, elementary school teachers who provided STD prevention education spent a median of 1 hour per school year teaching the topic, middle/junior high school teachers spent a median of 2 hours, and senior high school teachers spent a median of 3 hours (SHPPS, 2001)
During the two years preceding the SHPPS study (2001):
Percentage of Schools Teaching Topics and Skills
Middle/junior high schools
Senior high schools
Abstinence as the best way to avoid pregnancy, HIV, or STDs
How HIV is transmitted
How to correctly use a condom
Risks associated with having multiple sexual partners
Communication skills related to sexual behaviors
Decision-making skills related to sexual behaviors
Goal-setting skills related to sexual behaviors
Resisting peer pressure to engage in sexual behavior
Health Services (SHPPS, 2001)
31.4% of states and 47.4% of districts require that districts or schools provide one-on-one or small-group discussions on HIV prevention to students when needed (not including classroom instruction). 12.0% of states and 15.4% of districts require districts or schools to provide HIV testing and counseling services to students when needed. 30.4% of districts have arrangements with organizations or professionals not located on school property to provide one-on-one or small-group discussions on HIV prevention to students when needed, and 25.2% have arrangements to provide HIV testing and counseling. 2.0% of middle/junior high and 4.1% of senior high schools make condoms available to students as part of standard health services.
Healthcare professionals have an additional challenge in dealing with adolescent patients because of their developmental stage as well as their propensity for risky behavior. The healthcare professional needs to understand the adolescent’s special circumstances when working with an adolescent client.
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