Adolescent Health, Vol. II: Background and

the Effectiveness of Selected Prevention and

Treatment Services

October 1991

OTA-H-466

NTIS order #PB92-157577

GPO stock #052-003-01235-9
Recommended Citation:

U.S. Congress, Office of Technology Assessment, Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services, OTA-H-466

(Washington, DC: U.S. Government Printing Office, November 1991).

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Sup(.[ IIIILI1(ICIII (11 I)(Kulll(l)l\, Nlclll \lo J) Ssol’. M J.lllllgloll. [)(’ 3)402 -’)328

ISBN 0-16 -035981-3
Foreword

Adolescence, the poet suggested, ‘‘is the one age [that] defeats the metaphor. ’ In many respects, such

as legal and financial dependence, adolescents are still children; in other respects, such as physical

development, they approach and then reach adult status. In part because they experience profound biological,

emotional, intellectual and social changes, adolescents as a group-and some adolescents more than

others-are uniquely vulnerable to the impact of many of the Nation’s social policies. For numerous reasons,

policymakers and the public have long struggled with the establishment of appropriate health-related policies

and programs for adolescents.

OTA’s report responds to the request of numerous Members of Congress to review the physical,

emotional, and behavioral health status of contemporary American adolescents, including adolescents in

groups who might be more likely to be in special need of health-related interventions: adolescents living in

poverty, adolescents from racial and ethnic minority groups, Native American adolescents, and adolescents in

rural areas. In addition, OTA was asked to: 1) identify risk and protective factors for adolescent health problems

and integrate national data in order to understand the clustering of specific adolescent problems, 2) evaluate

options in the organization of health services and technologies available to adolescents (including accessibility

and financing), 3) assess options in the conduct of national health surveys to improve collection of adolescent

health statistics, and 4) identify gaps in research on the health and behavior of adolescents.

Senator Daniel K. Inouye, Chairman of the Senate Select Committee on Indian Affairs, and Senator Nancy

Landon Kassebaum, Ranking Minority Member of the Subcommittee on Education, Arts, and Humanities of

the Senate Committee on Labor and Human Resources, were the lead requesters of OTA’s adolescent health

study. Requesters included chairmen or Ranking Minority Members of the Senate Appropriations Committee,

the Senate Commerce, Science, and Transportation Committee, the Senate Finance Committee, the Senate

Labor and Human Resources Committee, the Senate Small Business Committee, the Senate Veterans’ Affairs

Committee, and the House Interior and Insular Affairs Committee; and the Chairman and six senatorial

members of the congressional Technology Assessment Board. A letter of support was received from the House

Select Committee on Children, Youth, and Families.

This OTA assessment is being published in three volumes: Volume I, Summary and Policy Options;

Volume II, Background and the Effectiveness of Selected Prevention and Treatment Services; and Volume III,

Crosscutting Issues in the Delivery of Health and Related Services. Volume I was published in April 1991,

and Volume III was published in June 1991. Two related reports have already been issued as part of this study

(see appendix A in Volume I).

OTA was greatly assisted by an advisory panel, chaired by Felton Earls, Professor of Behavioral Sciences

at the Harvard University School of Public Health. Michael I. Cohen, Chairman of the Department of Pediatrics

at the Albert Einstein College of Medicine in New York, served as vice chairman. In addition, many individuals

from academia, the Federal Government, the private sector, and the public provided information and reviewed

drafts of the assessment. OTA would like to especially thank Carnegie Corporation of New York, and its

operating program, the Carnegie Council on Adolescent Development, for their generous and diverse

assistance throughout the course of this assessment. Finally, the members of our Youth Advisory Panel-a

group of 21 individuals ages 10 through 19, who met often with OTA staff, with OTA’s advisory panel, and

with workshop participants-were essential to the study. These young people provided the adolescent

perspective on health concerns of importance to young people, and made valuable suggestions for improving

health services and health policy. The final responsibility for the content of the assessment rests with OTA.

&f a’&#&&L9-A

JOHN H, GIBBONS

Director

,.. ///
Adolescent Health Advisory Panel

Felton Earls, M. D., Chair

Professor, Department of Behavioral Sciences

Harvard School of Public Health, Boston, MA

Michael I. Cohen, M. D., Vice Chair

Chairman, Department of Pediatrics

Albert Einstein College of Medicine, Montefiore Medical Center

Claire Brindis, Dr. P.H.

Center for Reproductive Health

Policy Research

Institute for Health Policy Studies

UCSF School of Medicine

San Francisco, CA

Ann W. Burgess, R.N., D.N.Sc.

van Amerignen Professor of

Psychiatric Mental Health Nursing

University of Pennsylvania School of

Nursing

Philadelphia, PA

Delores L. Delaney

President

State of Virginia Parent and Teacher

Association

Virginia Beach, VA

Abigail English, J.D.

Staff Attorney

Adolescent Health Care Project

National Center for Youth Law

San Francisco, CA

Jewelle Taylor Gibbs, Ph.D.

Associate Professor

School of Social Welfare

University of California

Berkeley, CA

Michael Graf, Ph.D.

Director, Mental Health

Tanana Chief Conference, Inc.

Fairbanks, AK

David E. Hayes-Bautista, Ph.D.

Professor, School of Medicine

Director, Chicano Studies Research

Center

University of California, Los Angeles

Los Angeles, CA

Karen Hein, M.D.

Associate Professor

Division of Adolescent Medicine

Department of Pediatrics

Albert Einstein College of Medicine

Montefiore Medical Center

Bronx,

NOTE:

iv

Bronx, NY

Charles E. Irwin, Jr., M.D.

Director

Division of Adolescent Medicine

Department of Pediatrics

School of Medicine

University of California

San Francisco, CA

Robert Johnson, M.D.

Associate Professor

Division of Adolescent Medicine

Department of Pediatrics

New Jersey Medical School

Newark NJ

Alan Kazdin, Ph.D.

Professor

Department of Psychology

Yale University

New Haven, CT

Teresa LaFromboise, Ph.D.

Assistant Professor

Counseling Psychology and

Counselor Education

The School of Education

University of Wisconsin

Madison, WI

Mary Nell Lehnhard

Vice President

Office of Government Relations

Blue Cross & Blue Shield Association

Washington, DC

Barbara D. Matula, M.P.A.

Director

Division of Medical Assistance

Department of Human Resources

State of North Carolina

Raleigh, NC

Robert B. Millman, M.D.

Director, Adolescent Development

Program

Director, Alcohol & Substance Abuse

Service

Cornell University Medical CollegeNew York Hospital

New York, NY

Leticia Paez, M.P.A.

Associate Director

Area Health Education Center

School of Medicine

Texas Technical University

El Paso, TX

Cheryl Perry, Ph.D.

Associate Professor

Division of Epidemiology

School of Public Health

University of Minnesota

Minneapolis, MN

Anne C. Petersen, Ph.D.

Dean, College of Health &

Development

Human

Pennsylvania State University

University Park, PA

Lee Etta Powell, Ph.D.

Superintendent

Cincinnati Public Schools

Cincinnati, OH

Roxanne Spillett

Director, Program Services

Boys and Girls Clubs of America

New York, NY

Edward Tetelman, J.D.

Assistant Commissioner

Intergovernmental Affairs

New Jersey Department of Human

Services

Trenton, NJ

Myron Thompson

Trustee

Bernice Pauahi Bishop Estate

Honolulu, HI

NY

OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the advisory panel members.

The panel does not, however, necessarily approve, disapprove, or endorse this report. OTA assumes full responsibility for the

report and the accuracy of its contents.
Adolescent Health

Roger C. Herdman, Assistant Director, OTA

Health and Life Sciences Division

Clyde J. Behney, Health Program Manager

Project Staff

Denise Dougherty, Senior Associate/Project Director

Jill Eden, Senior Analyst

Kerry B. Kemp, Senior Analyst/Division

Kelly Metcalf, Research Analystl

Kirsten Rowe, Analyst2

Gloria Ruby, Senior Analyst

Pamela Simerly, Analyst

Editor

Andrea Solarz, Carnegie Detailee3

Urvi Thanawala, Research Assistant4

Paul Robertson, Research Assistant5

Other Staff

James Havel, Carnegie Contractor6

Charlotte Clarke, Carnegie Contractor

Elizabeth Anglarill, Work Study Student8

Helima Croft, Summer Intern9

Jennifer Hart, Summer Intern10

Alex Ching. Summer Internll

Rachel Wolfe, Research Assistant

Heather Francese, Research Assistant

Administrative Staff

Virginia Cwalina, Office Administrator

Carolyn Martin, Word Processor Specialist12

Eileen Murphy, P,C. Specialist

Marian Grochowski, Word Processor Specialist

IUntil July 1990

2From octo~r 1988 to Mach 19~

3From Decem& 1988 to Au~st 1990

4From June 1990

sFrom September 1990

6From April to September 1990

7From May to Augllst 1990

sFr~m November 198910 May 1990

%om May 1990 to August 1990

loFrom June 1988 to August 1988

I IFrom June 1991 to Au~st 1991

‘

2 Until June 1991
Contractors

LaRue Allen, Ph. D., University of Maryland and Christina Mitchell, Ph. D., New York University*

Trina Anglin, M.D:, Ph.D., Cleveland Metropolitan Genera! Hospital*

Lois Bergeisen, Gaithersburg, MD

Barbara Burns, Ph. D., Duke University,

Carl A. Taube, Ph.D. (deceased 9/28/89), Johns Hopkins University,

and John E. Taube, University of Maryland*

Paul Casamassimo, D. D. S., M. S., Children’s Hospital, Columbus, OH

Johanna Dwyer, D.Sc., R. D., New England Medical Center Hospital, and

Carol N. Meredith, University of California at Davis

James Emshoff, Ph.D. and Ronnie Margolin, Georgia State University*

Mathea Falco, J. D., New York, NY

Ronald A. Feldman, Ph.D., Columbia University

Michelle Fine, Ph.D., University of Pennsylvania

James Garbarino, Ph.D., Erikson Institute

Josephine Gittler, J. D., Mary Quigley-Rick, J.D., and Michael J. Saks, Ph. D., University of Iowa

Robert Guntow, Hyattsville, MD

Thomas Hoffman, Washington, DC

Angela Holder, LL.M., Yale University*

Jonathan Klein, M.D., M. P.H., Milton Kotelchuck, Ph. D., and

Gordon H. DeFriese, Ph.D., University of North Carolina at Chapel Hill*

Barry Krisberg, Ph. D., National Council on Crime and Delinquency*

Richard Kronick, San Diego, CA*

Spero Manson, Ph. D., University of Colorado

Margaret McManus, M. H. S., Harriette Fox, M.S.W., Paul Newacheck, D.P.H., Lori Wicks,

and Rebecca Kelly, McManus Health Policy, Inc.

Gary B. Melton, Ph.D. and Lois B. Oberlander, M.A.,

University of Nebraska-Lincoln

Scott Menard, Ph.D., University of Colorado

Larry Mi’ike, M. D., J. D., University of Hawai’i*

Edward P. Mulvey, Ph. D., Michael A. Arthur, M.A., and N. Dickson Reppucci, Ph. D.,

University of Pittsburgh

D. Wayne Osgood, Ph. D., and Janet K. Wilson, University of Nebraska-Lincoln*

Carol Runyan, M. P. H., Ph. D., Elizabeth A. Gerken, M. S. P. H., and

Laura S. Sadowski, M. D., M. P. H., University of North Carolina

Stanley Sue, Ph. D., University of California, Los Angeles, and

Nolan Zane, University of California at Santa Barbara*

Dalmas A. Taylor, Ph. D., Wayne State University, and

Phyllis A. Katz, Ph. D., Institute for Research on Social Problems*

H. Rutherford Turnbull, Esq., J. D., LL.M. and Lisa Dorrill, M. A.,

University of Kansas

Robert Valdez, Ph. D., University of California, Los Angeles*

Margaret West, M. S.W., Ph.D. and Sally N. Stuart, M. S.W.,

University of Washington*

● Supported by Carnegie Co~oration of New York and the Carnegie Council on Adolescent Development,

vi
Volume II

BACKGROUND AND THE

EFFECTIVENESS OF

SELECTED PREVENTION

AND TREATMENT
Contents

Page

Chapter 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Part I: Background on Adolescent Health

Chapter 2. What Is Adolescent Health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Chapter 3. Parents and Families’ Influence on Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . 35

Chapter 4. Schools and Discretionary Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Part II: Prevention and Services Related to Selected Adolescent Health Concerns

Prevention and Services Related to Physical Health Problems

Chapter 5. Accidental Injuries: Prevention and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Chapter 6. Chronic Physical Illnesses: Prevention and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Chapter 7. Nutrition and Fitness Problems: Prevention and Services . . . . . . . . . . . . . . . . . . . . . . . 193

Chapter 8. Dental and Oral Health Problems: Prevention and Services . . . . . . . . . . . . . . . . . . . . . 231

Prevention and Services Related to Sexually Transmitted Diseases and Pregnancy

Chapter 9. AIDS and Other Sexually Transmitted Diseases: Prevention and Services . . . . . . . 257

Chapter 10. Pregnancy and Parenting: Prevention and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

Prevention and Services Related to Mental Health Problems

Chapter 11. Mental Health Problems: Prevention and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

Chapter 12. Alcohol, Tobacco, and Drug Abuse: Prevention and Services . . . . . . . . . . . . . . . . . 499

Prevention and Services Related to Delinquency and Homelessness

Chapter 13. Delinquency: Prevention and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583

Chapter 14. Hopelessness: Prevention and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663

Appendix A. Glossary of Abbreviations and Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 695

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729

. . . VII!
Chapter 1

INTRODUCTION
Contents

Page

Chapter 1 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Boxes

Box Page

l-A. Full Table of Contents for OTA’s Adolescent Health Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

l-B, Summary of Major Policy Options Related to Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . 5

l-C. Requesters of OTA’s Adolescent Health Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Chapter 1

INTRODUCTION

This is Volume II of OTA’s assessment, Adolescent Health. This volume, Background and the

Effectiveness of Selected Prevention and Treatment

Services, provides background information on important aspects of adolescents’ lives and detail on the

effectiveness of selected prevention and treatment

interventions. Volume I is entitled Summary and

Policy Options (2). Volume III is entitled Crosscutting Issues in the Delivery of Health and Related

Services (3).

As shown in box l-A, which lists the table of

contents for all three volumes of the assessment,

:

1 Volume II has two major parts. Part I: Background

on Adolescent Health and Part II: Prevention and

Services Related to Selected Adolescent Health

Concerns.

Part I: Background on Adolescent Health

provides a framework for viewing the lives and

social environments of contemporary adolescents.

Chapter 2, ‘‘What Is Adolescent Health?” provides

a brief overview of aspects of adolescent development that may affect adolescents’ health, the delivery of health services, and public policy with respect

to adolescents. This chapter notes that researchers

have found that popular conceptions of adolescents

as a group whose behavior is overwhelmingly

determined by ‘‘raging hormones’ and of adolescence as a period when to be abnormal is normal are

misguided. These misconceptions are not benign:

they may have deleterious effects on attitudes

towards individual adolescents and on interactions

with individual adolescents and on policy and

program development, with neglect of adolescents

being a predominant response. Adolescence is a

period of profound biological, emotional, intellectual, and social transformation, and substantial

societal support may be needed by adolescents and

their families in order to promote healthy development. Chapter 2 also discusses conceptualizations of

health, providing background for the broad conceptualization used by OTA in its assessment.

Chapter 3, “Parents and Families’ Influence on

Adolescent Health,” addresses a most important

aspect of adolescents’ lives and social environments,

their families. Research suggests that being the

parent of an adolescent requires an approach different from that required for being the parent of a

younger child. But relative to the amount of guidance and support provided to parents of infants and

young children, little guidance and support are

provided to parents as their children mature into

adolescence. promising models of parent-adolescent

interaction are available, however, and these are

reviewed in chapter 3. More research is needed on

these models and on models of appropriate governmental and private support to make parents more

appropriately available to their adolescent children.2

Chapter 4, “Schools and Discretionary Time,”

turns to two other important aspects of adolescents’

lives. These two facets of the social environment

become increasingly important as adolescents spend

more time physically away from their families and

testing a range of skills, beliefs, and behaviors.

Although little systematic empirical research has

been supported, the studies that have been conducted

suggest that academic and health outcomes of

adolescent students are influenced by school environments; studies of school environments and the

policy implications of the studies are reviewed in

chapter 4. Also discussed is the time that adolescents

spend away from school in ‘‘discretionary’ activities such as being with their friends, solitary leisure

activities, doing volunteer work, and engaging in

hobbies. Although information is again scarce, the

chapter focuses on the apparent paucity of activities

for adolescents that are satisfying to adolescents,

conducive to healthy development, and acceptable

to the adult community.

Part II: Prevention and Services Related to

Selected Adolescent Health Concerns includes

chapters 5-14, each of which examines a specific

health problem of concern to policymakers, the

public, parents, and, to varying degrees, to adolesIVo[ume I+jummry andpo[icy Options was pub;ished in April 1991 (2), and Volume III<rosscutting Issues in the Deliveq of Health a~Related

Services was published in June 1991 (3). An order form for all three volumes is at the back of this publication. Copies for congressional use only may

be obtained by contacting OTA.

~amily factors found to be specific to the occurrence of particular problems (e.g., pregnancy and parenting; alcohol, tobacco, and drug use;

delinquency; hopelessness) are discussed in the risk factors sections of the chapters in Part II of this volume.

-11-3-
II-4 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box l-A—Full Table of Contents for OTA’S Adolescent Health Report

VOLUME I: SUMMARY AND POLICY OPTIONS

Appendixes

A. Method of the Study

B. Acknowledgments

C. Issues Related to the Lack of Information About Adolescent Health and Health and Related Services

D. Glossary of Abbreviations and Terms

VOLUME II: BACKGROUND AND THE EFFECTIVENESS OF SELECTED PREVENTION AND

TREATMENT SERVICES

1. Introduction

Part I: Background on Adolescent Health

2. What Is Adolescent Health?

3. Parents and Families’ Influence on Adolescent Health

4. Schools and Discretionary Time

Part II: Prevention and Services Related to Selected Adolescent Health Concerns

Prevention and Services Related to Physical Health Problems

5. Accidental Injuries: Prevention and Services

6. Chronic Physical Illnesses: Prevention and Services

7. Nutrition and Fitness Problems: Prevention and Services

8. Dental and Oral Health problems: Prevention and Services

Prevention and Services Related to Sexually Transmitted Diseases and Pregnancy

9. AIDS and Other Sexually Transmitted Diseases: Prevention and Services

10. Pregnancy and Parenting: Prevention and Services

Prevention and Services Related to Mental Health Problems

11. Mental Health Problems: Prevention and Services

12. Alcohol, Tobacco, and Drug Abuse: Prevention and Services

Prevention and Services Related to Delinquency and Hopelessness

13. Delinquency: Prevention and Services

14. Hopelessness: Prevention and Services

Appendix

A. Glossary of Abbreviations and Terms

VOLUME III: CROSSCUTTING ISSUES IN THE DELIVERY OF HEALTH AND RELATED SERVICES

15. Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Services to Adolescents

16. Financial Access to Health Services

17. Consent and Confidentiality in Adolescent Health Care Decisionmaking

18. Issues in the Delivery of Services to Selected Groups of Adolescents

19. The Role of Federal Agencies in Adolescent Health

Appendixes

A. Glossary of Abbreviations and Terms

B. Burden of Health Problems Among U.S. Adolescents

C. HCFA’s Method for Estimating National Medicaid Enrollment and Expenditures for Adolescents

cents themselves: accidental injuries (ch. 5); chronic and drug abuse (ch. 12); delinquency (ch. 13); and

physical illnesses (ch. 6); nutrition and fitness hopelessness (ch. 14). As discussed in each chapter,

problems (ch. 7); dental and oral health problems the problems reviewed do not constitute the entire

(ch. 8); AIDS and other sexually transmitted dis- set of possible adolescent health problems; rather,

eases (ch. 9); pregnancy and parenting (ch. 10); the intent of the chapters is to provide detail on

mental health problems (ch. 11); alcohol, tobacco, selected problems illustrative of important policy
Chapter I—Introduction ● II-5

Box l-B—Summary of Major Policy Options Related to Adolescent Health

In Volume I of this Report, OTA suggests a range of options that could be implemented in an effort to help

improve adolescent health, broadly defined (2). Three major options that OTA believes Congress may want to

consider are as follows:

1. improving U.S. adolescents’ access to appropriate health services,

2. restructuring and invigorating Federal efforts to improve adolescent health, and

3. improving adolescents’ environments.

Strategies to improve U.S. adolescents’ access to appropriate health services include:

. support the development of centers that provide, in schools and/or communities, comprehensive and

accessible services designed specifically for adolescents-e. g., by providing seed money, continuation

funding, or removing existing financial barriers;

. increase financial access-e. g., by expanding Medicaid to immediately include all poor adolescents, by

increasing access to private insurance, and by increasing outreach for Medicaid;

● increase legal access to health services-e. g., by supporting the development of a model State statute, or

requiring or conditioning States’ receipt of Federal moneys for specific programs on substantive changes

in consent and confidentiality regulations;

. increase support for training for the providers of health and related services; and

. empower adolescents to gain access to health and related service --e.g., through education and encouraging

adolescent participation in the design of services.

Strategies to restructure and invigorate Federal efforts to improve adolescent health include:

. create a new locus for a strong Federal role in addressing adolescent health issues;

. strengthen traditional U.S. executive branch activities in: 1) program development for promising or

neglected areas of intervention, 2) research, and 3) data collection.

Strategies to improve the social environment for adolescents include:

. increase support to families of adolescents-e. g., through tangible supports such as child allowances or more

flexible working hours, and through providing information on appropriate, health-promoting parenting for

adolescents;

. support additional limitations on adolescents’ access to firearms;

● support the expansion of appropriate recreational opportunities for adolescents; and

● monitor the effects on adolescents of the implementation of the National and Community Service Act of

1990.

In addition to these major options and strategies, which cut across the areas examined by OTA, a number of

topic-specific policy options are listed in Volume I of the Report.

OTA notes that, apart from whatever specific strategies the Federal Government may adopt to improve

adolescents’ health, there is a need for a basic change in approach to adolescent health issues in this country, so that

adolescents are approached more sympathetically and supportively, and not merely as individuals potentially

riddled with problems and behaving badly.

issues. This detail provides support for the major chapter. It is important to note that OTA generally

policy options discussed in Volume I of this found data limitations to be considerable.3 Using

assessment (see box l-B). available sources of data, the background section of

Each of the 10 chapters in Part II follows a similar each chapter also provides information on the

format. A background section in each chapter prevalence of the problem among adolescents.

discusses limitations of existing sources of data on These sections typically provide support for OTA’s

the adolescent health problem that is the focus of the conclusion that individuals may encounter signifi3See app. C, “Issues Related to the Lack of Information About Adolescent Health and Health and Related Services,” in Vol. I, for a synthesis of

limitations in available data.
II-6 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

cant health problems during the course of adolescence.

4 Also presented in the background section of

each chapter is available information about differences in prevalence by selected sociodemographic

characteristics (e.g., age, gender, race, ethnicity,

social class, and residence) and nondemographic

risk factors (e.g., family factors, community and

peer influences, biological factors, adolescents’

beliefs and attitudes). These sections provide support for the importance of targeting interventions to

adolescents based on demographic characteristics

and other risk factors but also for the conclusion that

many adolescent health problems (e.g., alcohol use,

suicide) cut across a wide variety of ages, races,

ethnicities, and social classes.s

The primary focus of OTA’s analyses in the 10

chapters in Part II of this volume was to determine

the effectiveness of prevention and treatment interventions for adolescent health problems. Thus, each

chapter in Part II has sections on the prevention and

treatment of the health problem that is the focus of

the chapter. Information is presented on the appropriateness of prevention and treatment interventions

and problems adolescents may encounter in gaining

access to services. Particular attention is paid to the

effectiveness of interventions, in terms of improved

health outcomes for adolescents. Evaluations of

preventive interventions for adolescents suggest that

many of the interventions are not based on available

knowledge about risk factors, and that too many

interventions rely on attempts to change individual

behavior, when research-albeit limited6

-ha s

shown that primary preventive interventions based

on automatic protection and other environmental

change (e.g., legislation and regulation) are more

effective than those that rely solely on education and

persuasion. Too little attention has been paid to

secondary prevention through early intervention:

adolescents face many barriers to gaining access to

needed health services.7

Each of the 10 chapters in Part II also includes a

section on Federal policies and programs that are

most relevant to the health problem discussed in the

chapter. Federal agencies’ attention to adolescent

health problems has varied over time and by topic,

with much attention now being paid to illicit drug

use and preventing sexual activity. OTA’s analysis

identifies a number of problems with the Federal

approach to adolescent health topics. A major

problem is the very limited attention being paid by

Federal agencies to providing adolescents with

needed health and related services. Another problem

is that the sheer number of congressional committees and U.S. executive branch agencies and programs contributes to fragmentation in data collection, research, and service delivery related to adolescents. 8

Finally, it should be noted that each chapter in this

volume ends with conclusions and policy implications. Specific legislative options pertinent to each

of the issues discussed in this volume (and in

Volume III of this assessment) can be found in

Volume I-Summary and Policy Options (2). Appendix A of this volume is a glossary of terms and

abbreviations.

The way OTA went about conducting the assessment—including lists of workshop participants and

members of OTA’s Youth Advisory Panel for the

assessment—is described in appendix A of Volume

I. The many individuals who assisted OTA in the

development of the three volumes of this Report are

listed in appendix B of Volume I. The congressional

requesters of the assessment are listed in box 1-C

below.

Chapter 1 References

1. Osgood, D.W., and Wilson, J.K., “Covariation of Adolescent Health

Problems, ” paper prepared under contract to Carnegie Council on

Adolescent Development and Carnegie Corporation of New York

for the Office of ‘Ech.nologyAssessment.j U.S. Congress, Washing4For a review of the r~~ch on c~variation in adolescent herdth problems, see Osgood and Wilson (l). Covariation is the tendency of health problems

to occur in the same individual at about the same time. Most of the evidence on covariation of adolescent problems is based on cross-sectional studies,

so it is still unclear for many problems whelher one problem leads to another or the problems occur together, due to a single cause or set of causes. Another

limitation of the evidence on covariation is that most of the evidence is limited to covariation in adolescent behaviors and does not consider emotional

or physical problems. Nonetheless, there is evidence for statistically signiilcant covariation among several adolescent health behaviors (l).

5A @buIM s~ary of prevalence data and capsule statements of adolescents most at risk (usually in terms of demographic characteristics) for the

problems discussed in this volume can be found in app. B, “Burden of Health Problems Among U.S. Adolescents,” in Vol. III of this Report (3).

6The fact that the research on environmental change is limited is in part related to the fact that much of the literature on risk factors limits itself to

studies of individual or, at most+ family factors. It is also difficult to evaluate the impact of global environmental changes on adolescents specfkally.

7Barriers t. he~th sewic~ are discussed in each chapter and in Vols. I and III of thk assessment (2,3).

s~ Ovewiew of Feder~ programs relevant to adolescent health ~& fo~d ~ ch. 19, “The Role of Federal Agencies in Adolescent Heal@” in

Vol. III of this Report (3). Major policy options related to the Federal role in adolescent health are presented in Vol. I (2).
Chapter l—introduction ● II-7

Box l-C—Requesters of OTA’s Adolescent Health Report

(with current committee chair or ranking minority assignments)

Senator Daniel K. Inouye, chairman of the Senate Select Committee on Indian Affairs;

Senator Nancy Landon Kassebaum, Ranking Minority Member of the Subcommittee on Education, Arts, and

Humanities of the Senate Committee on Labor and Human Resources;

Senator Bob Dole, Minority Leader of the Senate;

Senator Robert C. Byrd, Chairman of the Senate Committee on Appropriations;

Representative William H. Gray, III, Majority Whip of the House of Representatives;

Senator James M. Jeffords, Ranking Minority Member of the Subcommittee on Labor of the Senate Committee on

Labor and Human Resources;

Senator Orrin G. Hatch, Ranking Minority Member of the Senate Committee on Labor and Human Resources;

Senator Edward M. Kennedy, chairman of the Senate Committee on Labor and Human Resources;

Senator Quentin W. Burdick, Chairman of the Senate Committee on Environment and Public Works;

Senator Mark O. Hatfield, Ranking Minority Member of the Senate Committee on Appropriations;

Senator Alan K. Simpson, Assistant Minority Leader of the Senate;

Senator Alan Cranston, Chairman of the Senate Committee on Veterans Affairs;

Senator Ted Stevens, Ranking Minority Member of the Senate Committee on Rules and Administration;

Senator Bob Packwood, Ranking Minority Member of the Senate Committee on Finance;

Senator Charles Grassley, Member of the Technology Assessment Board;

Senator Barbara Mikulski, Chairman of the Subcommittee on Veterans Affairs, Housing and Urban Development,

and Independent Agencies of the Senate Committee on Appropriations;

Senator Ernest Hollings, Chairman of the Senate Committee on Commerce, Science, and Transportation;

Senator Arlen Specter, Ranking Minority Member of the Subcommittee on Veterans Affairs;

Representative Henry A. Waxman, Chairman of the Subcommittee on Health and the Environment of the House

Committee on Energy and Commerce;

Senator Daniel K. Akaka;

Representative Morris K. Udall, Chairman of the House Committee on Interior and Insular Affairs;

Senator Frank H. Murkowski, Vice chairman of the Senate Select Committee on Intelligence;

Senator Christopher J. Dodd, Chairman of the Subcommittee on Children, Family, Drugs, and Alcohol of the Senate

Committee on Labor and Human Resources;

Senator Claiborne Pen, chairman of the Senate Committee on Foreign Relations;

Senator Dale Bumpers, Chairman of the Senate Committee on Small Business;

Senator Lloyd Bentsen, Chairman of the Senate Committee on Finance;

Senator Daniel P. Moynihan, Chairman of the Subcommittee on Social Security and Family Policy of the Senate

Committee on Finance;

Senator John D. Rockefeller, IV, Chairman of the Subcommittee on Medicare and Long Term Care of the Senate

Committee on Finance;

Representative Don Young, Ranking Minority Member of the House Committee on Interior and Insular Affairs.

A letter of support was received from the House Select Committee on Children, Youth, and Families.

ton, DC, 1990 (Springfield, VA: National Technical Information 3. U.S. Congress, OffIce of ‘Ikchnology Assessment, Adolescent

Service, NTIS NO.-PB 91-154 377/AS). Health: V;lume 111-Crosscutting Issues in the Delivery of Health

2. U.S. Congress, Office of Technology Assessmen~ Adolescent

Health: Volume L-Summary and Policy Options, OTA-H-468

and Related Services, OTA-H-467 (Washington DC: U.S. Govem-

(WashingtoL DC: U.S. Government Printing Office, April 1991).

ment Printing Office, June 1991).
Part 1:

BACKGROUND ON

ADOLESCENT HEALTH
Chapter 2

WHAT IS ADOLESCENT HEALTH?
Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

What Is Adolescence? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,

Historical Perspectives on Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Basic Physiological Changes in Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Overt Physical Changes in Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hormonal Changes in Adolescence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cognitive Changes During Adolescence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

A Perspective on Adolescent Risk-Taking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Defining Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Current Conceptualizations of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Measures of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,.,.... . . . . . . . . . . . . . . . . . . . . .

Measures of the Health of Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Measures of the Social Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Factors Affecting Conceptualizations of Adolescent Health ..........,.. . . . . . . . . . . . . . . . . . . .

summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chapter 2 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

13

13

17

17

18

20

23

24

24

24

26

26

26

26

27

27

29

Boxes

Box Page

2-A. Examples of Differences in the Legal Status of U.S. Adolescents by Category of Activity . . 16

2-B. In Search of Self: Identity Development in Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

2-C. Toward Improving Adolescent Health: Key Concepts Developed by Adolescent Health

Scholars at the1986 National Invitational Conference on the Health Futures

of Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Figures

Figure Page

2-1. Sequence and Timing of Four Key Pubertal Events During Adolescence:

Adolescent Females . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-2. Sequence and Timing of Four Key Pubertal Events During Adolescence:

Adolescent Males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-3. Growth Spurts During Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18

18

19
Chapter 2

WHAT IS ADOLESCENT HEALTH?

Introduction

Although analyses by OTA and others certainly

suggest a need for attention to the health of U.S.

adolescents, it is important to note that what is meant

by adolescent health is still not all that clear (37,56).

Considerations of the meaning of adolescence and

the way the health of adolescents is conceptualized

are important, because such conceptions have significant consequences for:

● judgments about how healthy adolescents are;

. judgments about which adolescent health problems are most important;

. judgments about what health-related policies

are justified; and

. decisions about the development of measures

of health and health services utilization that are

in turn used to help judge the need for changes

in services and policies.

Conceptualizations of health are important in

considering the health of any segment of the

population, but because of the unusual social status

of adolescents (55), unique issues are raised. This

chapter provides a brief overview of some of the

basic changes that occur during adolescence and

their implications for adolescent health policy. It

then discusses issues in defining health and adolescent health in particular. As discussed below, the

focus of the chapter, and of this Report, is on

adolescents ages 10 through 18 years.

What Is Adolescence?

For some adults, the period of adolescence is one

they would rather forget (they “learned the truth at

17’ ‘). For others, it is a period they continue to recall

with happy memories (the ‘Glory Days’ ‘). Probably

most adults view adolescence, like other periods of

development, as a period of both positive and

negative experiences and emotions. But there is

something about the intensity of adolescence that

marks it as subjectively different from other periods.

At the same time, no two adolescent experiences are

alike, and “capturing the adolescent experience”

(18) in research, and on paper, is a difficult task. This

section on adolescent development reviews evidence for the notion that adolescence is “a social

construct, one that is changing even as we examine

it” (55). It then describes the basic biological and

cognitive foundations of change during adolescence.

The section relies heavily on chapters by Modell and

Goodman (55), Keating (43), and Brooks-Gunn and

Reiter (11) in the recent volume, At the Threshold:

The Developing Adolescent (24), which should be

consulted for more comprehensive analyses, and on

a summary of these chapters and others by Zaslow

(89).

Historical Perspectives on Adolescence

As Zaslow notes, ‘‘our understanding of adolescence is enhanced by placing it in a historical

context” (89). Basic physical changes do mark the

transition from childhood to maturity (see below),

but the long period that we now refer to as

adolescence has largely been constructed in response to economic and social changes in the last 2

centuries (55), According to Modell and Goodman,

in terms of the current social status of adolescents,

‘‘The most critical component in this evolution was

the spread of schooling. . .“ (55).1

According to Modell and Goodman, the contemporary idea of adolescence in Western Europe and

the U.S. emerged from particular economic and

social circumstances associated with industrialization (55,89). Just prior to the industrial revolution,

there was a special status for young people that

IModell and Goo&na,n provide an interesting comparison of changes in the status of adolescents and the retative iInpOrtanCe of schooling V. labor

in Great Britain and the United States (55). This portion of Modell and Goodman’s analysis suggests that it is not only economic forces, but the

predominant ideology of a nation, that determines a nation’s sociat structure (55). A comprehensive analysis of the forces that determine a nation’s social

structure is beyond the scope of this Report. As summarized by Modell and Goodmq the British tended to be more concerned with inculcating and

maintaining ‘‘internalized codes of behavior appropriate to one’s station in life, ” while the Americans were interested in ‘‘conveying to its citizens the

sense of a capacity to master whatever situation might arise” (55). Thus, ‘‘when American school authorities urged children to stay in school, they

reflected the ideological structures that held that extended schooling meant opportunity” (55). In contrast, the British system made decisions early on

about educational and thus employment opportunities for young people. For example, until 1921, Britons as young as ages 12 and 13 could attend school

for only balfa day and leave school by age 14 (55). The American experience was also marked by a great influx of unskilled immigrants at around the

turn of the century, with fewer requirements for the labor of children (55).

-II-13 -
//-14 ● Adolescent Health-Volume //: Background and the Effectiveness of Selected Prevention and Treatment Services

“gave modest recognition to [youth] as [a period] of

preparation for adulthood” (55). But in this period,

“youth roles were almost continuous with adult

roles” (55).2 In the agrarian societies that predominated, the family was the primary economic and

social unit and thus the dominant force in an

individual’s life.3 Occupational choices were limited and fairly well-defined.

With the coming of the industrial revolution and

the urbanization of industrialized nations, the progression from childhood to adulthood became more

difficult:

It was no longer entirely clear what steps one had

to take to become an adult. The shrinking of

opportunities for farming led families to encourage

sons to seek other professions requiring formal

training. The tradition of apprenticeship declined.

Adolescents became economically dependent on the

family. Adult roles were no longer inherited and

prescribed, but now involved choice and initiative

(89).

Whereas before young people were integral to the

economic survival of their families and thus to

society, they came increasingly to be seen as

“marginal” (55). For a while, young peopleespecially those in cities—were viewed as ‘‘brash

and troublesome. This perception shifted to a view

of young people as ‘‘vulnerable and in need of

help,’ and ‘‘various extrafamilial institutions came

into being to help socialize individuals into the new

corporate and bureaucratic world’ (55,72). Chief

among these extrafamilial institutions was the public

high school, which was becoming an upward route

into the American middle class (55).4 Other institutions (e.g., Boy Scouts, settlement houses5

) also

became part of the child development movement.6

As summarized by Modell and Goodman:

With the industrialization and urbanization of the

nineteenth century, the orderly progression of young

people toward adulthood became so widely problematic that concerned middle-class adults elaborated a

specialized vocabulary and set up special institutions

for adolescents (55).

According to Modell and Goodman, “no single

individual did more to popularize and solidify

adolescence as a critical developmental phase than

G. Stanley Hall,” the psychologist and author of the

1904 volume Adolescence: Its Psychology, and Its

Relations to Anthropology, Sex, Crime, Religion,

and Education (28,55). According to Modell and

Goodman, Hall’s volume “contributed to the cooperation in America between academic psychology,

the rapidly spreading public school bureaucracy, and

the lesser groupings of professionals outside the

schools committed to the task of aiding child

development” (55).

Hall and his followers’ conception of adolescence

was as a period in which a person is virtually reborn;

it was “a phase of upheaval and trauma, storm and

stress, corresponding to mankind’s evolutionary

progress from savagery to civilization” (55).7 8

These conceptions of adolescence also became “a

powerful justification for the institutional specialization and even segregation of youth, so they might

%e term youth was used, but it was not age-specific, and it overlapped considerably with use of the term childhood (55). “Youth’ referred to ‘‘an

extended stage defined by the economic status and role of the individual who was not fully dependent on his or her parents for economic suppon who

contributed to the fmcial stability of the family, but who was nonetheless not in a position to assume an independent adult role and set up his or her

own household” (55). Individuals as young as age 12 or as old as age 24 could be referred to as youths, but the term children encompassed individuals

ages 18 or 21 and younger (55).

sModell and Goodman note the tradition of “fostering out’ that seems contrary to the dorninance of the family of origin (55). Children who were

“fostered out’ worked in other households while they were aged 12 to 15. This tradition provided “further txaining in economic roles, [and] a transitional

period toward independence but within a family setting” (89).

AEven~y,tie (’to~ ~gh school exyfience ~c~e]ro~tic~ed as ~ episode of irrepla~able soc~ md perso~ discovery. The h@ school

popularized a new image of youth. . .as a creative and progressive life stage’ (74). The reality of the contemporary high school experience varies

considerably, of course. Evidence for the impact of middle and high school environments on adolescent health is reviewed in ch. 4, “Schools and

Discretionary Time,” in this volume.

sse~ement hous~ were institutions providing various community Se~lCeS, cXptX~y to hge city pop~tions.

6At abut me Sme time, here Wm concern abut he fate of c~&en on a Mtioti level. ne es~bhstient of a Children’s Bureau h the U.S.

executive branch is described in ch. 19, “The Role of Federal Agencies in Adolescent Heal@’ in Vol. III.

7T0 H~ ~d M5 followem, e~h s~ge of life corresponded to the developmental process of the human race m a whole (55).

8AS discuss~ el=whem ~ ~S Re~rt, ~s formerly pop~~ notion ~ ~n diSCr~i@d (2A). such notions led to the view that poor health, in

particular, poor mental healt.& odd behavior, and sub@tive distress, were to be expected during adolescence.
Chapter 2—What Is Adolescent Health? ● /1-15

more productively act out phase-specific turmoil

understood as characteristic of their age’ (55).

It is usually more difficult to characterize contemporary times than to reflect on historical changes.9

As noted above, there are many adolescent experiences, in the past (55) and in modern times (12a). It

seems fair to say that many of the changes in

conceptualizations and social structure of adolescence that occurred following the industrial revolution (e.g., 28) persist today. As summarized by

Modell and Goodman:

At the beginning of the twentieth century, most

youth were in the work force, not in school.10 Good

behavior was positively sanctioned not by promises

of future utility and reward but by immediate

payment and preferment. Bad behavior was sanctioned negatively not by physical or social humiliation but by the threat of dismissal, At the same time,

marriage was typically far in the future,l1 and a

youth’s commitment was solidly to the family of

origin.

There were many points of tension in the turn-ofcentury transition pattern. . .The modal adolescent

increasingly found herself or himself at school, and

his or her perceived needs and deficiencies changed

accordingly. School, unlike the work force, is an

age-segregated institution which, by its nature,

focuses on socializing young people for adult

roles. . .In th[e school] setting, adolescence has

evolved as a transitional period of preparation for

adulthood (55).

In late-20th century United States, there is some

ambiguity about social expectations during adolescence (box 2-A), although there continues to be

considerable age-segregation of youth. Staying in

school until high school graduation (typically age

1 8

12) or, increasingly, beyond (i.e., college or

graduate school) is the preferred norm13 (87). There

is increasing concern that adherence to this norm

results in the neglect of the millions of young people

who do not go on to college-the so-called ‘‘forgotten half”14 (87), as well as to a prolonged sense of

rolelessness among young people who remain in

school (60a). The young people who do not go on to

college and who obtain jobs15 may be better able

than young people still in school to perceive

themselves as adults in some respects (i.e., they are

more financially independent), but the reality is that

the initial earning power and the long-term prospects

for advancement of these young people have declined considerably in comparison with the earning

power and prospects for advancement of young

gAs Modell and Goodrnan, note, however, ‘social-historical accounts are r~e!y definitive”; thus, a chapter like theirs is necessarily interpretive (55).

IOIn 1900, u.S. males typically left school at age 16 and entered the work force at age 15.5; British males left school at age 13 and entered the work

force at age 14 (55).

] I The typical age of marriage for U.S. females in 1900 was 22.5 years; in 1960, it was about 20 years; and in 1980, about 24 years (55).

lzwithout attempting to come to a definitive definition of adolescence, OTA decided to focus thk Report on 10- tiough 18-yem-olds. Many

individuals have begun puberty by age IO, and health issues of young adolescents have been relatively neglected. While the Iegat age of majority is 18

in most States (and thus many 18-year-olds are legally adults), many adolescents are still in high school at age 18 and thus are more or less dependent.

High school completion continues to define the end of adolescence in many ways; age 18 is used as a surrogate marker for high school completion. As

discussed in the W.T. Grant Commission report, the fact of high school graduation or legally becoming an adult creates a whole new set of contingencies

and opportunities for addressing health issues (87). OTA felt that attempting to address these issues as well as those affecting younger adolescents would

compromise its overatl effort; however, this does not mean that the post-high-school period is not potentially fraught with health-related difficulties and

does not deserve attention (58,87).

The Report tries to k as specific as possible in referring to adolescents of different developmental stages. However, much of the research refers to

adolescents of unspecified ages. When ages are indicated, the adolescents involved in the research are more likely to be older than younger adolescents.

As a generat matter, 10- to 14-year-olds are considered early adolescents, 15-to 17-year-olds are considered middle adolescents, and 18-to 21-year-olds

are considered late adolescents (e.g., 18). But, as discussed below, age is not an ironclad indicator of developmental status.

131n 1988, 80 percent of U.S. 25- t. 29-yem-olds, and approximately 70 Pacent of those 25 and older, had&n graduated from high school and had

some college (76). Many individuals finish high school and go on to college, but do not complete 4 years of college. In 1988, 60 percent of U.S. 25-

to 29-year-olds had completed at least 12 years of high school, but had less than 4 years of college; 20 percent had completed 4 or more years of college

(76).

14~e ~~culation tit c *M’ ~ ~e forgotten is bm~ on he 20 ~lllon 16- to zq-y~-olds in the us. population Who have not graduated from high

school or gone on to college and who are unlikely to go to college (87). Note that this calculation is somewhat different from calculations of the numbers

who have been graduated from high school or gone to college by age 25 or older (76).

15[n June 1991, ~emplopentrates for Youg us. workers ages 20 to 24 were 9,9 per~nt for whites and 22.7 percent for blacks (83). In June 1991,

unemployment rates for adolescents ages 16 to 19 were 17.5 percent on average (19.9 percent for white mates), and 33.7 percent for btacks (37.4 percent

for black males) (83). Unemployment rates are calculated onty for those who are looking for employment; they do not include adolescents attending

school or keeping house, or adolescents who are discouraged workers, defined as persons who did not look for work because they believed that no jobs

were available in the area or that no jobs were available for which they could qualify (83).
II-16 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 2-A—Examples of Differences in the Legal Status of U.S. Adolescents by Category of Activity

Although the age of majority is 18 in all States but three (Alaska Nebraska, and Wyoming, where it is 19),

adolescents can legally assume adult-like rights and responsibilities at different ages. Depending on the privilege

or obligation in question, and, sometimes, the State in which they live, adolescents:

● are able to work part time at 14, full time at age 161 (84);

. are able to leave school at 14, 16, 17, or 18, depending on the State2 (76);

● can be licensed to drive at age 143 or 16 (2a);

. are able to buy cigarettes at age 17 (80);

● are able to sign contracts at age 184;

. are able to consent to health care at age 18 or 19, except in five States5 (27,75a);

. are able to vote at age 18 (Public Law 91-285);

. must enlist for draft at 18 (males) (Public Law 96-107); and

. are able to buy alcohol at age 21 (78).

Illlese are the basic minimums fornonagricukural industries set by the Fair Labor Standards AX of 1938 (Chapter 676 of the U.S. Code)

(84). Different standards for agricultural industries, famUy f- and hazdous occupations, as well as rostrictiona on hours W are

Summarkd in the Us. General Accounting 0.tllce report on chUd labor violations (84).

ZAS of 1%$, Omy one State (Mississippi) pcmnitted imiividuala to leave school at age 14 (76). Thil’ty-two S* -CO-W *1

attendance at age 16 (76).

3M~_tiOIIS in the States tbat aUoW driving at age 14, but the restrictions vary (2a). In some of the States tM dow M*

at age 14, the driver merely must have completed an approved driver education course (e.g., in Idaho) or must have a guardian’s or parent’s

consent to get the driver’s Iicemse (e.g., Nevada). Ln other States, 14-year-old licensed drivers must be awmpmed“ byanolderliccnsedd river

(e.g., aged 18 in Wyoming aged 21 in ~).

4h ~sh& (aN_ and Wyoming), the age of majority is 19. See ch. 17, “Cement ~dC~tiality in Adolescent

Health ~Decisionmaking,” in VOL III.

.

5Five States (AabamIL _-qSouth Cam- and Oregon) have enacted statuta that specifically authorize minors who

have reached a designated age—rangingfiom 14 to 16-to consent to health care. In- the body oflawgoverningthe auocationofauthority

for health care decisionmahlg concerning adolescents is large and compUcated and there are many exceptions to tbe commm law rule that

parental consent is generaUy required for the medical or surgical care of a child who has not ~the age of majority. See ch. 17, “Consent

and Confidentiality inMolewxnt Health Care Decisionmaking,” in Vol. III (75a), and Oittleret al., “MolescatHealthC sre Decision-I$fak@

the Law and Public Policy” (27).

people who go on to college (87).16 The impact of than the current average of about 121/2 years (29,70).

‘‘rolelessness’ on adolescent health is less well- As discussed below, maturation of the reproductive

documented, but anecdotal evidence suggests that it glands (e.g., the ovaries and testes) begins at about

may be considerable. ages 9 to 10, before overt signs of reproductive

In addition to the lengthening of adolescence, maturity such as menstruation (68). Thus, individubiological changes in the past 2 centuries, induced als are becoming reproductively mature at earlier

by the control of infection and better nutrition, have ages. Although she is in the minority with respect to

caused adolescence to begin earlier, at least in the the upper age bound for adolescence,17 Baumrind

biological sense (29,52). According to McAnarney, suggests with good reason that contemporary adorecent decreases in the average age of menarche lescence can be said to span ages 10 through 25, with

have occurred at approximately 3 months per decade biological markers indicating the youngeragebound-

(52). Thus, at the turn of the century, the average age ary and social changes (end of postsecondary

of menarche in the United States would have been education, marriage) indicating the upper boundary

about 141⁄2 years of age, approximately 2 years older (6).

16~cord@ t. fie W*T. &~t co~~~ion’s ~~ysi~ of dab from U.S. Cems Bureau C=nt Population Surveys, between 1973 ~d 1986, ~d

mean annual earnings of 20-to 24-year-old civilian males not enrolled in school declined 42 percent for those without a high school diplo~ 28 percent

for high school graduates, 16 percent for those with some college, and 6 percent for coUege graduates (87). Another comparison of census data on avexage

earnings of slightly older groupings of males (males ages 25 to 34 and 35 to 44) from 1979 and 1986 found results that were similar, though not as striking

(61).

170~a ~m~es on ~olescence include ~e~ 10 to 20 (2); ages 10 to 18 (39); ages 10 to 18 ad 10 to 19 (3,58); ~d ages 12 to 17 (46).
Chapter 2—What Is Adolescent Health? . II-17

Photo credit: Ca[pitol Hill Arts Workshop, Washington, DC

Adolescence is a period of profound biological, emotional,

intellectual, and social transformation.

In the contemporary United States, the core

‘‘developmental tasks’ 18 of adolescence can be said

to be the following (18):

●

●

●

●

●

becoming emotionally and behaviorally interdependent, rather than dependent;

dealing with emerging sexuality;

acquiring interpersonal skills and preparing for

mate selection;

acquiring education and other experiences needed

for adult work roles; and

resolving issues of identity and values.

Societal expectations may make appropriate completion of the developmental tasks difficult by at the

same time: 1) expecting all adolescents to take one

developmental pathway; 2) sending ambivalent

messages about the completion of adolescence and

the beginning of adulthood; and 3) lending relatively

little support for coping with developmental changes.

A return to a more structured, family-dominated,

agrarian life in the United States, and thus a more

well-defined adolescence, is unlikely; in any event,

it would be foolhardy to romanticize pre-20th

century life for young people (55). But in considering public policy related to adolescents, it is

important to recognize that, as a consequence of

economic and social changes, the years of preparation for adulthood in contemporary times may be

“fuller, tenser, and more overwhelming for the

young people moving through them’ (55); they may

also span a longer portion of an individual’s life. As

noted by Modell and Goodman in the conclusion to

their chapter, ‘‘these observations may be somewhat

troubling to readers,’ but the notion that adolescence is a social construct ‘‘should not deflect our

attention. Rather, the malleability of adolescence

points to the deep importance of understanding its

attributes within a concrete context;. . . . [y]oung

people. . . need more guidance from caring and

watchful adults” (55).19

Succeeding parts of this section provide a brief

review of basic physiological and cognitive foundations of change that occur during adolescence. The

recent book At the Threshold: The Developing

Adolescent provides a more comprehensive review

of the knowledge base on adolescent development

(24). Understanding these changes is basic to

understanding the experiences of contemporary

adolescents.

Basic Physiological Changes in Adolescence

Physical development, in particular ‘‘the spectacular development of the reproductive system’ (69)

permeates every aspect of development during

adolescence, especially early adolescence (1 1,24,69).

The progression of physical development during

adolescence has been well-described (see 11,69), but

the physiological mechanisms responsible for initiating and regulating maturation and bodily growth,

and the environmental factors that may interact with

biological ones to enhance or impede maturation are

still not fully understood (11,68).

Overt Physical Changes in Adolescence

Figures 2-1 and 2-2 present several of the critical

overt physical aspects of the developmental course

of adolescence in relation to each other: the height

spurt, the beginning of menstruation (menarche),

breast development, and pubic hair development in

adolescent females (figure 2-1); and the height spurt,

penile and testicle development, and pubic hair

development in males (figure 2-2). In females, the

height spurt takes place between 9.5 and 14.5 years

on average; menarche between 10.5 and 15.5 years

on average; breast development in five stages

18Deve/opmenta/ fa& we ~~11~, levels of achievement, ad social adjus~ent considered impoflat at cefiain ages for the successful adjustment Of

the individual, and for the individual to progress to the next ‘‘stage’ of development (e.g., adulthood).

l~e idea tit it is ~w~t t. unders~d tie ~~ent s~~ context for yo~g p~ple wfi ~so reflect~ in the w.T. ~mt cOllMIIiSSiOII IEpOfi On

youth ages 16 to 24 who do not go on to college: ‘‘The world around us hais changed, but our institutions have not responded with the flexibility required

to help lay a new foundation under young families and their children” (87).
II-18 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 2-l-Sequence and Timing of Four Key

Pubertal Events During Adolescence:

Adolescent Femalesa

8 9 10 11 12 13 14 15 16

I I I 1 I 1 I 1

Height spurt 9A91/~ .14 I/*

Menarche ■ 10-16V2

Bud

8-13

Pubic hair 2

~354

8-14

8 9 10 11 12 13 14 15 16

Age (years)

%Jote that the figure indicates averages, ranges, and the normative

sequence forfour specific events. The horizontal lines and rating numbers

marked pubic hair stand for its advent and development. The rating

numbers for pubic hair indicate stages of pubertal development (69). The

appearance of the breast bud is as a rufe the first sign of puberty in the

female, though the appearance of public hair may sometimes precede it.

Stages of breast development are incorporated within the solid line to the

right of the word breast. The range of times for appearance of the breast

bud, the beginning of pubic hair, menatie, and peak voliaty in height are

shown directly under those events (69).

SOURCE: J.M. Tanner, Growth dAdo/escence, 2d ed. (Oxford, England:

Blackwell Scientific Publications, 1962). Reprinted with permission.

between ages 8 and 18; and pubic hair development

in several stages between ages 11 and 14 (figure

2-l). In males, the acceleration of penis growth

begins on average at about age 12.5, but sometimes

as early as 10.5 and sometimes as late as 14.5 (70).

According to Tanner, “the sequence of events,

though not exactly the same for each boy, is much

less variable than the age at which the events occur.

The spurt in height and other body dimensions

begins on average about a year after the first

testicular enlargement [ages 10 to 13.5] and reaches

its maximum. . after about a further year. . .“ (figure 2-2) (70). At various points, dramatic changes

occur in other body systems (e.g., weight, facial

structure and expression, brain structure) (see figure

2-3). The fact that these changes are not simultaFigure 2-2-Sequence and Timing of Four Key

Pubertal Events During Adolescence:

Adolescent Malesn

10 11 12 13 14 15 16 17 18

I I I I ‘ 1

n Apex strength spurt

/\i

Height spurt 6 h

101/2 .1 fj 13-17 1/2

Penis

11-14 Y2 1 31/2

.17

Testis

10-13 v2 14 1/2

.18

Pubic 2

hair

=3=4 5E

10-15 14-18

I I I I 1 I 1 1

10 11 12 13 14 15 16 17 18

Age (years)

3

aNote that the figure indicates averages and ranges for four smcific events.

as well as the &erage sequence o~ four pubefial events, as follows: The

solid areas marked penis and testis represent a general picture of the

period of accelerated growth of these organs, and the horizontal lines and

rating numbers marked pubic hair stand for its advent and development,

with the rating numbers for pubic hair indicating stages of pubertal

development (69). Figures for the range of ages at which the spurts for

height and for penis and testis growth begin and end are inserted

underneath the first and last points of the curves or bars. The acceleration

of penis growth, for example, begins on average at about age 13, but

sometimes it occurs as earfy as 11, and sometimes as late as 141/2. The

completion of penis development usually occurs about age 15, but

sometimes at 131/2 and sometimes at 17. At ages 13 and 14, there is an

enormous variability among any group of boys, who range practically all

the way from wmplete maturity to absolute preadolescence. The

sequence of events, though not exactty the same for every adolescent

male, is much less variable than the time at which the events ocxwr (69).

SOURCE: J.M. Tanner, Growth at Addescencq 2d ed. (Oxford, England:

Blackwell Scientific Publications, 1962). Reprinted with permission.

neous is important to understanding what individuals face during adolescence.

Hormonal Changes in Adolescence20

In addition to confronting overt and discontinuous

changes in themselves and others, with attendant

concerns about being “normal,” adolescents must

begin to deal with sexual arousal and other internal

changes (11). Prior to and during adolescence, the

following normative physiological and hormonal

changes occur, as summarized by Susman and her

colleagues:

20~ormne~ Me ~h~mi~ ~u~~c=, fo~ed ~ one org~ or pm of the My and carried in the blood to another organ or part of the body, thilt ~

alter the functional activity (and sometimes the structure) of another organ or organs.
Chapter 2—What Is Adolescent Health? ● II-19

Figure 2-3-Growth Spurts During Adolescence

r

L

r

L

Height

1

# !

1’

Bi-iliac /~, ‘ $

\ \ / ‘. 1’

J+&

\

,., ‘. /~ t

\ /

)

\ \ ~- /( !$

Hand length \

,’\ #\ )

\

\

/! L -------

1’ \

. .

‘ .

“, Head Circ. ,--0 “, “ ‘~,

.

\ /

\

!1 \

A

\

\

\ ’ \

\

/1 \ 1’ !- - -- \ -\ /

\ \/ \

● . .

J

\

-. \

\

\

~\

\

,

Weight

\

L , 1 , I , 1 1 I

8 9 10 11 12 13 14 15 16 17 18

Age, years

SOURCE: Figure 5 on p. 13 in J.M. Tanner, Growth atAdo/escer?ce, 2d ed.

(Oxford, England: Blackwell Scientific Publications, 1962) based

on L. Reynolds and G. Schoen, “Growth Patterns of Identieal

Triplets From 8 to 18 Years,” American Journal of Physical

Anthropo/ogy5:l 65-200, 1947. Copyright O 1947 by John Wiley

& Sons. Reprinted by permission of Mley-1-iss, a Division of

John Wiley & Sons.

Adrenarche, maturation of the adrenal glands,21

begins at ages 6 to 8. Following adrenarche, there is

a gradual rise in adrenal androgens22 that continues

up to the age of 18 to 20, when levels reach a plateau.

Adrenarche is followed in rather rapid succession by

gonadarche [maturation of the reproductive organs],

which is accompanied by a rise in gonadotropins”

and gonadal steroids that continue to rise up to age

15 or 16, when adult levels are reached (68).

The physiological changes during adolescence

are profound and discontinuous with earlier periods

of development (68). According to Tanner, ‘ ‘Puberty is the time of the greatest sex differentiation

since the early intrauterine months” (70). Thus, it is

not surprising that a popular conception about

adolescents is that they are controlled by raging

hormones. Many commonly observed adolescent

‘‘attitude problems’ such as talking back to teachers

and parents, sullenness, moodiness, and irritability,

as well as major emotional and behavioral disturbances, have been attributed to the hormonal changes

that occur prior to and during adolescence (68).

According to Susman and her colleagues, “the

natural rise in hormone levels at puberty provides for

an experiment in nature. . . adolescence is an ideal

developmental period in which to trace the patterns

of change in both hormones and behavior within a

short period” (68). Unfortunately, research in this

area has begun relatively recently (circa 1978), and

the effects of the rise in many hormones on the

behavior of adolescents generally are unknown (68).

While there is some evidence that hormonal changes

in adolescence influence some behaviors (see 68),

there is also considerable evidence for the primary

influence of prior expectations and social environment on adolescents’ behavioral responses to pubertal processes (24).

As Susman and her colleagues note, ‘‘the connection between normal ‘attitude’ problems and

hormone changes is of major concern to those

individuals who are entrusted with the socialization

of youth’ (68). She and her colleagues suggest that

additional resources and effort be put into studying

the hormonal and other aspects of emotional development in normal adolescents. Important research

questions include: What are the mechanisms whereby

pubertal hormone changes affect brain development

and behavior during adolescence? To what extent is

adolescence continuous or discontinuous with other

periods of development? What is the causal role of

hormonal variations in adolescent mood fluctuations? As noted elsewhere in this Report, very few

21~e ~dremf ~fd~~ Me ~nd~rine ~lands sit~ted ~~he ~~ey tit pr~”cc steroids we Sex hormones (e.g., estrogen, testosterone, eS@lldiOl),

hormones related to metabolic functions, and adrenaline.

~AndrOgens (or ~drogenic hormones) are male sex hormones such as testosterone, which is responsible for inducing maintaining secondary male and

sex characteristics.

~Gon~o(ropins me hormones tit act upon tie gomds (e.g., follicle-s~ulating hormone, which stimulates the grOWh Of fOfiC1eS COn@g OVa

[eggs] and activates sperm-forming cells).
11-20. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 2-B—In Search of Self: Identity Development in Adolescence

The development of an integrated, positive, yet realistic identity has long been considered a hallmark of healthy

emotional and social development; optimally, much of this development takes place during the adolescent years

(23). Harter’s recent review of the process of identity development during adolescence in At the Threshold: The

Developing Adolescent (32) helps to encapsulate the subjective mcaning for adolescents of some of the basic

processes described in other chapters in that volume (1 1,43,55).

An adolescent’s emerging ability to think abstractly makes it possible to imagine “ideal” selves, which can

be compared to perceived actual selves. Yet the same cognitive changes that can facilitate the journey of

self-development during adolescence make its navigation difficult. Like inconsistencies between the real world and

the ideal world (24,43), substantial inconsistencies between one’s actual and ideal selves can be a cause of extreme

subjective distress (35), as is evident from the following synthesis of a self-portrait at mid-adolescence:

What am I like as a person? Complicated! I’m sensitive, friendly, outgoing, popular, and tolerant, though I can

also be shy, self-conscious, and even obnoxious. Obnoxious! I’d like to be friendly and tolerant all of the time. That’s

the kind of person I want to be, and I’m disappointed when I’m not. . .

Sometimes I feel phony, especially around boys. Say I think some guy might be interested in asking me out. I

try to act different, like Madonna. I’ll be flirtatious and fun-loving. And then everybody, I mean everybody else is

looking at me like they think I’m totally weird! Then I get self-conscious and embarrassed and become radically

introverted, and I don’t know who I really am! Am I just trying to impress them or what? But I don’t really care what

they think anyway. I don’t want to cam, that is. I just want to know what my close friends think. I can be my true self

with my close fiends. I can’t be my real self with my parents. . .

At least at school people treat you more like you’re an adult. That gets confusing, though. I mean, which am I,

a kid or an adult?. . . (32).

As summarized by Harter:

This personal narrative exemplifies numerous prototypic features of self-description during middle adolescence. . . . We witness an introspective self-portrait that is couched in the language of traits of the self-obnoxious,

tolerant, introverted, popular, cheerful, depressed-many of which appear to be contradictory. We glean that the

display of different selves in different social contexts is cause for concern, as the adolescent struggles to reconcile

these different selves as well as determine which is the ‘real me.’ Experimenting with one’s persona. . .is typically

an emotional experience for the adolescent preoccupied with the challenge of self-definition. . . (32).

Federal resources are dedicated to studying normal

adolescent development.24

Cognitive Changes During Adolescence

The evidence suggests that the early adolescent

period is a key juncture in the development of human

cognitive capabilities, in that, across the age range of

11 to 14, “what was previously a minority of

successful reasoners becomes a majority” (43,89).25

Thus, in contrast to younger children, adolescents:

. show an increased ability to generate and hold

in mind more than one complex mental representation;

● show an appreciation of the relativity and

uncertainty of knowledge;

● tend to think in terms of abstract rather than

only concrete representations;

. show afar greater use of strategies for obtaining

knowledge, such as active planning and evaluation of alternatives; and

● are self-aware in their thinking, being able to

reflect on their own thought processes and

evaluate the credibility of knowledge sources

(43,89).

Although these changes clearly give adolescents

an advantage over younger children in daily decisionmaking, the process of going through these

changes may be difficult for some adolescents and

Msw ch. 19, “me F~er~ Role in ~Ol~Cent Heal@” in Vol. III, which notes that under 7 percent of the budget of the National I.IMitute fOr Child

Health and Human Development (Nationat Institutes of Heal@ Public Health Semice, U.S. Department of Health and Human Services) is devoted to

adolescent issues. Much of this is problem-oriented rather than focused on normal development.

2s~s is ~omistent wi~ tie evidence (sptise ~ou@ it my be) on adoles~nts’ remoning during health care decisions (see ch. 17, “Consent ad

Confldentirdity in Adolescent Health Care Decisio~g!’~ VO1. ~). ~so see -,Harmoni, and Power (49) whose review found that ~m<itio~

periods for shifts in decisionmaking tend to fall at about 11 to 12 years, and again at 15 to 16 years.
Chapter 2—What Is Adolescent Health? ● II-21

Harter notes further that these processes “do not occur within an introspective vacuum” (32). Peers, parents,

and teachers are important sources of expectations, evaluations, values, directives, feedback and social comparison

(32). Others have noted that adolescent experiences can vary considerably in different gender groups (26) and racial

groups (66a,71).

An important contribution of work on the process of identity development by Harter and others is the finding

that the dramatic changes in the conceptions of self that occur during adolescence do not occur overnight; important

changes occur throughout the adolescent period (13,32). The most subjectively distressing shift appears to occur

around ages 14 or 15, when individuals not only detect inconsistencies across what they perceive as their various

selves (e.g., their behavior in relation to parents, friends, romantic partners), but “are also extremely troubled and

conflicted over these contradictions, much more so than are the youngest (around ages 11 to 12) or oldest (around

ages 17 to 18) groups” (13,31,32). For example, the youngest adolescents, who are apparently unconcerned about

potential contradiction, make remarks such as “Well, you are nice to your friends and then mean to people who don’t

treat you nicely; there’s no problem” (31,32). By about age 17 or 18, many adolescents have reached an

accommodation with their different “selves’ and can make such statements as: ‘‘Sometimes it’s fun to be rowdy,

but at other times you just want to be in a quiet mood; you really need to do both with really good friends’ (31 ,32).

Harter refers to these shifts as “normative” because they typically happen in a normal adolescent; however,

certain deficiencies in an adolescent’s social and psychological environment may interfere with their occurrence.

In addition, although these shifts are normal, some of them are accompanied by significant subjective distress while

they occur. As Harter points out, it is a ‘‘myth’ that these “normal” changes necessarily produce happy outcomes

in the short run (e.g., 21). Further, adolescents may act out these possible selves (22,62), and this role

experimentation can “usher in another potential source of tension among multiple selves” (32).

To summarize, the elements of self and identity development during normal adolescence include

differentiation of the self into multiple domains (e.g., scholastic competence, athletic competence, physical

appearance, social acceptance), the construction of actual and ideal selves, and the integration of multiple

self-concepts into a unified self-theory (32). It is no wonder that adolescents often evidence a preoccupation with

the self (17,32,40,41).

SOURCE: Office of Technology Assessment, 1991, based on S, Harter, “Adolescent Self and Identity Development,” At the Threshold: The

Developing Adolescent, S.S. Feldman and G.R. Elliott (eds.) (Cambridge, MA: Harvard University Press, 1990).

the adults in their lives. For example, while Keat- cognitive changes to the process of thinking about

ing’s review concludes that, in general, the 11- to themselves.

14-year-old range is the period during which a

minority of generally successful reasoners becomes The origins of these new or more developed

a majority, he also finds some evidence that there is abilities and strategies are an important research

a period in early adolescence that Keating terms question with practical implications for educating

‘‘rampant relativism. That is, when early adoles- adolescents and for their abilities to make decisions

cents first begin correctly to give a ‘ ‘can’t tell’ affecting their health. For example, whether and how

response to logical syllogisms, they also give such physiological and cognitive changes may be related

an answer when, indeed, there is a valid conclusion— is still a matter in dispute (19,43,68).26 According to

and one that younger children can infer (43). Keating Keating, the available evidence indicates that changes

suggests that this may be a necessary cost of in cognitive ability occur gradually with age and

becoming a critical reasoner. Additional research is over time, rather than showing a sudden onset or

needed on this apparent propensity to question irreversible stepwise increments (43,89). But, as

everything, which is a familiar one to parents of Keating notes, at the beginning of the 1980s,

early adolescents. Box 2-B suggests some of the research on adolescent thinking could easily have

necessary difficulties adolescents face as they apply been organized around a few central questions, but

‘GFor example, Susman and her colleagues note thiit gonadal steroids are thought to affect brain development during adolescence, and changes in

cognitive abilities arc hypothesimd to be related to changes in gonadal steroids, although the findings reviewed by Susman and her colleagues in 1987

were not consistent across studies (68). According to Kcating, while theories of brain maturation associated with pubertal development continue to arise,

the cvidcncc has not been found sufficient to support some of the changes in educational policy that have been suggested (43).
II-22 ● Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

‘‘since then, accumulating evidence from a variety

of perspectives has strikingly expanded the questions that must be considered and [has] made

consensus a more distant goal” (43).

One major change in conceptualizations of adolescent thinking has been the lack of independent

support for Piagetian stage theories of cognitive

development. Piaget theorized that the changes in

thought processes in adolescence reflected internal

structural changes in the ability to think logically

regardless of content. Although Piaget, his colleagues, and others found evidence of sequential

changes in children’s abilities to make logical

inferences, the identification of structural changes in

logic as the source of the age-related changes has

proved problematic (43).27 There are other potential

limitations on the cognitive abilities of younger

children that researchers have not been able to rule

out as accounting for changes in individuals’ cognitive abilities, such as memory capacity or efficiency,

content knowledge differences, and task familiarity

(43).

There is a practical implication of the lack of

evidence for cognitive developmental stages as

such. One common use of the Piagetian model was

to view age-related shifts as placing limits on the

ability of adolescents to think logically or critically

(43). 28 On the contrary, much of the research has

shown that ‘‘supportive contexts and early attention

to the development of reasoning are precisely what

is required to increase the likelihood of its emergence” (43). For example, Vygotsky has found that

many differences in cognitive performance may be

related to identifiable features of the cognitive

environment (86,44).

Nonetheless, Keating concludes that the current

research provides “encouraging” evidence that

higher order “thinking among adolescents is attainable (43). The caution, he says, is that desirable

cognitive outcomes are neither easily nor automatically attainable. Positive outcomes have largely

been achieved in controlled situations in which

ample time is given to solve problems. In the real

world, adolescents’ and adults’ “spontaneous thinking’ is rarely as systematic, reflective, or intentional

as in controlled situations (14).29 At a practical level,

then,

. . . it would be foolhardy to assume that cognitive

interventions for adolescents could rely on highly

active and reflective engagement with demanding

material. Yet attempts to encourage such higherlevel engagement, if carried out systematically, do

offer considerable promise.

The implications of research on adolescent thinking for the delivery of health care services and

health-related education to adolescents seem clear.

Adolescents cannot be expected to automatically

have the cognitive wherewithal to understand disease processes and the increasingly complicated

delivery of health services. As is true with adults, a

certain amount of ability to draw inferences and

make reasonable decisions will depend on adolescents’ experience and the accumulation of knowledge. The context in which the knowledge is

delivered also appears to be important (86). But

rather than assuming that adolescents are incapable

of making health care decisions,30 the working

assumption might be that adolescents have the

capacity and can be taught to do so in a participatory

fashion (43). Certainly, it would be preferable for

parents to be the teachers of this information, but

often parents and children experience discomfort in

discussions of sensitive topics or are themselves not

knowledgeable (1 1).31 Thus, schools and a broad

range of health service providers could broaden their

roles as educators. Such an expansion of roles

zT~e tenets of Piaget’s theory have been well-described (43). AS s ummarized by Keating, “Piaget focused on the development and organization of

logicomathematical operations through four major stages or periods: the sensorimotor functioning of infancy; the preoperational, largely egocentric

. . thmkmg of early childhood; the concrete operationat logic of middle and later childhood; and the formal operational logic that characterizes adolescence

and adulthood’ (43). Further, ‘the cognitive operations within any given stage are organized in a structure; thus, stage changes imply shifts in underlying

structure brought about through the constructive interaction of the individual with the physical and social world. . .This progression is presumed to be

universal and invariable’ (43).

2ESfim1y, EpStein~S ~eo~es abut possible Whole brain growth spurts inspired a move in education to delay C~eW@ cow~work ~til late in

adolescence (19,43).

29f30~ Kea@ (43) ~d Ko510wski ~d og~ (45) fmd tit adolescen~ me more simi~ to, ~&fferent from, ad~~ in drawing causal hlfereIICeS.

Level of education appears to make a difference as well, with non-college-educated adults scoring between sixth- and ninth-graders (47).

%%e legal presumption that minors are incompetent to make health care decisions is discussed inch. 17, “Consent and Confidentiality in Adolescent

Health Care Decisionmakm“ g,” in Vol. III (75a).

31Also see ch. 3, 14 Pmnts ~d F~lies’ ~uence on Adoles~nt H~l@” in ~vol~e.
Chapter 2—What Is Adolescent Health? ● II-23

Photo credit: Benjamin Smith

Available evidence suggests that higher-order thinking

among adolescents is attainable, but it is neither easily nor

automatically achieved. Attempts to encourage higher

level cognitive engagement require intensive, systematic

efforts that involve real-world content.

would, however, have training32 and cost implications.

A Perspective on Adolescent Risk-Taking

An area important to the delivery of health

services (particularly health education) that is related to research on cognitive development is the

area of adolescent risk- taking .33 As noted in a recent

review of adolescent risk-taking by Furby and

Beyth-Marom, “Although there is little empirical

research on adolescent decisionmaking and risk

taking, there is no paucity of beliefs about how to

characterize adolescent behavior in these areas’

(26b). In their review of the empirical literature

relevant to these beliefs,34 Furby and Beyth-Marom

conclude:

. . . there is as yet little evidence that adolescents are

more likely than adults to engage in behavior that

seems risky to them. That is, there is little evidence

that they seek out or are willing to accept greater

risks. However, neither is there clear evidence that

they do not seek or accept greater risks. The 1ack of

empirical evidence on this issue reflects, in large

part, the dearth of information on how adolescents

(and adults) perceive the options they do consider

[and] the likelihood of [the options’] possible

consequences. . .This lack of information on option

and consequence perception and evaluation is not

surprising, given the methodological difficulties

involved in measuring these variables. However,

without better evidence, it is hard to justify the

[perception] that teenagers are particularly prone to

seek out or accept risks. . . (26b).

Knowledge about adolescent risk-taking and decisionmaking is important in considerations of

adolescent health policy. For example, Furby and

Beyth-Marom raise the possibility that, instead of

being poor decisionmakers, many adolescents may

be making rational decisions, given the existing

conditions and contingencies (26b).35 If adolescents

are engaging in faulty decisionmaking, it seems

reasonable to focus on improving their capacity to

make better health-related choices, for example,

szFor ex~ple, Keating notes two findings with implications for an intensity of effort: 1) that modest intementions kve litfle impaCt (in improving

formal logic); and 2) that the greatest difficulties arise when individuals are asked to reason in tasks for which there is no real content. Those who become

involved in improving adolescents’ cognitive development would also have to be aware of other purported aspects of adolescent thinkm“ g that may affect

adolescents’ abilities to make rational health-related decisions: adolescents appear to have great difficulty in attempting to achieve an integrated

understanding of their persoml and social experiences (32,42,64) and adolescents may have a specific form of egocentrism in which they assume

themselves to be the focus of most other people’s perspectives much of the time (17). (Keating notes that the latter model is intuitively appeating but

has little empirical support (43).)

s~F~by and Bey~-M~om provide definitions of risk and risky behavior: ‘ ‘The te~ risk. .refers to a chance of loss, that chance being greater than

0 percent but less than 100 percent. Thus, the definition of risky behavior . . .is action (or inaction) that entails a chance of loss’ (26b). They note that

risk taking “may or may not be deliberate. That is, one mayor may not be conscious that a given behavior entails a non-zero probability of loss’ (26b).

Furby and Beyth-Marom’s perspective on risk taking is based on a decision-making perspective: “Decision theorists define decision making as the

process of making choices among competing courses of action. . .The normative models of decision theory prescribe the processes that people should

follow in order to have the best chance of maximizing their well-being, given their beliefs and values” (26b). (Furby and Beyth-Marom also provide

a review of other perspectives on risk taking (e.g., risk taking as sensation-seeking).)

%l~e following, according t. Furby and Bey&Mmom, Me some common m~s abut adolescent decisionm~ng and risk-taking: 1) adolescents

are not capable of competent decisionmaking; 2) adolescents take more risks than do adults, and their risk taking endangers their well-being; 3)

adolescents do not consider sufficiently those possible consequences (of various options) that might occur in the distant future; 4) adolescents think that

they are invulnerable; 5) adolescents let emotions rule their choices; 6) adolescents rely heavily on peer information and attitudes when making decisions

about risky behavior (26 b),

JSFor exmple, if ~1 known alternative outcomes ~e t~en ~to ~cco~t, it may seem most ration~ to an adolescent female to beaI a child. h abused

adolescent may seek refuge in the use of alcohol or illicit drugs. Reviews of risk factors and preventive interventions related to selected adolescent health

concerns can be found throughout this volume and in Vol. I of this Report (75).
II-24 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

with training in decisionmaking.36 If, on the other

hand, adolescents are, from their own perspectives,

making rational choices, the emphasis should be on

encouraging changes in the social structure that

would make health-generating choices more likely

among adolescents (26b).37

A potential implication of realistically evaluating

the literature on adolescent decisionmaking and

risk-taking relates to adults’ attitudes towards adolescents and towards particular activities. As have

adolescents themselves (74a), Furby and BeythMarom note inconsistencies in societal attitudes

around sexuality, drug use, and risk taking in

general, suggesting that adults may have concerns

other than adolescents’ health:38

Exactly what these other concerns are is an open

question, . .Perhaps it is somewhat threatening to

adults to see their children acquiring this new (and

more equal) status. Or, perhaps these are simply

behaviors about which adults are quite ambivalent

themselves, being uncertain whether to condemn or

condone them even in adults (26b).

A considerable amount of additional research and

. . thnking needs to be done with respect to conceptualizations of adolescent decisionmaking and risktaking. 39

Summary

Adolescence is a period of profound biological,

emotional, intellectual, and social transformation,

which appears to be lengthening as a result of

national economic demands. One difficulty in gaining the attention of policymakers for some adolescent health concerns is that adolescence is often

viewed solely as a transitional period between

childhood and adulthood (93). But this ‘‘transitional

period” can take as long as one-seventh of the

typical life span. One can argue-without coming to

the conclusion that to be normal in adolescence is in

itself abnormal (26a) (and, perhaps, therefore, that

striking aberrations in behavior, should be ignored

(88))-that contemporary adolescents deserve sympathetic societal attention, including attention to

their perspectives on health, during their second

decade of life.

Defining Adolescent Health

As noted in the introduction to this chapter,

definitions of health have

for:

● judgments about the

particular group;

● judgments about what

important implications

health status of any

health-related services

and policies are justified; and

. decisions about the development of indicators

of health status that are in turn used to help

judge the need for services and policies.

For adolescents, these implications translate to:

How healthy are adolescents? What kinds of interventions, if any, should be developed to improve

their health? How shall the health of adolescents—

and the effectiveness of interventions-be monitored?40 Hence, an understanding of contemporary

conceptualizations of health, and of their implications for the allocation of health-related resources, is

important.

Current Conceptualizations of Health

As is adolescence, the concept of health is socially

defined and subject to change. To some extent,

adolescents have been affected by recent reconceptualizations of health and attributions of responsibility for health status.

~As discussed below, this approach is part of the approach to health improvement that emphasizes individual mspomibility.

sv~s ~omapond~ t. tie he.~ protection approach t. Prmmtion, des~bed blow ~d & FMby ~d Beyth-Marom (26b).

38 For example, “. . the considerable controversy over whether to make contraceptives easily available to teenagers suggests that there may be

something other than the risk of pregnancy that bothers adults about adolescents being sexually active. Likewise, the much greater concern expressed

about the risks some adolescents take by smoking marijuana than about the risks many more adults take by drinking alcohol. . suggests that there may

be something other than the possibility of negative behavioral or health effects that bothers adults about adolescents’ smoking marijuana” (26b).

JgSuggest~ directions for future research can be found in Furby ~d Beyth-Mamm (Zbb).

%ese questions are addressed throughout this Report,
Chapter 2—What Is Adolescent Health? ● II-25

A complete history of evolving conceptions of

health is beyond the scope of this Report.41 In the

past century, as measures such as improved sanitation, and later, immunizations against bacterial and

some infectious diseases have helped to improve life

expectancy,

42 there has come to be more of an

emphasis on nonphysical aspects of health and on

the notion that much disease and disorder is avoidable (5a,53a,77,82a). For example, in 1948 the World

Health Organization (WHO) defined health as ‘complete physical, mental, and social well-being, not

merely the absence of disease or infirmity” (33).

While the WHO definition has not been completely

adopted, the accepted definition of health is, according to some observers, evolving toward including

well-being as well as the absence of disease (8).

The idea that, especially for younger people,

“natural” causes of death, disease, and disability

had been largely replaced by mortality and morbidity related to behavior is an idea that has taken hold

in the last 15 or so years (e.g., 56,60,82). However,

most health data systems, health care systems, and

insurance reimbursement arrangements in the United

States continue to emphasize care for physical

illness.43

The idea that much premature death, disability,

and disease is largely avoidable (and even associated

with behavior) should not lead exclusively to the

notion that preventable avoidable death and disability are the sole responsibility of the individual. For

example, a 1979 U.S. Surgeon General’s report

placed approximately equal emphasis on societal

measures to protect the health of the U.S. population

(“health protection”), on health promotion, and on

prevention of specific diseases and disorders (77).44

By at least 1984, however, many in the field of

public health had come to recognize that much of the

responsibility in health promotion and prevention

had fallen to individual, rather than collective, action

(5a,73) and one of the main objectives of a WHO

conference in the mid-1980s was ‘‘to shift the focus

from individualistic explanations of variations in

health to an awareness of the public policies which

were necessary to promote and protect health” (5a

emphasis added). Thus it was at the 1984 conference

that the idea of the “healthy city” (later to become

the “healthy community”) took root as a WHO

strategy for promoting health for all by the year 2000

(5a).

The notion that the health of adolescents is

grounded in the health of their communities is

that may be gaining momentum (e.g., 78a).

also

one

For

example, a recent publication by the Office of

Substance Abuse Prevention in the U.S. Department

of Health and Human Services sought to “provide

balance to the public health model of agent, host, and

41A~ht~~ ~ecenfly de~e~ted four ~~~ ~public fieafth ~mtie 18* ~td tie 1970s tit may & useful iKI providing some historicld clXltt?xt: 1)

the period of sanitary reform (1840-1900), which responded to the miserable living conditions for the urban poor arising from the rapid urbanization

that accompanied the industrial revolution (see above); 2) the period of personal prevention opportunities (e.g., child and family health clinics; birth

control services; the provision of free milk and meals in schools) (1880-1930) that arose with advances in bacteriology and the development of

immunization 3) the therapeutic era (1930-1974) that arose with the advent of insuliq antimicrobial, and a later explosion of other therapeutic

possibilities, which in m according to Ashton, coincided with ‘‘the apparent disappearance of the major infectious diseases on the one hand, and the

increasing involvement of goverrunents in the provision of health and social semices on the other”; and 4) the new public health movement

(1975-present), which can be traced to increases in longevity, recognition that a great deal of premature death and disability was avoidable, and growing

awareness of the limitations of therapy (5a,53a).

dz~e life ex~~cyof ~average ~e~cm(all races, both genders) bo~ iII 1988 WaS 74.9 y~s; ~ c0mpti50Q tie We exPec~cY of ~av~ge

American born in the period 1900 was approximately 47.3 years (82a). (The figure for 1900 is approximate because it included only the U.S. “death

registration area’ of 10 States and the District of Columbia (82a).) In both 1988 and 1900, the life expectancy of nonwhite Americans was lower than

that of whites, although the gap narrowed between 1900 and 1988. For example, in 1988, the life expectancy for black Americans was 69.2 years; in

1900, the life expectancy for Americans of ‘all other” races than white was 33.0 years (82a). Figures specifically for black Americans are not available

for the year 1900.

qsFor examples, SIX ch. 15, “Major Issues Pertaining to the Delivery of primary and Comprehensive Health Services to Adolescents,” and ch. 16,

“Financial Access to Health Services, ” in Vol. III.

44Hea/rh protection compfis~ s~ate~es for h~~ p~rnotion ~d dis~se prevention that are related tO envho~~~ or rewatovmeas~~ ‘it

confer protection on large population groups. As most broadly defined, health promotion is a philosophy of health or a set of activities that takes as its

aim the promotion of health, not just the prevention of disease; WHO has defiied health promotion as the ‘‘process of enabling people to increase control

over and improve their health” (5a). Sometimes, however, health promotion is more narrowly defined as the set of prevention efforts aimed at changing

individual behavior. Prevention is used most often to refer to primary prevention which is a category of health and related interventions that aim to

eliminate a disease or disordered state before it can occur.
II-26 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

environment by targeting the environment” (78a).

However, relatively few of the Healthy People 2000

national objectives related to adolescents (or to other

age groups) were objectives requiring environmental or regulatory measures to improve health

(82b). 45 - -

Measures of Health

Measures of the Health of Individuals

In no sense have widely published measures of

health status in the United States approached broader

and more positive definitions of health (8).46 In the

United States, the health status of the population is

still measured primarily in terms of mortality or is

inferred from the extent to which individuals seek

care from physicians (e.g., 82a).47 48 There is increasing publication of behavioral risk factors as

indicators of the health of the U.S. population (79).

Measures that are limited to the absence of

physical health problems can be used to infer that

U.S. adolescents as a group are healthy and,

therefore, that they may not require health care

services and other health-related resources (37,88).

As noted above, a potential problem with an

exclusive emphasis on individual behaviors, however, is that social and environmental factors that

play a role in eliciting individual behaviors may be

overlooked (8,73).

Measures of the Social Environment

The literature on health does not typically include

objective measures of social and physical environments and the ways in which those factors affect

adolescent health.49 For example, precious little

research has been done on how adolescents perceive

their environments and the effects those perceptions

have on their health (for examples of exceptions, see

20,85). 50

The evidence that is available suggests that

adolescents believe that there is considerable social

ambivalence when it comes to adolescent behavior

such as sexuality, alcohol, tobacco, and drug use,

and other risk-taking behaviors (e.g., dangerous

driving practices) (74a),51 that many adults do not

really care about them (85), that health care providers do not discuss the issues of concern to them

(36,48,66), 52 and that many adults seem only to see

the negative when it comes to adolescents (34).

Adult observers have also noted that public attitudes

toward adolescents are, if not negative, then largely

unsympathetic (7,65).

Factors Affecting Conceptualizations of

Adolescent Health

Apart from considerations of adolescence as a

period of life, additional issues relating to the

definition of adolescent health include: who defines

health and health problems, the social context of the

definition of health problems, difficulties in operaqSFor~~~ysis of tie Healthy people 2000 obj~tives pertahing to adolescents, see the discussion of Major option 3 in VO1. I, ‘ ‘S ummary and policy

Options,” of this Report.

~For a sP~esis and critique of widely published measures of adolescent health, see app. C, “Issues Related to the Lack of Information About

Adolescent Health and Health and Related Services,” in Vol. I.

dT~e presence of a ment~ he~ti problem is also considered an aspect of health (56), although Federal overviews of the hdti Shhls of tie PoP~tion

rarely include information on mental health status measures (e.g., 82a). Further, many adolescent meutal disorders are defined in behavioral terms (5).

~~ditio~ issues concerning tie tio~tion available about adolescent health status, even using widely accepted indicators ZN measures, are

discussed in app. C, “Issues Related to the Lack of Information About Adolescent Health and Health and Related Services, ” in Vol. I.

qsAJzen notes tit me=uement of social ~d contextual factors in he~~ ~d h~ behavior is underdeveloped (l). Although the health of

communities as well as that of individuals is becoming anadditionalfocus in changing conceptualizations of health (8), measures of a community’s health

appear at this point to be limited to aggregations of the health status of the community’s individual members (8). For example, a recent ‘consensus set

of indicatom for assessing community health status’ published by the Centers for Disease Control in the U.S. Department of Health and Human Services,

includes only one measure of the physical environment (proportion of persons living in counties exceeding U.S. Environmental Protection Agency

standards for airqwdity during the previous year) and one measure of the socioeconomic environment (childhood poverty, as measured by the proportion

of children less than 15 years of age living in families at or below the poverty level) among 18 suggested indicators (81). Nine of the indicators are

mortality rates, 4 are reported incidence rates for physical illnesses (i.e., acquired immunodeficiency syndrome, measles, tuberculosis, and primary and

secondary syphilis), and 3 are “indicators of risk factors” (i.e., incidence of low birth weight, births to adolescents, and lack of prenatal care) (81).

‘Also see app. A, “Method of the Study,” in Vol. I (75).

S] For e-pie, OTA~s you~ A&isowPmel pointed Out tit w~e hey me fo~y ks~cted to abstain from sex, drinking, ~d (hgs, they We

bombarded daily with contradictory messages from the adult-controlled media.

sZFor discussion of time s~dies, ~d ~yses of tie competence of he~fi c~e providers in @eating adolescenfi, see ch. 6, “(hollic Physical

Illnesses: Prevention and Services, ‘‘ in this volume, and ch. 15, ‘‘MajorIssues Pertaining to the Delivery of Primary and Comprehensive Health Services

to Adolescents, ’ in Vol. III.
Chapter 2—What Is Adolescent Health? ● /1-27

tionalizing well-being, and the potential consequences of broadening the definition of adolescent

health.

The way that adolescent health and health problems are defined and measured greatly influences

adolescents’ lives, but as a generally (legally)

powerless group, adolescents have very little say in

the way health and health problems are defined and

measured. As noted above, adolescents have been

found to see discrepancies between issues of concern

to them and issues likely to be discussed by health

care providers and others who have the potential to

affect adolescent health and make referrals to health

care services. Clearly, if there is disagreement on

what adolescent health and health problems are,

there is likely to be disagreement on appropriate

approaches to promoting health and to addressing

problems.

Another factor in defining adolescent health

problems is some things that are regarded as

adolescent health problems are problems only in the

context of the contemporary social environment

(55). Possibly, for example, droppinq out of high

school (or not going on to college) might not be so

terrible for some adolescents if jobs at living wages

or other alternatives were available (87) or if

academic paths were more flexible. The social

environment is the product of longstanding cultural

and philosophical roots in this country that are not

about to be changed in a wholesale manner (9,55),

but in considering what an adolescent health problem is, it is important to recognize the social

environment’s impact on the way adolescent health

problems are defined.

A related social dilemma concerns operationalizing the concept of ‘‘complete. , , well-being’ or

‘‘optimal functional status’ (33,37). Although broadly

acceptable definitions of complete well-being could

be socially constructed, they would be difficult to

devise because to a large extent complete well-being

is inherently a subjective notion. Findings such as

those by Malus and colleagues suggest, for example,

that, in contrast to health care providers, adolescents

perceived sexual intercourse, alcohol and drug use,

as common occurrences, but not serious health

problems (48). Malus’s findings suggest a gulf

between adult and adolescent perceptions of adolescent well-being. Broadening the definition of health

can have implications for the organization of health

services and, as a consequence, cost implications.

Summary

Clearly, the issue of defining health as a general

matter across the life-span-and all the implications

of that definition for intervention and resource

allocation-is not yet settled. Scholars in the field of

adolescent health, realizing the limitations of more

traditional definitions of health and health-related

interventions for that group, seem considerably

more inclined to subscribe to broad definitions such

as WHO’S. For example, Irwin argues that a

reconceptualization of adolescent health as “optimal functional status’ may provide a better understanding of the broader issues affecting adolescents’

health (37,53).

Issues surrounding the definition and measurement of adolescent health may receive greater

attention as the findings of OTA’s Report, and others

related to adolescent health (e.g., 3,4,12,15,54,57,

58,59,60), are considered by local and national

policymakers, parents, researchers, and adolescents

themselves. Many of these issues are relevant to

populations other than adolescents, but a broader

definition of health is especially important for

adolescents because adolescence is both a critical

transitional period (24,29) and a period that comprises perhaps one-seventh of the life span, and

because narrower definitions of health can lead to

the neglect of important health issues during adolescence (88).

Conclusions and Policy Implications

The discussion of adolescent development in the

frost part of this chapter, as well as discussions of

specific health and related topics later in this

volume, suggest that, in attempts to define health for

adolescents, is important to consider a broad range

of issues and to include measures of adolescents’

sense of well-being, their social environments, as

well as the more familiar individual measures of

physical illness, mortality, and behavioral risk

factors. However, OTA found during its assessment

that existing quantitative assessments of adolescent

health, and even attempts to further develop definitions of adolescent health have not caught up with

the conclusion that adolescent health needs to be

thought of broadly (37,56).

Throughout this Report, OTA attempts to take a

broad view of adolescent health. Health is viewed

in this Report in the most ‘‘traditional” terms of

the presence or absence of physical disease and
II-28 ● Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 2-C--Toward Improving Adolescent Health: Key Concepts Developed by Adolescent Health

Scholars at the 1986 National Invitational Conference on the Health Futures of Adolescents

1. Provide a prolonged supportive environment for adolescents Healthy adolescent development is

fostered by providing a prolonged supportive environment during early adolescence, with graded steps toward

autonomy.

2. Devise a precise conceptualization of risk-taking behavior. Positive as well as negative developmental

and healthy outcomes are associated with certain exploratory behaviors. A more precise conceptualization of “risk

taking” is needed to study and distinguish between constructive exploration and potentially destructive behaviors

occurring during adolescence.

3. Increase the focus on positive aspects of adolescence. The major biological and psychosocial changes

occurring during adolescence are not necessarily associated with negative outcomes and instability. Adolescence

is not necessarily turbulent. Understanding positive growth, the acquisition of new skills and health-promoting

behaviors, and the changing nature of interpersonal relationships deserves increased attention.

4. Mutually engage with adolescents in a positive way. Healthy development is encouraged by a process of

mutual, positive engagement between the adolescent and various adults and peers. This process should occur

through family and other significant adults and take place in schools, health institutions, and the community.

5. Study adolescence in multiple contexts. Healthy development must be studied and viewed in relation to

the various contexts within which it occurs. Demographic, socioeconomic, psychological, biological, sociological,

and historical factors can modify the characterization of normal development.

SOURCE: C. I.rw@ “Editor’s Notes,” MoZescent Sociaf Behuvior and Heufth (San Fran&co: Josscy-Bass, Inc., 1987).

disability; the implications of that view for adolescent development (e.g., 13) are important to

interventions and the allocation of resources are

discussed. As has become well-accepted in the

adolescent development and health research communities, the health of adolescents is also viewed

in this Report in behavioral terms-such as

engagement in behaviors variously characterized

as “risky,” “health-compromising,” “healthenhancing,” or “problem” behaviors. The Report also attempts to measure health in positive

terms (e.g., social competence) and health and

well-being from the perspective of adolescents

themselves (e.g., perceived quality of life). The

influence of the social context on health-related

behaviors is also discussed (e.g., families, schools,

discretionary time).

In many cases, however, OTA’s attempt at a broad

analysis of adolescent health was hampered by a

lack of data. The future of monitoring adolescent

health needs to take a well-rounded approach to

measuring health and the factors that affect it, rather

than continuing its emphasis on mortality and

behavior. In addition, the differences that occur

during the long (10 or more years) period of

integrate into an agenda for monitoring adolescent

health and well-being.

In addition, it is important to continue the

‘‘renaissance’ in research on normal adolescent

development noted recently by the Carnegie Council

on Adolescent Development (24,25,89). The Carnegie volume suggests many opportunities for such

research and emphasizes three priority areas of

crosscutting importance (24,25).53

In order to make adolescence a better period of

life, it may also be important to attempt to ‘market’

adolescents differently to the American public and

to health care providers. As discussed above, many

earlier hypotheses that seemed to describe universal

processes in adolescent development have now been

tested and found wanting (24). In the process of

testing grand theories, the field of adolescent development has found that the popular conceptions of

adolescents as a group whose behavior is overwhelmingly determined by ‘‘raging hormones’ and

of adolescence as inevitably a period of storm and

stress are overstated. But on the other hand, the rapid

ss~cording to Fel@ and Elliott, the three crosscutting areas of primary impOrtitnCC Me: i- more about nonwhite youth; examining the

contexts of adolescent development and considering adolescence as part of the life course (24,25). Suggestions for future research can also be found

in various reports from the 1986 National Invitational Conference on Health Futures of Adolescents (e.g., 37,39) and in a reeent review by Susman and

her colleagues (68).
Chapter 2—What Is Adolescent Health? ● //-29

physical change that occurs during adolescence, and

the increasing ability of adolescents to think reflectively, can make adolescence a difficult period for

some individuals, their parents, teachers, other

adults, and their peers. Little help is provided to

adolescents, and their parents and teachers, as they

try to cope with these changes. Societal expectations

for adolescents are inconsistent and may simultaneously restrict adolescents unnecessarily and demand

from them an unrealistic level of maturity.

It is important to consider the basic physiological

and cognitive changes that occur during adolescence

in the design of health and related services, health

education, and adolescent environments generally.

It is important to continuously acknowledge that

adolescence is largely a social construct, and one

that is continuously changing, even as we study it

(55). As a starting place, the key concepts developed

by participants in the 1986 National Invitational

Conference on the Health Futures of Adolescents

deserve additional application arid testing (box 2-C).

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Chapter 3

PARENTS AND FAMILIES’ INFLUENCE

ON ADOLESCENT HEALTH
Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

The Changing Nature of the American Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Positive Parental Influences on Adolescent Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Parents Who Serve as Positive Behavioral Role Models and Transmitters of Values

and Information ...,.,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Parents Who Provide Emotional/Psychological Support and Encouragement . . . . . . . . . . . . . . . . 38

Parents Who Connect Adolescents to Needed Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Parents Who Promote Adolescents’ Autonomy and Independence . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Negative Parental Influences on Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. 41

Parents Who Serve as Negative Behavioral Role Models and Transmitters of Values

and Information . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Substance-Abusing Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Violent Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Parents Who Are Unable To Resolve Conflicts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Parents Who Do Not Have Accurate Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Parents Who Maltreat Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Incidence and Prevalence of Adolescent Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Gender Differences in Adolescent Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Perpetrators of Adolescent Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Genesis of Adolescent Maltreatment: When Does It Begin? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Effects of Adolescent Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Who Investigates Adolescent Maltreatment Cases? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Adolescents in the Child Welfare System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Chapter 3 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Box

Box Page

3-A. Limitations of Research on Adolescent Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Tables

Table Page

3-1. Studies of Adolescent Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

3-2. Case of Maltreatment per 1,000 Children/Adolescents, 1979 and 1986 . . . . . . . . . . . . . . . . . . . . 46

3-3. Incidence of Maltreatment Among Children/Adolescents in Two Poor inner-City Areas

of Chicago . . . . . . . . . . . . . . . . ., . . . . . . . . ..0...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Chapter 3

PARENTS AND FAMILIES’ INFLUENCE ON ADOLESCENT HEALTH

Introduction

The family has long been considered the bedrock

of American society. Pictured as a place of refuge

from the trials and tribulations of everyday life, the

family has been praised from podium and pulpit.

Poets remind us that the family ‘‘is where, when you

go there, they have to take you in. It is a safe harbor,

a supportive environment for personal growth and

expression. And, indeed, for most people, the family

is a place of succor and nourishment-if not always,

then at least most of the time.

But there is a darker side to some families that

belies these virtues. Life in such families can be

terrifying, as violence replaces tranquility, hatred

preempts love, hope becomes despair, and a corrosion of character directs the development of family

members. These are the families in which nightmares are real and children and adolescents are

transformed into victims of oppression.

Adolescent growth and development are deeply

affected by the family environment in manifold and

enduring ways—for good or for ill. This chapter

explores the positive and negative influences of

families on the health and maturation of adolescents.

Since parents are central authority figures in most

families (even during their children’s adolescence,

when peers’ influence increases), the discussion that

follows emphasizes the role of parents vis-a-vis

adolescent family members. The interactions of

siblings, grandparents, and other significant individuals in a variety of family structures are clearly

important for adolescent health, but the body of

research on their significance to adolescent health is

sparse,

This chapter provides a brief overview of the

changing nature of the American family, and discusses positive, then negative, influences of parents

on adolescents, including maltreatment of adolescents. The chapter is intended to provide an overview of the importance of parents in the lives of

adolescents. For some specific adolescent health

problems, there has been considerable research on

the negative impact of specific features of parentadolescent relationships; this research is discussed

in more detail in the relevant chapters in this

volume.l It is important to keep in mind, however,

that some widely held views that parents are not an

important positive influence in the lives of their

children during adolescence are now seen as inappropriate inferences drawn from a small body of

influential writings earlier in this century. The

relationship between parents and their children

during adolescence is complicated and clearly differs from that between parents and their younger

children. This chapter concludes that more research

is needed to investigate the positive and negative

features of the parent-child relationship during

adolescence, and more guidance is needed for

parents during this important period.

The Changing Nature of the

American Family

The traditional American nuclear family is often

depicted in popular culture as a father, a mother, and

several children. Grandparents are depicted either as

living with the family or residing somewhere

nearby. The father works and the mother cares for

the children and home. Today the picture of the

traditional family is evolving rapidly into a pluralistic collage of alternative structures (79).

Economic and social forces have brought about

significant demographic changes that are reflected in

family life throughout the Nation. Divorce, for

example, has made the one-parent family commonplace, and remarriage has introduced a stepparent

into many homes. Over one-third of the marriages

performed in 1988 were second marriages (47,93).

With about half of all marriages now ending in

divorce and about 23 percent of children born today

born outside of marriage, 15.5 million children

under age 18—including 6.7 million 10- to 17-yearolds (92a)—live with one parent. In the vast majority

of cases (90 percent), children in single parent

lsecespml~]y Ch, IO, 1‘Pregm~cy~d Parenting: Prevention and Services, ‘‘ ch. 12, ‘‘Alcohol, Tobacco, and Drug Abuse: Prevention and Semices,

and ch. 13, ‘‘Delinquency: Prevention and Services, ’ in this volume.

-II-35-
II-36 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

households live with their mother (47,92a).2

3 According to the U.S. Department of Commerce,

Bureau of the Census, in 1990, only 28 percent of

households consisted of married couples living with

their own children4 underage 18; in 1970,64 percent

of households consisted of married couples living

with their own children under age 18 (92a).5 Data

from the Bureau of the Census’s Current Population

Survey indicate that 6,789,000 U.S. children under

18 (approximately 11 percent of the resident population) lived in stepfamilies in 1985 (92d). In 1986,

Garbarino and his colleagues estimated that about 11

percent of all adolescents lived in stepfamilies (67).

New social values and fiscal imperatives (e.g.,

self-actualization, professional opportunities, desire

for a higher standard of living) have enabled or

compelled many women to work outside the home.

Two-thirds of adolescents (17.5 million of those

ages 10 to 17) live in households where both parents

(or a single parent) work full time (92c). Group

housing or similar extended family configurations

are sometimes encountered. And all of these and

other forms of nontraditional family structures are

now part of the domestic landscape of America (3).

In addition, changes in employment are now

routine, and families may move from one geographic area to another several times during the

course of a decade, removing a child or adolescent

from close contact with grandparents and altering

the stability of peer relationships. Changes in

longevity, later/delayed childbearing, and improvements in health care and nutrition have increased the

number of older parents of adolescent children. The

automobile and easy access to mass transit in urban

areas have also provided adolescents a broader

degree of mobility, and with it certain independence

from parental influence. Although the specific

influences of television and other electronic media

on adolescents are not known with certainty, it is

widely believed that adolescents are exposed to a

more diverse set of messages through the media than

they would be through their parents alone (92).

For parents with responsibility for their minor

children, these changes can be confusing. Families

modeled along traditional lines may feel embattled

as they witness the changes occurring around them.

Furthermore, many of the new family models have

no established or tested guidelines for raising

children. Instead, they place parents in the position

of having to improvise without the benefit of the

historical experience of others to assist them.

Neither research nor custom yields much counsel

outside of the traditional nuclear setting. In fact,

society tends to question (and sometimes condemn)

nontraditional families, so that support is virtually

nonexistent. At the same time, those in nontraditional families sometimes criticize traditional family

arrangements, further adding to the confusion surrounding families in contemporary society.

Science, too, has added to the problem. New

discoveries offering genetic linkages to a variety of

health problems raise unanswered ethical questions

about parental responsibilities for preventing hereditary conditions. There is increasing evidence, for

example, that genetic factors play a role in schizophrenia, major affective disorders, and alcoholism

(16,37,38,39,81,106). Genetic factors may also play

z~cor~g to the U.S. Department of Commerce, Bureau of the Census, the increase in the number of family households maintied by women done

has accounted for a considerable amount of the change in family compositio~ especially during the 1970s (92b). About 17 percent of family households

were maintained by women alone in 1990, compared with 15 percent in 1980, and 11 percent in 1970 (92 b). However, it is important to note that families

maintained by women do not necessarily include any dependent children. For example, these families could include a woman sharing her home with

an elderly parent or any other adult relative. In about 61 percent of these families in 1990, one or more of the woman’s children underage 18 was present

(92b).

s~e prow~on off~ti~~ depndent children ti~ti by mothers alone is much higher for blacks (56 percent in 1990) ~ for whites (18.8

percent in 1990) (92b). About 30 percent of Hispanic family groups with children under age 18 were maintained by mothers alone (92b).

d“~wn children” in a family me sons and daughters, including stepchildren and adopted childreni of ti householder (92b).

sIt my~somew~t~~t t. note tittie a~lute n~~ of U.S. hou~holds incr~ed &tween 1970 ~d 1990, from 63 million to 93 tdhO~

largely because of large increases in nonfamily households (e.g., men or women living alone) (92b). Even so, there was a greater absolute number of

family households consisting of married couples living with their own children under age 18 in 1970 (40.3 millio% or 50 percent of family households)

than in 1990 (26.3 households, or 27 percent of family households) (92b). (The U.S. Department of Commerce, Bureau of the Census defines afanu’ly

as a group of two persons or more, one of whom is the householder, related by birtlq marriage, or adoption and residing together (92b). A househoki

consists of alt the persons who occupy a housing unit (a house, an apartment or other group of rooms, or a single room occupied or intended for occupancy

as separate living quarters, that is, when the occupants do not live and eat with any other persons in the structure and there is direct access from the outside

or through a common hall) (92 b). A fa”Zy k.wehofd is a household maintained by a family; in addition, any unrelated persons who may be residing

there are included in the count of household members (92b).)

bsee ch. 7, “Nutrition and Fitness I%oblms, ’ and ch. 13, ‘‘Delinquency: Preventions and Service, ’ in this volume for further discussion.
Chapter 3—Parents and Families’ influence on Adolescent Health ● 11-37

a role in some cases of obesity and violent delinquent behavior.6

As if these points of departure from past experience were not enough, parents of adolescents also

must face an additional transition in their parenting

roles. Adolescents bring challenges that may demand revision of parenting skills; as a result, parents

may confront personal uncertainty about appropriate

responses to adolescence. Furthermore, some parents may be experiencing significant life changes

themselves. And, indeed, studies have found that the

parents of adolescents feel less adequate and more

anxious about their roles than do parents of younger

children (2,48,101).

Positive Parental Influences on

Adolescent Health

Many nontechnical books on parenting laud the

role of parents in shaping the character of their

children,7 but the predominance of this theme in the

popular press is not paralleled in research literature

on adolescent health. Instead, most research concentrates on adolescent behaviors, attitudes, and problems and systemic or institutional approaches to

problem solving. As Irwin observes, much of the

existing research on adolescent health has serious

limitations:

Past research has been guided by the ‘‘storm and

stress” perspective of adolescence and has focused

on what goes wrong, went wrong, or is going wrong

during adolescence. Less is known about what

contributes to positive growth and health-enhancing

behaviors (51).

To be sure, demonstrations and “projects” that

marshal schools and community agencies in efforts

to promote improved adolescent health abound—

and some of these include family components. But

the concept of the family as a front line of defense

against adolescent health problems has not permeated the research or services consciousness to any

significant extent. As pointed out elsewhere in this

OTA Report, for example, there are few carefully

evaluated primary prevention efforts that target

families for the prevention of human immunodeficiency virus (HIV) infection in adolescents and

virtually none that target families to prevent sexually

transmitted diseases in adolescents.8 Furthermore, in

those research studies where the family is considered

at length, it is usually considered in one of two

contexts-either the family’s economic or caregiving burden for adolescent health problems or the

family’s role in causing or exacerbating adolescent

health problems (73a).9 10

A balanced approach would seem to demand

some recognition of the positive parental influence,

in the majority of families, on the health and

well-being of adolescents. Yet there is a clear need

for additional research in this arena-for all family

structures, but particularly for separated, minority,

and nontraditional families (6,42,43,45,85). In 1987,

Campbell noted that fewer than 5 percent of the

articles in the literature on families and health were

empirical studies (96). If, in fact, parents serve as

role models for their children, then the behaviors of

parents and the strength of adolescent behavior

modeled after parents would seem appropriate areas

of investigation. Unfortunately, the old adage “Like

father, like son’ has not been evaluated extensively

from a serious scientific perspective.

The opportunities for significant research on the

positive influence of parents and families on adolescent health are manifold. Examples are cited below.

Parents Who Serve as Positive Behavioral

Role Models and Transmitters of Values

and Information

To what extent are the values and behaviors of

parents regarding health practices, personal hygiene,

and safety transmitted to adolescents? Do parent

models influence adolescent attitudes and behavior

to any significant extent? Under what conditions are

parental values and behaviors imitated by adoles7vev few nonc~c~wks m written to guide the parents of adolescents, however.

s~~ Petit is made ti ch. 9, ‘‘AIDS and Other Sexually Transmitted Diseases: Prevention and Services, ” in this volume.

‘Whis observation+ of course, is not intended to denigrate the importance of a famiIy’s fmcial contribution to adolescent health, nor is it intended

to diminish the significance of caregiving within the family setting.

lqn ~on~~t, Sal’s review of preventive pro-~tended to ~pport parents of adolescen~ fo~d tit most pro- adtiss~ the parental rOle

in enforcing rules and limits and in communicating with their childre~ no programs addressed the basic resource provision function of parents, and very

few addressed the role of parents as advocates for their children (i.e., by attempting to help parents become more knowledgeable about the availability

and use of community resources) (83a). Very few of the programs had been evaluated for their effectiveness (83a).
//-38 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

cents? How do a parent’s positive health- and

safety-related values and behaviors relate to adolescent health outcomes? If a parent always uses a seat

belt, is an adolescent driver any more likely to do so?

If parents have strong objections to alcohol, marijuana, or other psychoactive substance use, will the

adolescent be less likely to engage in the use or

abuse of such a substance? To what extent do family

attitudes about sexuality affect risk of pregnancy,

sexually transmitted diseases, and HIV-infection?

Do sound family exercise and nutrition practices

reduce adolescent problems of obesity or dietary

deficiencies?ll Are parental dental practices correlated with the presence or absence of caries in their

adolescent children?

Several studies have found that adolescents agree

with their parents on most basic values (7,21,53,56,

72). It has been established that parents are viewed

by most adolescents as credible sources of information (17,46,74,88,105). To what extent is this

credibility merited? Do parents generally transmit

accurate and current information on health, mental

health, and safety issues to adolescent family

members, or is their information incomplete, outdated, or incorrect?

There is some evidence to suggest that parents

exert a great influence on particular health behaviors

of adolescents (particularly daughters) within a

family (4). When one examines risk factors for

adolescent pregnancy, for example, there emerges a

strong relationship between the mothers’ experiences and those of their daughters (70). Girls in

female-headed households are more likely to have

intercourse at earlier ages, as are those who have

large numbers of siblings (49,109). Although the

evidence is not strong, some studies suggest that

open communications between parents and adolescents about sexual issues result in less sexual

activity, better use of contraceptives, and parental

support in seeking family planning services (27,50,

59). And Rosen has shown that parents play a major

role in the decision to terminate an unintended

pregnancy-particularly among young adolescents

(81). 12

What is not known is how generalizable the

limited existing data on the parental influences are

to subjects that have not received the close scrutiny

given to the parental role in adolescent pregnancy,

nutrition and fitness, or substance use and abuse. Do

parental influences shape the type and quantity of

foods consumed by adolescents? Are cautious parents more or less likely to raise adolescents who

escape accidental injury or avoid risk taking behaviors? Are childhood handwashing and teethbrushing drills effective in shaping the personal

hygiene habits of adolescents?

Parents Who Provide Emotional/Psychological

Support and Encouragement

Adolescence is a time of rapid changes.13 Relations with peers—and particularly with members of

the opposite sex—raise new and perplexing questions. Can the experiences of parents provide a

useful reservoir for adolescents seeking counsel on

issues surrounding dating behavior, friendships, and

appropriate interactions in society? If so, under what

conditions? How is such counsel best conveyed?

Similarly, for those physical and emotional changes

which may seem inexplicable, can parents help

guide their adolescent to greater understanding and

knowledge, a sense of perspective, and self-acceptance-thereby reducing unnecessary anxiety? To

what extent can a parent’s views about an adolescent’s disability-r sexuality, or need for increased

autonomy, or any of a number of other issues—

enhance or impede sound psychological development in the adolescent?

Parents Who Connect Adolescents to

Needed Services

To what extent do parents serve as early screeners

of health care needs for adolescents, either making

their own discretionary diagnoses and referrals or

providing direct health care services themselves?

How important are parental “home remedies” for

adolescent health care? Are these parental interventions appropriate and beneficial? What role do

parents play in connecting an adolescent to dental,

1 Ich. 7, $ *Nurnti~n ad Fitness ~oblems: ~vention and Services, “ in this volume, notes that exercise levels are similar among members of the same

family and that children in obese families expend less energy than those in lean families, suggesting that family lifestyle can be a strong factor influencing

healthy behavior in adolescents. However, findings such as these must be tempered by the recent finding that obesity may have a genetic component.

lzfie limited research on the eff@s of parental pressure on hdth care decisio~“ g by adolescents is discussed in ch. 17, “Consent and

Contldentiality in Adolescerit Health Care Decisionmaking, ‘‘ in Vol. III, A 1988 study by Scherer and Reppucci examin ed the effects of parental pressure

on hypothetical health decisions by adolescents ages 14 and 15 and found that these adolescents yielded greatly to parental pressure (82).

Iss& Ch. 2, ‘{~tI.s Adolescent He~ti?” in this volume fOr discussion of these ChangeS.
Chapter 3-Parents and Families’ Influence on Adolescent Health ● II-39

health, and mental health services?14 How important

are the financial, transportation, and scheduling

roles of parents in the connection of adolescents with

needed services? What are the role and significance

of family caregivers in the system of adolescent

health care? How can parents become more effective

in promoting the health maintenance of their adolescent family members?

These are just a few areas where families maybe

making a major, and largely unrecognized, contribution to the overall health of their adolescent members (73a). Future research should help illuminate

how the “personal’ family sector interacts with the

public and private systems of health care, since

many health problems may be first noticed in the

home setting and decisions to seek professional

intervention are initiated through the threshold of

family concern.

Parents Who Promote Adolescents’ Autonomy

and Independence

As they mature, adolescents typically demand a

more nearly equal and active role in family discussions and decisionmaking (87). Thus, it is perhaps

not surprising that families which allow latitude for

adolescent participation in family decisions have

fewer problems during adolescence than more rigid

and authoritarian families. According to Laurence

Steinberg, a family that combines democracy with

warmth and demandingness is likely to foster an

adolescent’s mental health:

Generally speaking, adolescents thrive develop

mentally when their family environment is characterized by warm relationships in which individuals

are permitted to express their opinions and assert

their individuality and in which parents expect

mature behavior and set and enforce reasonable rules

and standards. This constellation of warmth, democracy, and demandingness has been labelled ‘authoritative. According to several comprehensive reviews of the literature on parenting practices and

their outcomes, adolescents who grow up in authoritative homes score higher on indices of psychological development and mental health, virtually however defined (86).

Thus, basic questions on parent-child relationships

during adolescence include: How can parents best

facilitate movement toward adolescent autonomy

Photo credit: Office of Technology Assessment

Views on the nature of adolescent and family development

have undergone radical transformation. Rather than

becoming detached and independent of their parents,

adolescents need to learn to assume increasing

responsibility y and decision making within the context of

their close relationships, not away from them. A

burgeoning body of research suggests that parents can

help their adolescent children become socially and

cognitively competent by adopting a style of interacting

that is simultaneously stimulating, demanding, loving,

supportive, and committed to the adolescent.

and interdependence? What external controls should

be relaxed and when should relaxation occur? Most

parents continue to exercise some restrictive authority throughout adolescence. Where behavioral restrictions are imposed for health or safety reasons, to

what extent are these effective? What kinds of

restrictions are appropriate and under what circumstances? How can parents more effectively transfer

external controls to internalized self-controls in

adolescents?

As S ummarized recently by Ooms and Owen for

the Family Impact Seminar:

Views on the nature of adolescent and family

development have undergone radical transformation. Earlier research and writing about adolescence

described the central [developmental] task of adolescence as . . becoming detached and independent of,

in effect ‘emancipated’ from, parents. Recent research has led to a reconceptualization of the

developmental tasks of the adolescent stage of the

family life cycle.

14we d. know hat ~o~t ~hildh~~d ~an~ers, for example, are detected a[ early s@ges, as parents are ]ike]y (O seek m~ic~ care soon after ob~ing

a health problem (100).
11-40. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Adolescents need to learn to assume increasing

responsibility and decision making but within the

context of their close relationships, not away from

them. They must renegotiate their relationship with

their parents so that they can assume greater

autonomy, but they also need to remain connected

with their parents in a new relationship of mutuality

and friendship rather than dominance and control.

Parents need to gradually ‘let go,’ but stay interested

in their children, and provide them with continued

advice and support. . .(73a).

Baumrind describes two parent types that have

positive outcomes for adolescents: authoritative and

democratic parents (3,6). She states:

Authoritative parents, by definition, are not

punitive or authoritarian. They may, however, embrace traditional values. Authoritative parents, in

comparison to lenient parents, are more demanding

and, in comparison to authoritarian-restrictive parents, are more responsive. Authoritative parents are

demanding in that they guide their children’s activities firmly and consistently and require them to

contribute to family functioning by helping with

household tasks. They willingly confront their children in order to obtain conformity, state their values

clearly, and expect their children to respect their

norms. Authoritative parents are responsive affectively in the sense of being loving, supportive, and

committed: they are responsive cognitively in the

sense of providing a stimulating and challenging

environment. Authoritative parents characteristically maintain an appropriate ratio of children’s

autonomy to parental control at all ages. However,

an appropriate ratio is weighted in the direction of

control with young children and in the direction of

autonomy in adolescence. Authoritative parents of

adolescents focus on issues rather than personalities

and roles, [and] they encourage their adolescents to

voice their dissent and actively seek to share power

as their children mature (3).

Democratic parents are highly responsive, moderately demanding, and not restrictive. They are less

conventional, directive, and assertive in their control

than authoritative parents, but like authoritative

parents are supportive, caring, personally agentic,

and manifest no problem behavior or family disorganization (6).

The extent to which American families follow

these models is not known. Research has shown,

however, that adolescents in authoritative and democratic families on the average are better adjusted in

terms of mental health, self-image, social integration, and ability to make independent decisions

(self-directed) than their peers from authoritarian

homes (i.e., homes in which parents exert rigid

controls) or permissive homes (i.e., homes in which

parents are either uninvolved or are lax in controlling behavior of their children) (3,5,6,15,20,44,45,63,

78,86).

In the Family Socialization and Developmental

Competence Project, Baumrind evaluated the consequences for children of four parental styles in terms

of the children’s social and cognitive competence:

● authoritative,

● authoritarian,

● permissive, and

● rejecting-neglecting (or indifferent) (6).

Preadolescent children from authoritative/democratic families, Baumrind found, had developed the

greatest social and cognitive competence (6). Preadolescent girls from permissive families were less self-

-assertive than preadolescent girls from authoritative

families, and boys and girls from permissive families were less cognitively competent than those from

authoritative families. Preadolescent children from

rejecting-neglecting families, were the least socially

competent of all. Baumrind found that the effects of

family structure among preadolescents varied with

the socioeconomic and demographic characteristics

of the family. An authoritarian family upbringing,

for example, was more harmful, as measured in

terms of a variety of social competency scales, to

middle-class boys than to girls; more harmful to

preschool white girls than to black girls, and more

harmful to white boys than Hispanic boys (6).1s

When children in the Family Socialization and

Developmental Competence Project were adolescents, Baumrind measured the consequences of

different parental styles again (using a different

categorization), and the findings were similar to

those for preadolescents (6). Adolescent children

from democratic/authoritative homes were the most

socially competent, and adolescents from permissive

and rejecting-neglecting families continued to have

the most interpersonal problems.

Researchers other than Baumrind have identified

yet another type of family that frequently produces

15~e ~mblem fxed by mmy poor adolescen~ and adolescents in speci13c racial and ethnic minoriw wups we ~scussed ~ ch. 18, “Issues in tie

Delivery of Semlces to Selected Groups of Adolescent&” in Vol. III.
Chapter 3-Parents andFamilies’influence on Adolescent Health ● II-41

psychological dysfunction and involvement in various problem behaviors in adolescents—the indifferent family (63). An indifferent family is one in which

the parents are uninvolved, making few, if any,

demands on their adolescent family member. In this

model, decisionmaking is laissez-faire and there is a

low level of warmth and affection among family

members.

Negative Parental Influences on

Adolescent Health

Whereas positive family influences on adolescent

health have received only scant attention from

researchers, negative parental influences are more

widely documented. Dysfunctional families,l6 for

example, have been shown to be associated with

poor diabetic control in adolescents (96). Furthermore, there is some evidence to suggest that stresses

within families can ‘‘trigger’ streptococcal infections or increase the severity of respiratory illnesses

(12,66). And, while the ‘schizophrenogenic mother’

concept has been largely discredited as a causal

factor in major mental illnesses and replaced by

genetic/biological or other theories of etiology, there

is evidence that environmental factors (including

family interactions, support, and stress) contribute to

both the course and treatment of such illnesses (96).

High levels of family conflict and lack of intimacy

have been correlated with heroin abuse in adolescents (40). Some other adverse ways in which

families can affect the health and well-being of their

adolescent members are described below.

Parents Who Serve as Negative Behavioral

Role Models and Transmitters of Values

and Information

Just as parents can presumably contribute in a

positive way toward adolescent development

through their behaviors and values, so too can they

provide negative role models. Furthermore, wellintentioned but uninformed parents may, through

ignorance, provide adolescents with information

that is incorrect.

Substance-Abusing Parents

Alcoholism and illicit drug use by an adolescent’s

parents or siblings have been shown to significantly

increase an adolescent’s vulnerability to becoming

an alcohol or drug abuser (18,38,84,91).17 Some

research suggests that sons of alcoholic fathers may

have up to nine times greater probability of becoming alcoholics than sons of nonalcoholic fathers

(11,16).

Whether these increased risks are due to an

inherited genetic vulnerability, adolescent identification and mimicking of parental or sibling substance use, easy accessibility to substances, or lack

of family prohibitions and punishments has not been

established. According to Kandel, however, parents

who use alcohol can become role models for an

adolescent’s use of alcohol, while families characterized by lack of closeness, lack of maternal

involvement in the activities of children, lack of or

inconsistent parental discipline, and low parental

educational aspirations for the children tend to

experience greater adolescent illicit drug use (55).

Kandel identifies three parental factors that help to

predict initiation into drug use during adolescence:

parental drug-using behaviors, parental attitudes

about drugs, and parent-child interactions.

Violent Parents

The risk of a child’s being physically abused

increases proportionately to the degree and severity

of assault between that child’s parents (89). This

relationship appears to carry over into the child’s

adolescence, although the greater physical power of

abused adolescents may lead to reciprocal assault

(and even parricide) in some instances (13,76). In

fact, adolescents who kill their parents (and wives

who kill their husbands) often do so in retaliation for

abuse, usually as the culmination of a long period of

mutual assault (31).

In 1980, one research group found that 18 percent

of the children and adolescents they studied engaged

in physical attacks on their parents (90). Since the

research team interviewed mothers in half of the

families and fathers in the other half, the team

estimated that as many as one out of every three

16Dy@nctioM/fam”/ie~ me f~~e~~~~h lack ~~h~ion ad mu~ support wi~ a fr~ework of ~ection tit respects individual differences ad

the need for personal expression of autonomy. Such families may either stifle individuality or use inappropriate means of expressing such individuality

(conflict and confrontation).

ITFor a gena~ discussion of substance use and abuse by adolescents, s= ch. 12, “Alcohol, Tobacco, and Drug Abuse: Prevention and Services, ”

in this volume.
//-42 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

children in their sample hit their parents at least once

during the year in which the interviews occurred.

They attributed this violence to retaliation for

physical abuse and mimicking of parental behavior

which was itself violent. Within families where

parents were categorized as “nonabusive,” the rate

of assault by a child upon a parent was only 1 in 400.

Parents Who Are Unable To Resolve Conflicts

Observational research shows that abusive families are behaviorally differentiated from nonabusive

families mainly in their handling of the 5 to 10

percent of parent-child interactions that are negative

(80). Nonabusive families are able to conclude (or at

least terminate) these negative interactions quickly.

Abusive families are ineffective and become enmeshed in escalating conflict.

Parents Who Do Not Have Accurate Information

Parents, in assuming a conscious teaching role or

as unintentional conveyors of knowledge and attitudes, may not always possess accurate or current

information. Thus, parents may sometimes inadvertently transmit erroneous “facts” or myths and

superstitions, causing potential problems for the

adolescent who acts on the basis of the information.

The low rates for which adolescent girls seek care for

dysmenorrhea, 18 for example, may be due in part to

their mothers’ beliefs that nothing can be done about

menstrual cramps (61).

In addition, although parents are often seen as

credible sources of information, they do not often

discuss sensitive topics like sexuality, homosexuality, or prostitution with their adolescent family

members (46,88,99). Sixty percent of U.S. parents

receiving the brochure “Understanding AIDS”

from the Centers for Disease Control in the U.S.

Department of Health and Human Services (DHHS)

did not discuss it with their 10- to 17-year-olds

according to a 1988 National Health Interview

Survey (97,98).

Parents Who Maltreat Adolescents

As noted earlier, some parents abuse or neglect

their adolescent children, either emotionally or

physically .19

Emotional abuse and neglect are difficult to

define (31,34). Emotional abuse can involve the

deliberate or unintentional assault on the emotional

well-being of a dependent. Emotional neglect is the

withholding of warmth, affection, and psychological

support necessary to maintain sound mental health.

Mild emotional abuse or neglect is difficult to

differentiate from normal and occasional ‘‘ribbing’

or expressions of disapproval. But in extreme cases,

parents can destroy an adolescent’s self-esteem or

ability to cope by belittling the person and making

repetitive attacks on personality traits or ego needs.

Some, emotional abuse results from wellmeaning ignorance, as when a parent taunts an

adolescent about acne, ascribing the condition to a

failure to attend to personal hygiene. Sometimes,

however, emotional abuse is pathologic in origin and

may reflect a parent’s need to maintain dominance

and control in the face of increasing resistance by an

adolescent. Like emotional abuse, emotional neglect

can be innocent and unknowing. The parents of an

adolescent with a disability, for example, may deny

the adolescent’s growing sexuality or limit his or her

socialization with able-bodied peers out of protective instincts and ignorance, but the adolescent must

pay the price in stunted sexual development, a more

confining self-image, and restricted opportunities

for emotional expression (64).

Whether resulting from benign motives or not,

emotional abuse and neglect can have long-lasting

adverse consequences for an adolescent.20 In her

studies of parenting styles, Baumrind has demonstrated that adolescents from families characterized

by a lack of warmth and affection-families whose

members are disengaged from any emotional involvement with one another--consistently rank

18~y~menorr~ea is p~~ me~mticm and may & caused by my of sev~ factors. See ch. 6, “Chronic Physical Illnesses: Prevention and

Services, “ in this volume, for information on the rate at which adolescents seek care for dysmenorrhea.

19Ma/~earment ficl~des ~A abuse ~d negl~t. Abuse, w~ch refers to tie active assa~t upon a dependent victim (as diSti.l@shd fmm ViOlenCe

against an individual over whom the perpetrator has no dependency relationship), may be physical, sexual, or psychological. ~eglecf, which refers to

acts of omission that include failure to meet basic needs (as def~ed by prevailing community standards), may be either physical neglect (i.e., grievous

failure to provide physical necessities such as food or clothing) or psychological neglect (i.e., failure to provide appropriate supervision or basic emotional

responsiveness and stimulation necessary for development).

~At 1emt one au~ofi~ ~~ev= tit ~otio~neglect gene~ly ~ more S~OUS consequences than emotional abuse for personality development

(30).
Chapter 3—Parents and Families’ Influence on Adolescent Health ● 11-43

lowest on social competency scales and highest on

substance use and other problem behaviors (6).

Physical abuse and neglect are less elusive than

their emotional/psychological counterparts and have

been studied in greater depth. Wauchope and Straus

have analyzed parental self-reports of “minor violence” (i.e., corporal punishment such as spanking,

pushing, or slapping generally accepted as nonabusive in American communities) and found that

prevalence varies with the age of recipient (104).

Minor violence by parents against children increases

from a prevalence of 20 percent in the first year of

life, to a high of 90 percent at age 3, and then

declines to approximately 15 percent by age 17, The

prevalence of ‘severe violence”21 exhibits a similar

pattern, moving from 5 percent during the first year

to a high of 16 percent at age 6, and then declining

to 6.5 percent by age 17. When ‘‘hitting or trying to

hit” was removed from the data, however, age

differences disappeared, yielding a uniform 2 to 4

percent prevalence of physical abuse throughout

childhood and adolescence.

There is some evidence that physical maltreatment is related to an adolescent’s behaviors considered unacceptable to the abuser (e.g., disobeying or

arguing), Libby and Bybee report that in more than

90 percent of the cases they studied, specific abusive

incidents were preceded by negative adolescent

behavior (60). One cannot tell from the existing data,

however, precisely what is cause and what is effect.

The precipitating behavior may itself be the result of

earlier maltreatment.

As defined by the U.S. Department of Health and

Human Services’ National Center on Child Abuse

and Neglect, sexual abuse of a child can take three

forms: actual penile penetration; molestation with

genital contact; and other unspecified acts not

known to have involved actual genital contact (e.g.,

fondling of breasts or buttocks, exposure), or inadequate or inappropriate supervision of a child’s

voluntary sexual activities.

Incidence and Prevalence of Adolescent Maltreatment

Table 3-1 outlines the small body of research on

adolescent victims of maltreatment. As noted in box

3-A, studies of adolescent maltreatment have several

limitations related to the availability of data. Furthermore, such studies use different definitions of

maltreatment.

Table 3-1 includes both surveys and small-scale

studies. The surveys are as follows:

●

●

●

The

two studies of the national incidence and

severity of child abuse and neglect conducted

by the National Center on Child Abuse and

Neglect in DHHS----one in 1979-80 (published

in 1981) (94) and the other in 1986 (published

in 1988) (95);

the annual tabulation (through 1986) of reported cases of maltreatment compiled by the

American Humane Association (l), and

two national probability samples assessed for

domestic violence conducted by Straus and

colleagues in 1975 and 1985 (89).

small-scale studies include clinical and questionnaire studies of identified or suspected cases of

adolescent maltreatment (34).

The National Center on Child Abuse and Neglect’s study of the national incidence and severity

of child abuse and neglect conducted in the late1970s defined maltreatment as “demonstrable harm

due to maltreatment” (94). Using a sample of 26

U.S. counties, this study estimated that there were

approximately 650,000 cases of maltreatment (including ‘‘educational neglect “

22) of children and

adolescents in the United States. The national

incidence study by the National Center on Child

Abuse and Neglect conducted in 1985 defined

maltreatment as instances where ‘‘a child’s health or

safety is seriously endangered. ’ This study estimated that there were 1,025,900 cases of maltreatment of children and adolescents in the United States

(95).

The 1979-80 national incidence study by the

National Center on Child Abuse and Neglect found

that 47 percent of the known cases of all forms of

child maltreatment were against adolescents, who

made up just 38 percent of the population under age

18 (94), A 1985 American Humane Association

survey, on the other hand, found that adolescents

were victims in 24 percent of all reported cases of

child maltreatment (1). The discrepancy between the

Zlsevere violence includes kicking, biting, hitting with one’s fist, beathg,b-g or scalding, and threatening to or using a weapon.

22EduC.ationa/ neg~e~f refers to tie failure to provide appropriate edu~tion (e.g.$ through failure to enroll a dependent in school or

permitting/encouraging truancy).
//-44 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 3-l-Studies of Adolescent Maltreatment

Studya Sample Age Types of rnaltreatrnent Measures

surveys

U.S. DHHS, Office of Human

Development Services, National

Center on Child Abuse and

Neglect, Survey of 1979,

1980

26 counties-all maltreatment cases known

to professionals surveyed

0-17

0-17

0-17

3-17

0-17

0-17

12-18

12-18

15-20

10-16

12-17

12-17

12-17

12-17

10-19

Alltypes, including educational

neglect

Case records

U.S. DHHS, Office of Human

Development Services, National

Center on Child Abuse and

Neglect, Survey of 1986,

1988

29 counties-all maltreatment cases known

to professionals surveyed

All types, including educational

negiect

Case records

American Humane Association,

Survey of 1985,1987

40 States’ case reports

of maltreatment

2,143 famiiies

All types Demographic and case records

Straus, Geiles, and Steinmetz,

1980

Gelies and Straus, 1987

Physical abuse and “normal

violence” (corporal punishment)

Physical abuse

All types (31% neglect, 42%

sexual abuse, 19% physicai

abuse)

Conflict Tactics Scale (parents’

seif reports)

Conflict Tactics Scaie

Protective servicesb case reports

3,229 famiiies

1,874 reported cases

(NY State)

Powers and Eckenrode, 1988

Small-scale studies

Farber et ai., 1984 199 runaways

47 abused protective

services cases

77 youth (diverse

sampie)

Physical abuse Conflict Tactics Scale

Physical abuse a) Conflict Tactics Scale

b) Structured Ciinicai Assessments

Checklist

c) Demographic background

Farber and Joseph, 1985

McCormack, Janus, and

Burgess, 1986

89 maie runaways

55 femaie runaways

Sexuai abuse interview on dealing with sexual abuse,

delinquency, and demographic background

Garbarino, Sebes, and

Schellenbach, 1984

27 females

35 maies

All forms of maltreatment a) Adolescent Abuse Inventory

b) Child Behavior Checklist

c) FACES-(famiiy cohesion and

flexibility)

d) Demographics

e) Adolescent Famiiy inventory of Life

Events and Changes

Berdie and Waxier, 1984 Ciinicai assessment

Libby and Bybee, 1979

163 families

25 reported cases

Ali forms of maltreatment

Sexuai abuse excluded Case history based Protective

Service

70 reported cases

33 cases to protective

services

2 neighborhoods, inner

Physical abuse

Physical abuse

Lourie, 1977 Clinical assessment case records

Pelcovitz et al., 1984 Clinical assessment

Garbarino and Kosteiny, 1989 Physical abuse, negiect,

citv Chicago sexual abuse

aFull Citations are listed at the end of this chapter.

b~rot~~ve ~em-m~ are an ~pat of s~al ~er~as designed t. prevent n%l=t, abuse, and exploitation of children by rewhing out with social services to

stabilize family life (e.g., by strengthening parental capacity and ability to provide good child care). The provision of protective services follows aeomplaint

or referral, frequently from a source outside the family, although it may be initiated by an adolescent him or herself.

SOURCE: Office of Technology Assessment, 1991.

national incidence study by the National Center for that the former study included data from not only

Child Abuse and Neglect and the American Humane children’s protective services23 but from other agenAssociation survey may be accounted for by the fact cies as well.

~Chil&~~’~ ~rOf~C~V~ ~~WiC~~ ~~ Saices provided by a State or loc~ c~d we~~e agency to chil&en md adoleswnts Whc) have been identified

as being abused or neglected. They may include assessment family support services, removal horn the home and placement in foster care, or similar

interventions and assistance by a caseworker.
Chapter 3-Parents and Families ’influence on Adolescent Health ● II-45

Box 3-A—Limitations of Research on Adolescent Maltreatment

Available studies of adolescent maltreatment, which includes abuse and neglect, have several limitations.

Perhaps the most important is that they rely on data from official reports and self-reports. Both these data sources

have serious limitations and are likely to underrepresent the extent of adolescent maltreatment. Parents who maltreat

their children are unlikely to give self-reports that accurately reflect the true incidence and prevalence of

maltreatment because abuse and neglect are criminal offenses. Official reports may significantly undercount the

incidence of abuse and neglect because public agencies are unlikely to learn about instances of abuse and neglect

that do not result in major physical injury. Furthermore, adolescent victims of maltreatment tend to be served by

agencies other than children’s protective services and hospitals, which makes adolescents less likely to be identified

and included in the hospital and children’s protective services samples. Finally, local jurisdictions may have varying

degrees of competence in and fidelity to reporting abuse and neglect cases or have administrative practices that

confound the data.

Yet another problem with available studies of maltreatment is that researchers have used various definitions

of maltreatment, with some including and others excluding spanking, verbal abuse, and emotional abuse. The

variation in definitions has made it difficult to compare data across studies and has led to contentious challenges

to survey findings. Compounding the problem, communities (and laws) vary in their tolerance and acceptance of

physical expressions of parental discipline; some actions deemed abuse in one area of the country maybe considered

appropriate--even commendable--in another.

An additional problem is that the bulk of family studies involving maltreated adolescents have been conducted

on samples of white, middle-class, two-parent families. Family influences within minority populations have not

been as intensively examined. As a result, ethnic, cultural, economic, and nontraditional family differences from

these samples await further research.

A limitation of available studies of adolescent maltreatment for the purpose of this OTA Report is that most

of these studies cite data on age groups other than the 10-to 18-year-old age group. Thus, the figures quoted from

these studies typically reflect a smaller number than the actual incidence of abuse and neglect among the population

focused on in this study.

SOURCE: Offke of ‘Rdmology Assessment, 1991.

Table 3-2 shows the overall rate of maltreatment enced physical abuse, 35 percent were neglected,

cases known to professionals (children’s protective

services and other agencies) from the 1975 national

incidence study by the National Center for Child

Abuse and Neglect. Also shown are rates of maltreatment cases from the 1985 survey. In both

surveys, known maltreatment rates were higher

among older children than among younger ones.

The 1986 national incidence study by the National

Center for Child Abuse and Neglect found that

psychological abuse was more common among

adolescents ages 12 and over than among children

ages O to 11 (32 percent of reported adolescent cases

v. 25 percent of cases reported among children) (95).

Conversely, it found that physical abuse was more

common among children ages O to 11 than among

adolescents (52 percent of reported children’s cases

and 42 percent of adolescent cases). In a smaller

clinical study, Berdie and Wexler reported that 68

percent of their sample of abused adolescents

suffered emotional maltreatment, 54 percent experiand 24 percent had been sexually abused (9).

Gender Differences in Adolescent Maltreatment

Some gender differences are evident in the data on

adolescent maltreatment. Females appear to be more

likely to be abused as they pass through adolescence

than in childhood, while risk for males peaks early

and generally declines through adolescence. The

study of the national incidence and severity of child

abuse and neglect conducted by the National Center

on Child Abuse and Neglect in 1975 identified two

female adolescent maltreatment victims for every

one male (73).

Small studies tend to confirm the finding that

female adolescents are at greater risk for maltreatment than males, with the reported figures for

females in their samples of maltreatment adolescents ranging from 55 percent (34) to 77 percent

(62). Powers and Eckenrode’s analysis of New York

State data found that among 12- to 17-year-olds,

females accounted for 65 percent of the physical
II-46 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 3-2-Cases of Maltreatment per 1,000 Children/

Adolescents, 1979 and 1986a

National Center on Child National Center on Child

Abuse and Neglect, Abuse and Neglect,

Age Survey, 1979 Survey, 1986

0-2 . . . . . . . . . 6 6

3-5 . . . . . . . . . 6 10

6-8 . . . . . . . . . 11 15

9-11 . . . . . . . . 11 15

12-14 . . . . . . . 12 23

15-17 . . . . . . . 14 28

aDefinitions for maltreatment were different in the two surveys. h the

survey ecmducted in 1979 -80the definition of maltreatment was “demonstrable harm due to maltreatment.” In 1986 the definition of maltreatment

included instances where “a child’s health or safety is seriously endangered.”

SOURCE: J. Garbarino, “Adolescent Viitims of Maltreatment,” contract

paper prepared for the Office of Technology Assessment, U.S.

Congress, Washington, DC, April 1990.

abuse cases reported, 88 percent of the sexual abuse

cases, and 54 percent of the neglect cases. A 1984

study by Pelcovitz and others, however, found that

only 45 percent of the abused and neglected adolescent population studied were females (75).24

Perpetrators of Adolescent Maltreatment

Families at high risk for maltreatment of adolescents can be characterized in terms of family

structure or family dynamics. These factors may not

be independent, but there has been little research on

family dynamics (e.g., authoritative v. other styles)

in nontraditional families.

Family Structure--Considerable research demonstrated that families at high risk for maltreatment

in adolescence often contain stepparents. A variety

of analyses point to the stepparent-adolescent relationship as a very risky one (19,54) and studies of

maltreatment discussed below tend to confirm this.

Libby and Bybee reported that 28 percent of the

families in their study of adolescent maltreatment

were stepfamilies, even though only 11 percent of all

adolescents live in stepfamilies (60). Berdie and

colleagues reported similar findings; 25 percent of

their families were stepfamilies (8). Olson and

Holmes analyzed the data from the National Center

on Child Abuse and Neglect’s 1979-80 study of the

national incidence and severity of child abuse and

neglect and concluded that 40 percent of the

adolescent maltreatment cases occurred in families

with a stepparent (73). Garbarino and his associates

found that, among a sample of 10- to 16-year-old

adolescents (from families containing two adults—

not always married) whom professionals identified

as ‘‘having problems, ’ families at “high risk” for

adolescent maltreatment were more likely to have a

stepparent (35). Farber and Joseph reported that only

30 percent of their maltreated adolescents were

living with both biological parents (25).

Obviously, these findings do not imply that the

majority of stepfamilies are abusive or that intact

birth families are nonabusive, but they do suggest

the stepfamily as a possible risk factor in adolescent

maltreatment.

Family Dynamics--Families characterized as

being high risk for adolescent maltreatment reveal a

general pattern of difficulty in relating as an

interpersonal system (6). Such families are at high

risk on the dimensions of adaptability, cohesion,

support, discipline, and interparental conflict.

Pelcovitz and colleagues conducted a clinical

analysis of 22 families in which adolescents were

physically abused, classifying them either as families in which the onset of abuse was during

childhood (8 families) or as families in which the

onset of abuse was during adolescence (14 families)

(75). The eight families with adolescents who were

first physically abused in childhood (involving 14

adolescents) manifested intergenerational abuse,

spousal abuse, and developmentally inappropriate

demands (75)—all elements of what has been

termed ‘‘the world of abnormal rearing” (41).

Pelcovitz and colleagues classified the 14 families

with adolescents where physical abuse first occurred

during adolescence (involving 19 adolescents) in

one of two categories on the basis of multiple,

independent clinical assessments—’ ‘authoritarian

families’ (7 families) and ‘overindulgent families’

(7 families). The authoritarian families (as distinguished from the ‘‘authoritative” families discussed

earlier) were characterized by paternalistic, harsh,

rigid, domineering styles of childrearing (75). They

were also characterized by denial by the parents of

their feelings toward each other and about the family

Z4However, thi5 s~dy o~y involved 33 a&les~nts from 22 f~es,titi ages ranging from 13 to 18. In 80 percent of the cases where girk were

the victims of maltreafmen4 the abuse was attributed to dating or sexual exploration% while in all cases of maltreatment of boys, the abuse was associated

with truancy or delinquent behavior. The investigators used the definition of ‘‘abuse’ found in the New York State Family Court Act of 1976, which

includes physicaf injury, risk of death or disfiguremen~ impairment of physical or emotional he.al~ and impairment of a bodily organ. The record does

not indicate if any of the maltreatment cases involved sexual abuse--the exclusion of which could be a source of sample bias.
Chapter 3-Parents and Families’ Influence on Adolescent Health ● II-47

system. Incidents of abuse typically arose from a

challenge by the adolescent (acting out or testing

behavior) that was met with overwhelming force.

The high priority placed upon control provided the

foundation for high levels of force.

In contrast, the overindulgent families were characterized by parental efforts to compensate for the

emotional deprivation that they had experienced in

their own childhood (12 of the 14 parents had lost

one or both of their parents during childhood) (75).

These families made few demands upon their

children, set few limits, and desired a high level of

emotional gratification from their children. But

when the children reached adolescence and sought to

form primary attachments outside the home or began

to act impulsively in important social settings, the

overindulgent parents also reacted with excessive

force.

Garbarino and his colleagues have contrasted the

family system of families judged to be abusive with

that of families judged to be nonabusive (34). These

researchers used FACES, a measure of family

adaptability and cohesion, to assess overall family

interactions. Abusive families were more likely to be

scored as ‘‘chaotic’ or ‘‘enmeshed. Nonabusive

families tended to fall into the more normal ‘ ‘flexible” and “connected” ranges.25 On a measure of

interparental conflict, adolescents in the abusive

families tended to rate their parents as evidencing

more conflict. It is important to note, however, that

the average difference masks the fact that some

abusive families evidenced extremely high conflict

while, consistent with the finding that abusive

families were more likely to be ‘‘enmeshed,’ others

evidenced extremely low conflict. In a 2-year

followup, it appeared that some abusive families

dealt with conflict by expelling the adolescent, while

others simply suppressed all manifestations of

conflict through a conspiracy of silence.

Poverty and Adolescent Maltreatment—

Families at high-risk for destructive parentadolescent relations are less heavily concentrated

among families living in poverty than families at

high risk for child maltreatment (34). The National

Center on Child Abuse and Neglect’s study of the

national incidence and severity of child abuse and

neglect conducted in the mid- 1970s suggests that the

big social class differences that characterize child

maltreatment cases are attenuated in the case of

adolescent maltreatment (94), Families in which

adolescents were abused were half as likely to be

poor (i.e., earning less than $7,000 per year in 1979

dollars) as families in which children were abused,

Presumably, some of the observed attenuation of

social class differences in adolescent maltreatment

is attributable to the fact that parents of adolescent

tend to be older, and thus earning higher wages (on

average) than the parents of young children. The

attenuation may also be due to the greater difficulties

that some families have in dealing with adolescence

than with early childhood.

Blum and Runyan reported, for example, that 42

percent of all confirmed cases of maltreatment in

Minnesota involved adolescent victims (10). Minnesota is a State with relatively little of the extreme

poverty that tends to be associated with maltreatment (particularly neglect) in early childhood, and

has been a leader in promoting professional awareness of adolescent maltreatment. In contrast to the

Minnesota study, Garbarino and Kostelny report an

intensive study of maltreatment rates in inner city

Chicago neighborhoods where poverty is a major

problem and there is little leadership in dealing with

adolescent maltreatment (32). This study revealed a

different picture, but still supported previous findings of a relatively poor predictive association

between poverty and adolescent maltreatment, at

least relative to child maltreatment (see table 3-3).

Garbarino and Gilliam also reported findings consistent with the National Center on Child Abuse and

Neglect’s study of the national incidence and

severity of child abuse and neglect (31). In their

work, they found that families with adolescent-onset

cases of maltreatment were about half as likely to be

poor as families with the child onset (and child

maltreatment) cases.

Despite the finding that family income alone is

not a powerful predictor of risk for adolescent

maltreatment, some research does suggest that a

feeling of deprivation and strained resources, often

associated with larger family size, may play a role

(102). In addition, other measures of social status not

based on income yield contradictory results. Farber

and Joseph report that their families were predomi-

~A Chuoric fhlyis a ftiychacterizti by lack of s~cture. An enmeshed family is a family in which individuals are excessively dependent upon

each other. Aj7exible family is one that is able to combine structure with responsiveness to situational conditions. A connected family is one that is able

to have close relationships without finding them stifling.
II-48 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 3-3-incidence of Maltreatment Among Children/Adolescents in Two Poor

Inner-City Areas of Chicago

Cases per 100 children/adolescents

Physical abuse Neglect Sexual abuse

Age Area la Area Ilb Area la Area Ilb Area la Area Ilb

0-4 . . . . . . . . . . . . . . . . 5.1 3.8 40.0 32.8 1.6 1.7

5-9 . . . . . . . . . . . . . . . . 5.2 4.6 22.3 22.5 0.7 1.8

10-14 . . . . . . . . . . . . . 2.4 1.8 10.8 13.5 0.5 1.9

15-19 . . . . . . . . . . . . . 1.5 1.8 3.9 4.6 1.0 0.1

afiea I ~verty rate -51 percent.

b~ea II poverty rate -40 percent.

SOURCE: J. Garbarino and K. Kostelny, “Patterns and Trendsin Reported Cases of Maltreatment and Infant Mortality

in Chicago Community Areas,” Erikson Institute, Chicago, IL, 1989.

nantly lower class, while Pelcovitz and his colleagues report that 59 percent of their families were

classified in the top two socioeconomic groups on a

five-point measurement known as the Hollingshead

Index (25,75). Only 12 percent of Libby and Bybee’s

families were categorized among the lowest socioeconomic groups, while Garbarino’s research team

found differences on the Hollingshead Index of

socioeconomic status among abusive and nonabusive families (35,60). Berdie and colleagues

reported that about 51 percent of the families in her

study of maltreated adolescents earned less than

$15,000 at a time when approximately 20 percent of

all families did so (8).

Genesis of Adolescent Maltreatment:

When Does It Begin?

Two theories dominate current thinking about the

origins of adolescent maltreatment. The first holds

that parents establish patterns of child abuse and

simply continue such behavior through their child’s

adolescence. The second avers that much adolescent

maltreatment occurs independently of earlier childhood abuse and may reflect the inability of a

previously functional family to adapt to the new

challenges of adolescence (28). The existing body of

research on this question suggests that both theories

account for a portion of the adolescent maltreatment

population, but that there is a distinctly adolescent

genesis to a significant number of cases-ranging

from a high estimate of 90 percent to a low of 24

percent (8,9,25,31,60,62,75).

Sexual abuse may represent a special case, since

studies suggest that sexual abuse begins in childhood, before the onset of adolescence. KendallTackett and Simon interviewed 365 adults who were

victims of childhood sexual abuse and found that the

average age of onset was reported to be 7.5 years,

with less than 10 percent having an onset after 12

years of age (57). In over half of the cases, the sexual

abuse did not continue past the age of 12. This study

offers an intriguing opportunity for further research

to identify factors related to the ages of the victim

and perpetrator which may be associated with both

the onset and the cessation of sexual abuse within

families.

Effects of Adolescent Maltreatment

Adolescents who are maltreated seldom die from

the maltreatment. The fatality rate declines with

age—from 0.09 per 1000- to 2-year-old children to

less than 0.01 per 1,000 adolescents. As Garbarino

notes, however, some adolescent deaths may be

indirectly attributable to maltreatment:

A full accounting of the adolescent fatalities

attributable to maltreatment could reasonably include numerous suicides and other self-destructive

behavior appropriately linked dynamically and developmentally to the experience of maltreatment.

For example, a runaway who leaves home to escape

abuse and then falls prey to AIDS, or is murdered, or

becomes suicidal on the streets is, in a very real

sense, an “adolescent maltreatment fatality” (29).

Berdie and her colleagues report that 49 percent of

their adolescent maltreatment victims exhibited

significant clinical indicators of depression (8).

Between 45 and 70 percent of the adolescents

showed problems such as nervous habits, isolation,

poor social skills with peers, lethargy, low self-

-esteem, low frustration tolerance, temper outbursts,

and stubbornness.
Chapter 3—Parents andFamilies’influence on Adolescent Health ● II-49

Running away from home is directly correlated

with maltreatrnent.26 Approximately 73 percent of

adolescent female runaways and 38 percent of the

male runaways in one recent study reported that they

ran away to avoid further sexual abuse (65).

Who Investigates Adolescent Maltreatment Cases?

The study of the national incidence and severity

of child abuse and neglect conducted by the National

Center on Child Abuse and Neglect concluded that

“the child’s age may be a major determinant of

whether or not a recognized maltreatment problem

is reported to CPS [children’s protective services]

for investigation and treatment” (95). The bulk of

adolescent maltreatment cases are reported to and

handled by agencies other than children’s protective

services. Thus, intervention models designed from

study findings that rely on data from children’s

protective services and hospital samples may not be

generalizable across the full range of adolescent

maltreatment cases.

One reason that adolescent maltreatment is so

often investigated by agencies other than children’s

protective services is that it is often viewed as a

consequence of ‘‘acting-out’ behavior by the adolescent or dysfunction within the family; and agencies such as community mental health centers or

family services may be called upon to provide

assistance.

Adolescents in the Child Welfare System

For children and adolescents who-for reasons of

parental abuse and neglect, findings of delinquency,

or other causes—are unable to live in an acceptable

home environment with their parents, an elaborate

child welfare system has been developed throughout

the Nation.27 This system includes the foster care

system, a network of public and private institutions

and agencies intended to provide substitute out-ofhome care for dependent youth. Primarily regulated

by the States, the child welfare system is backed up

by juvenile and family courts.

While child welfare programs have their historic

roots in orphanages and institutions, today the

emphasis is largely upon community-based care,

provided by surrogate families under professional

supervision by public entities (23).28 Two-thirds of

all children in foster care are placed in families; the

remainder are sent to institutions, including detention centers, mental hospitals, and special schools—

often because no suitable family homes can be found

(108). Foster care is designed as temporary placement until a child or adolescent can be returned to his

or her family or pending completion of necessary

treatment and rehabilitation.

Unfortunately, the reality has fallen short of the

promise of foster care. The criteria for removal of

children from their homes tend to be vague and

subjective, and studies have confirmed significant

differences in the handling of cases by caseworkers

and judges (58,68). Nonwhites and Hispanics are

placed out-of-home more frequently than other

children (108). But worst of all, the “system” has

tended to “lose” children and adolescents, in the

sense that temporary out-of-home placements have

resulted in permanent failures to reintegrate clients

back into their homes.29 In 1984, the average foster

care stay was about 17 months (108). Tragically,

children who remain in care longer than 18 months

are seldom ever returned to their parents (58,68).

The 1990 Family Impact Seminar notes that a

recent study of 500 adolescents/young adults who

received care from the Casey Family Program

indicates that the more placements they had, the

more difficulties they encountered later in life (23).

Between 20 and 30 percent of those evaluated had

serious difficulties. In addition, a significant number

of children in foster care were exposed to physical

and sexual abuse from foster parents (24). A 1988

zbFor a discussion of the health and other needs of homeless and runaway adolescents, see ch. 14, “Hopelessness: Prevention and Services,’ in this

volume.

zTchi/d ~e/fare ~enlc.e~ ~clude adoptlo~ Ctid prot~tio~ foster we ad centers, independent hving programs, drop-ill centers, sexual abuse ~d

prevention programs, victim assistance programs, adolescent pregnancy programs, and shelters for runaway children and adolescents. Frequently,

programs are operated by private nonprofit entities under grants or contracts with governmental agencies.

2$~ 1982, 76 Pement of ~hil&en in foster cme were in f~ly or group homes, ad o~y lb percent Were in institutions. tiOUp hOIIleS We the faStfXSt

growing form of care, yet they accounted for only 7 percent of out-of-home placements in 1982—mostly for adolescents.

z~ere ~e Clmly imtmces when ~ adolescent’s welfme r~uires continued out-of-home placement. But even tiough the ret~ of some adolescents

to the home environment may not always be desirable, the adolescents who are considered “lost” in the child welfare system do not return for other

reasons (e.g., because family reintegration efforts are nonexistent, superficially conducted, or easily abandoned in poorly monitored programs).
11-50. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

study by the William T. Grant Foundation’s Commission on Work, Family, and Citizenship found

that older adolescents average four different placements and at least one runaway episode while in

foster care (108).

There has in general been increasing recognition

that the child welfare and foster care systems are not

functioning well. In a recent article in the journal

Child Welfare, Woolf noted that:

A review of foster care history reflects a perpetual

march down a road of good intentions with the

failure to check the quality of the road, and, indeed,

whether the interim goals to be accomplished along

the way coincide with those of the final destination. . .The time has come to integrate good intentions and optimism with wisdom in the development

of child welfare strategies for foster care. Cooperation, teamwork, and self-discipline between professionals and organizations is imperative to the development, implementation, and monitoring of a systematic treatment approach to foster care services

(108a).

A 1989 National Health Policy Forum workshop

referred to the child welfare system as ‘‘a crisis

intervention system in crisis’ (58a). In their issue

brief for the National Health Policy Forum workshop, Koppelman and Jones noted the emerging

health and social problems that burden a child

welfare system; in turn, the child welfare system is

fraught with case overloads and personnel shortages

(58a). Personnel shortages include a shortage of

foster parents (58a).

Although they are indicative of the problems

faced by the child welfare system, it is important to

note that recent commentaries have not focused

specifically on adolescents in the child welfare and

foster care systems.

Recognition of the problems associated with

foster care has led to increasing emphasis on

preserving families and reuniting children with their

natural parents. Between 1977 and 1983, the number

of out-of-home placements for children of all ages

declined from 502,000 to 272,000 (108). Apparently

aiding this trend was passage of the 1980 Federal

Adoption Assistance and Child Welfare Act (Public

Law 96-272).30 In addition to requring child welfare

agencies to make “reasonable efforts’ to maintain

a child or adolescent in the home prior to placing him

or her in foster care, this act funded family preservation demonstration programs and research. Nonetheless, between 1984 and 1985, 31 States reported an

increase in foster care placements (108). In 1985,

there were 270,000 children in foster care, and about

45 percent of these (121,000 children) were between

the ages of 13 and 18.31

In an effort to reduce out-of-home placements,

State and local governments have experimented

with innovative family preservation programs in

which adolescents are viewed as an integral part of

their family system.32 These programs seek to assess

and treat families as units (23). The family is seen as

a part of the community in a broad ecological

context. Services provided to families are generally

oriented to specific and limited goals, which are

jointly defined by the family and a program worker,

in accordance with the expressed needs of the

family. Such services may include parent education

and skills training, referral to other services, family

therapy, and individual psychological support and

counseling. Family preservation programs attempt

to draw on the strengths of families, with a caseworker acting as a catalyst and enabler.

Among the widely replicated models of family

preservation programs are the following:

the Homebuilders model, a crisis intervention

model, which provides intensive services to .

families over 4 to 8 weeks, based on the

assumption that the placement crisis presents a

‘‘window of opportunity, ” when parents are

most likely to be able to learn and change;

the FAMILIES model, a home-based services

model, which is adapted to rural areas and

widely used in Iowa, where it had its beginnings; and

the Oregon Intensive Family Preservation Services model, which unlike the other two places

primary emphasis on family therapy rather than

on the provision of concrete services (23).

301n ~ 1989 ~epofl, fie U.S. Gener~ ~o~fig OffIce made the poirlt that k the absence of Mtiond evdwtions or comprehensive information

systems, they could not determine whether or to what extent the Public Law 96-272 reforms were responsible for reducing the number of unnecessary

out-of-home placements.

slIn the pr~edirlg year, about Igo,ooo children entered foster care ad an M@ number left It (108).

32~e Fmlly Impact Sefim ~s identifi~ pm~ams ~ c~ofia, Colorado, COMWtiCU~ Delaww, Florid% Illinois, IOW~ Kentucky, Wtid,

Michigan, Mimesot~ Missouri, New Jersey, New Mexico, New York North Dakot% Oregop Pemsylvania, Temessee, ‘Ikxas, and Washington (23).
Chapter 3—Parents and Families’ Influence on Adolescent Health . II-51

According to a review for the Family Impact

Seminar, 33 the Oregon Intensive Family Preservation Services model emphasizing family therapy has

the highest success rate (87.3 percent, measured at

termination of service) in terms of preventing

out-of-home placement of children and adolescents,

but the other two models have nearly as good

success rates (81.4 percent for the crisis intervention

model and 79.6 percent for the home-based services

model) (23).34

Implicit in family preservation strategies is the

assumption that it is better for a child or adolescent

to remain with his or her family than to be taken out

of the home and placed in foster care. It is important

to note, however, that there may well be circumstances when preservation of the family is not in the

best interests of the child or adolescent, For some,

like the runaway and homeless adolescents studied

by Shane, there isn’t always a home to which they

can return (83).35 For others, the home environment

is irretrievably hostile and destructive. Thus, reduction in out-of-home placements should not be the

sole criterion for program success or public policy.

Future evaluations of family preservation services

should develop broader measurements of effectiveness and clearer definitions of outcome expectations.

Finally, Woolf notes that the family preservation

policy mandated by Public Law 96-272 has meant

that only the severest cases are remanded to foster

care (108a). The implication has been that foster care

has had to become more treatment-oriented, although, according to Woolf, it is not nearly treatmentor family-oriented enough (108a). A true treatmentand family-orientation would place foster care in a

continuum of services for children and families, in

which ‘‘the entry of a family into the foster care

system should be accompanied by a diagnostic

component to assess specified areas such as family

system dysfunction, placement requirements for the

child, and recommendations for treatment of family

members’ (108a). Such an initial assessment would

be the frost component in determining the treatment

services needed to assist the family in becoming a

healthier, functioning system (108a). Additional

research on attitudes and skills needed by parents of

adolescents (e.g., 5,6,86) may help to keep adolescents in their homes or improve the foster care

system for adolescents.

Conclusions and Policy Implications

Adolescents do not grow up in a vacuum. Both

their health and their development are influenced by

myriad social and environmental interactions from

the immediate (e.g., daily contact with peers, parents, and teachers or physical contact with poison

ivy) to the global (e.g., changes in the ozone layer).

The family’s significance in this constellation of

influences, if not preeminent, is at least major—for

it touches the lives of most adolescents on a daily

and deeply personal basis. Because parents usually

have continuing proximity and can exercise some

degree of power over the actions of adolescent

family members, they are centrally important to any

configuration of social factors shaping adolescent

health. From time to time, peers and community may

loom larger or smaller among an adolescent’s

external influences, but the family and parents will

remain as constant elements despite fluctuations in

their relative importance.

Given their ongoing role, if parents and families

are to be a positive influence, they need to have

accurate and useful information about adolescent

development. Using parenting strategies with adolescents that were successful with children may

generate conflict that could be avoided through

alternative approaches to resolving differences.

Research (as documented through this Report) has

suggested that the enhancement of parenting skills

can improve the quality of life within families and

reduce conflict, but studies of the effectiveness of

JJ~e F~y~pact Semti is an activity of the American Association for Marriage and Family Therapy Research arid Education Foudatiow

Family Impact Seminar meetings provide information to public policy staff (23).

w~e F~ly Impact sem~ notes tit these Comparison are hampered by methodological concerns but suggests that the Oregon Intemive F~lY

Preservation Semices model emphasizing therapy seems best adapted to families with udofescen~s at risk of placement. At an average cost of $1,000

per family, the Intensive Family Presemation Services model also appears to be the lmt expensive (the average cost of Homebuilders is $2,600 per family

and that of FAMILIES is $2,000). The reader is cautioned, however, that these cost figures, in the absence of experimental designs, do not provide a

reliable basis for estimating cost savings over placement services.

35 While ‘‘rumway’ adolescents usually leave their homes voluntarily and without parental permission, sometimes parents or guardians encourage

them to leave, abandon them, or force them out of their residence. The parents or guardians of these ‘‘pushout” or ‘‘throwaway’ adolescents may resist

family presemation services and deny an adolescent reintegration into the family. For a general discussion of homeless and runaway adolescents, see

ch. 14, ‘‘Hopelessness: Prevention and Services, ’ in this volume.
II-52 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

parenting programs on improving parent-adolescent

relations and reducing specific problems of adolescence remain inconclusive (83a).36 Still, the evidence suggests that authoritative parenting skills

should be encouraged and information and training

about this family model more widely disseminated.

A variety of public and private supports could

help to relieve families in distress. Respite care to

relieve family caregivers, family and parental leave,

comprehensive (or at least catastrophic) insurance

coverage, and increased access to family therapy and

parenting education programs all merit serious

consideration for development or expansion.

Policy aimed at reducing adolescent maltreatment

should be a high priority. First, however, more

analysis is needed concerning the definition and

causes of adolescent maltreatment. Much of the

research, policy, and programs on the causes,

prevention, and treatment of maltreatment has not

been specific as to the age of the child victim or has

focused on younger children.

Additional research on a range of other issues and

aspects related to families and adolescent health

would be useful. Research on the effect of parenting

styles on adolescent health and development in

nontraditional families (e.g., stepfamilies and singleparent families) and ethnic and racial minority

families, for example, is sparse (42,43,45,85). It

would be useful if additional research emphasis were

given to examining effective, well-functioning families and their impact on adolescent health rather than

maintaining g the traditional focus of research on

family dysfunction and pathology. Knowledge of

family influences that work to enhance adolescent

health and development is as important as an

examination of negative family influences. To assist

researchers, improvements in the collection and

reporting of data about intrafamilial maltreatment

and family caregiving are desirable.

Perhaps most importantly, though, parents need to

be viewed with respect and treated with dignity in

their interactions with public and private agencies.

The institutions of society-religious, social, and

political institutions and the media—should recognize the diversity of America’s families and the

family’s potentially significant role in improving the

health of our Nation’s children and adolescents.

Rather than adhering to the outdated notion that

parents are solely the obstacles to treatment for

children and adolescents, many more professional

health/mental health care providers should try to

regard parents and other family members as partnerstogether with the practitioner and the patient—in the

prevention, treatment, and rehabilitation of adolescent health problems (73a). While some families

surely bear culpability for the health problems of

their members, a‘ ‘blame the family’ or ‘blame the

parents’ approach to understanding the problems of

adolescent health obfuscates more than it illuminates. Through strengthening the many positive

contributions of families and parents to adolescent

health, a more balanced and constructive perspective

can be maintained.

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Health: A Critical Review and Annotated Bibliography, ” prepared by T.L. Campbell, DHHS Pub, No. ADM 87-1461

(Rockville, MD: 1987).

U.S. Department of Health and Human Services, Public Health

Service, Centers for Disease Control, National Center for Health

Statistics, AIDS Knowledge and Attitudes for May-June, 1988,

D.A. Dawson, No. 160, DHHS Pub. No. PHS 88-1250

(Hyattsville, MD: September 1988).

U.S. Department of Health and HumanServices, Public Health

Service, Centers for Disease Control, National Center for Health

Statistics, AIDS Knowledge and Attitudes for July, 1988, D.A.

Dawson, No. 161, DHHS Pub. No. PHS 89-1250 (Hyattsville,

MD: October 1988).

U.S. Department of Health and Human Services, Public Health

Service, Centers for Disc&se Control, Natio’nal Center for Health

100.

lOOa.

101.

102.

103.

104.

105.

106.

107.

108.

108a.

109.

Statistics, AIDS Knowledge and Attitudes for January-March

1989, D.A. Dawson, No. 176, DHHS Pub. No. PI-IS 89-1250

(Hyattsville, MD: August 1989).

U.S. Department of Health and HumanSemices, Public Health

Service, National Institutes of Healti Nation.aJ Cancer Institute,

Z987 Annual Cancer Statistics Review, DHHS Pub. No. NIH

88-2789 (Bethesda, MD: February 1988).

U.S. General Accounting, Foster Care: Incomplete Implementation of the Reforms and Unknown Effectiveness GAO/PEMD-89-

17 (Washington DC: U.S. General Accounting Office, August

1989).

Veroff, J., and Felt S., Mam”age and Work in Amen”ca (New

York NY: Van Nostrand Reinhold, 1970).

Vondra, J., “Socioeconomic Stress and Family Functioning in

Adolescence, ’ Troubled Youth, Troubled Families, J. Garbarino,

C. Schellenbach, J. Sebes, et al. (eds.) (New York, NY: Aldine

Publishing Co., 1986).

Wald, M. S., Carlsmit4 J. M., and Leiderman, P. H., Protecting

Abu,sedand Neglected Children (Stanford, CA: Stanford University Press, 1988).

Wauchope, B., and Straus, M., “Age, Class, and Gender

Differences in Physical Punishment and Physical Abuse of

American Children, ” paper presented to the Third National

Conference on Family Violence Resea.rc~ University of New

Hampshire, DurharrL NH, 1987.

Weis~ C. S., Nathansou C.A., Ensminger, M., et al., “AIDS

Knowledge, Perceived Risk and Prevention Among Adolescent

Clients of a Family Planning Clinic, ’ Family Planning Perspectives 21(5):213-216, 1989.

Weissman, M. M., Gershon, E. S., Kidd, K.K., et al., “Psychiatric

Disorders in the Relatives of Probands With Affective Disorders, ” Archives of General Psychiatry 41: 13-21, 1984.

West, M., and StuarL S., “The Child Welfare System for

Adolescents,’ contract paper prepared for the Office of lkchnology Assessment, U.S. Congress, Washington DC, January 1990.

William T. Grant Foundation, Commission on Work Family, and

Citizenship, The Forgotten Half: Pathways to Success for

America’s Youth and Young Fam”lies (Washington, DC: November 1988).

Woolf, G.D., “An Outlook for Foster Care in the United States, ’

Child We~are 69:75-81, 1990.

Zeu M., Kantner, J., and Ford, K., Sex and Pregnancy in

Adolescence (Beverly Hills, CA: Sage publications, 1981).
Chapter 4

SCHOOLS AND

DISCRETIONARY TIME

Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

School Influences on Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

overview of the U.S. Educational System for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Relationships Between Adolescent Health and School Adaptation . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Overview of the Effects of Specific Factors on School Environments and on

Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Evidence for the Effects of Specific Academic Policies on Adolescent Health . . . . . . . . . . . . . 67

Evidence for the Effects of School Size on Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Evidence for the Effects of School Decisionmaking and Other Processes on

Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Evidence for the Effects of School Transitions on Adolescent Health . . . . . . . . . . . . . . . . . . . . . 71

Evidence for the Effects of Class Size on Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Evidence for the Effects of School Environments on Teachers’ Attitudes and Behaviors . . . . 73

Evidence for the Effects of Teacher Behaviors on Adolescent Health . . . . . . . . . . . . . . . . . . . . , 76

Evidence for the Effects of School Policies Regarding Cultural Diversity on

Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Evidence for the Effects of Parental Involvement in Schools on Adolescent Health . . . . . . . . 77

Summary: School Influences on Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Major Federal Policies and Programs Related to Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

U.S. Department of Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

U.S. Department of Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Adolescents’ Discretionary Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
How Do U.S. Adolescents Spend Their Time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Alternatives for the Constructive Use of Adolescents’ Discretionary Time . . . . . . . . . . . . . . . . . . 91

Basic Requirements of Alternatives for the Constructive Use of Adolescents’

Discretionary Time . . . . . . . . . . . . . . . ..0,.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Youth-Serving Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Community Service Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

School-Based Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Municipal Recreation Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Churches and Synagogues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Other Alternatives . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. 96

Major Issues in the Elaboration of Health-Enhancing Alternatives for the Use of

. . . . . . . ,.

Adolescents’ Discretionary Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Counterproductive Theories of Adolescent Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Categorical Funding Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Public Support v. Private Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Common Infrastructure v. Adolescents as a Special Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Adolescent Development, Recreation, or Employment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Extent of Adult Involvement and Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Differing Needs for Differing Adolescent Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

National Youth Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 100

Revitalization and Reinstitution of Social Service Agency Programs . . . . . . . . . . . . . . . . . . . . 100

Recent Federal Initiative: National and Community Service Act of 1990 . . . . . . . . . . . . . . . . 101

Conclusions and Policy Implications ....., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

Chapter preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Box

Box Page

4-A. Innovative Approaches to Improving American Schools ........, . . . . . . . . . . . . . . . . . . . . . . . 79

Figures

Figure Page

4-1. Typical Patterns of Progression From Elementary School Through High School, . . . . . . . . . . 61

4-2. High School Dropout Rates in the United States, 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

4-3. Possible Relationships Among School Environments, School Adaptation, and

Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

4-4. U.S. Department of Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Tables

Table Page

4-1. Evidence for the Relationship Between School Adaptation and Adolescent Health . . . . . . . . . 64

4-2. National Data on the Relationship of Students’ Race/Ethnicity and Socioeconomic

Status to School Adaptation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

4-3. Evidence for the Relationship of Various School Environments to Teachers’ Attitudes

and Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

4-4. Evidence for the Relationship of Parental Involvement in Schools to the School

Environment and Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

4-5. Where Adolescents Spend Their Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

4-6. What Adolescents Spend Their Time Doing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Chapter 4

SCHOOLS AND DISCRETIONARY TIME

Introduction

Every day, some 26 million U.S. adolescents ages

10 through 18 go to school. How do school

environments affect adolescents’ health-that is,

their physical, social, and behavioral development

and well-being? The role of schools in adolescent

health is the subject of increasing debate (e.g.,

27,147,210). School personnel often think that

adolescents bring their health problems to the

schools and regard efforts to address specific problems and generally improve adolescent health as the

responsibilities of adolescents themselves, their

parents, the health care system, and perhaps other

institutions in the community (107b). The view that

adolescents bring a considerable number of health

problems with them to the school building each day

is certainly supported by clinical evidence, but there

is also evidence that schools play a role in exacerbating or ameliorating adolescents’ health problems,

broadly defined.1

As discussed elsewhere in this Report, some

schools offer health education, fitness activities, and

lunch or other meals to students, and some schools

provide health care services through school nurses or

school-linked health centers (SLHCS).2 Some school

buildings, are located in unsafe neighborhoods and

have deteriorating facilities with asbestos, lead

paint, radon, or other problems with potential

implications for the health of their adolescent

students, but these risks will not be addressed in this

chapter. The question addressed in the first half of

this chapter is how school academic and social

environments affect U.S. adolescents’ health. As

discussed further below, particular aspects of school

academic and social environments have been correlated with indicators of school adaptation (e.g.,

school grades, attendance, educational attainment,

being retained in grade, and school dropout3

), and

some of these indicators have been correlated with

adolescent health outcomes (e.g., self esteem, substance use, adolescent pregnancy and childbearing,

and delinquency). Some major Federal policies and

programs related to the education of adolescents are

also discussed.

U.S. adolescents attending school spend some of

their time every day away from school. It is virtually

certain that the physical, social, and behavioral

development of adolescents is shaped, at least in

part, by the experiences that occur during their

discretionary time (i.e., time that is not spent at

school or in essential maintenance activities such as

eating or sleeping). The second half of this chapter

is devoted to an examination of adolescents’ discrePhoto credit: Bruce Clark/Education Week

Each day, some 26 million U.S. adolescents go to school,

but the role of school environments in promoting

adolescent health, whether discretely or through

academic achievement, only recently seems to have

emerged as a concern.

IAs noted iII Vol. I of thk R~ort ad in Ch. 2, ‘‘What Is Adolescent Health?’ in this volume, a broad deftition of health-including physical, social,

and mental aspects and emphasizing a sense of well-being in addition to the absence of problems-fits the period of adolescence better than a narrow

definition emphasizing the absence of physical health problems. In considering adolescent healm one should take into account traditional measures of

physical healh newer behavioral measures, and a broad range of indicators of optimal functional status (including emotional and social status, pereeived

quality of life). A fully realized view of adolescent health should also be sensitive to the developmental changes that occur during adolescence.

Nm_ition and fitness activities in schools are discussed in ch. 7, “Nutrition and Fitness problems: Prevention and Services, ” in this volume.

Information abut SLHCS is presented in ch. 15, “Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Services to

Adolescents, ” in Vol. HI.

qAl~ough 1 *sch@l &oPut” is aw~ard te~ology, ~s is such a common term ~ tie field tit OTA is Wing it. Sch~l drOpOUt Cm be rlletlNIRd

in various ways. In the U.S. Department of Education’s report Dropout Rates in the United Sfates.” 1988, distinctions are made among event dropout

rafes (the proportion of students who drop out in a single year), status dropout rufes (the proportion of the popdation that has dropped out at a given

point in time), and cohort dropout rates (the proportion of a group of students that drop out over time) (202b).

-II-59-
11-60. Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

tionary time. It discusses available research on how

adolescents spend their time and describes issues

related to the development of health-enhancing

alternatives, including the National and Community

Service Act of 1990 (Public Law 101-610). The

chapter ends with conclusions and policy implications.

School Influences on Adolescent Health4

Evidence that allows inferences about causal

relationships between school environments and

adolescent health outcomes such as substance abuse,

pregnancy, delinquency, or victimization to be made

with confidence is limited. The reason is that schools

are seldom considered as factors in discussions of

ways to improve adolescent health, and most of the

research that has been done in this area shows

correlational relationships rather than causal relationships. Another problem is that school and

nonschool factors (e.g., individual factors, family

factors, neighborhood factors) interact with each

other in complex ways that have yet to be fully

understood. When considering how school environments affect the health, behavior, and well-being of

10- to 18-year-old students, it is important to keep

these caveats in mind.

The bulk of the discussion below details available

evidence for the effects of different aspects of school

environments —academic policies, school size,

school decisionmaking and other processes, timing

of school transitions, and classroom size, teachers’

attitudes and behavior, school policies regarding

cultural diversity, and parental involvement in

schools-on adolescent health. First, however, overview of the U.S. educational system, with descriptions of Federal, State, and local funding responsibilities, and student enrollment statistics, is presented as background in the first section below.

Major Federal programs related to education are

discussed briefly after the discussion of evidence on

the effects of school environments on adolescent

health.

Overview of the U.S. Educational System

for Adolescents

Figure 4-1 provides an overview of the structure

of elementary and secondary education in the United

States. Students usually spend 6 to 8 years in the

elementary grades and then go on to a 4- to 6-year

program in high school. They normally complete the

entire program through grade 12 by age 17 or 18

(204).

Ten-year-olds typically enter grade 5, ll-yearolds grade 6, 12-year-olds grade 7, 13-year-olds

grade 8, 14-year-olds grade 9, 15-year-olds grade 10,

16- year-olds grade 11, and 17-year-olds grade 12. In

1987, adolescents ages 10 to 18 totalled an estimated

26.4 million students (13.2 million in elementary

school and 13.2 million in secondary school) (204).5

From 1971 to 1984, enrollment in U.S. elementary

and secondary schools steadily declined, but a new

wave of secondary school students is expected in the

years ahead (204).

U.S. schools are affected by funding, policies, and

regulations at various levels of government, but

public education is primarily a State and local

responsibility. States establish State educational

policies and determine how State monies are allocated. Generally, the States delegate operational

responsibility for schools to local school boards.

Some 15,000 local school boards set most policy for

over 100,000 individual elementary and secondary

schools in the United States (202).

The Federal Government supports elementary and

secondary education through financial aid programs

that include the Chapter 1 program discussed later in

this chapter. In fiscal year 1989, the appropriation

for Chapter 1 was $4.6 billion (202a). Federal

spending for education is a small percentage of

overall spending for elementary and secondary

education. At its highest point in 1979-80, Federal

spending accounted for 9.8 percent of total expenditures. In 1985-86, the Federal Government contributed only 6.7 percent of total revenues, with the

States picking up nearly half of the expenses (49.4

d~.s ~tlO~ &aW~ ~~bs~ti~y ~m a paper prep~~ under Contrwt to oTA by Michelle Fine entitled “Middle ~d !hXOn@ School

Environments as They Affect Adolescent Well-Being” (72a).

5AS noted in ch. 18, “lssues in the Delivery of Services to selected Groups Of Adolescent% ‘‘ in Vol. III, adolescents ages 10 through 18 numbered

about 31 million in 1987. About 22.01 million (71 percent) are white, non-Hispanic adolescents; about 4.65 million (15 percent) black non-Hispanic

adolescents; about 3.1 million (10 percent) are Hispanic adolescents; and 1.24 million (4 percent) are “other” (including Asian) adolescents. The

percentage of U.S. adolescents who are not‘‘white, non-Hispanic” is growing, and this trend can be expected to continue into the foreseeable future.

Racial and ethnic minority adolescents disproportionately live in poor or near-poor families.
Chapter 4—Schools and Discretionary Time .11-61

Figure 4-l—Typical Patterns of Progression From Elementary School Through High Schoola

High school diploma

17

12

11

10

9

8

I Senior

high schools

(grades 10-12)

4-year

high schools

(grades 9-12)

16

Combined

junior-senior

high schools

(grades 9-12)

15

14

13

7

12 I

schools

(grades 4-8)

11 LA (grades 1-6) u (grades 1-6) I

10

4

9

(grades K-3) I

3

8

Elementary (or primary) schools

2

7

I

6 ii

-.

0

3

5

5

I K

Nursery schools PK

4

3

Age

L I Grade

%hart reflects typical patterns of progression rather than all possible variations.

SOURCE: U.S. Department of Education, Office of Educational Research and Improvement, National Center for Educaticn Statistics, Digest of Education

Statistics, 1989 (Washington, DC: U.S. Government Printing Office, 1989).

percent) and local sources picking up the rest (43.9

percent) (72a). Schools have grown increasingly

dependent on local tax bases and other resources

(94).6

school is a serious problem in this country. Each

year, more than 425,000 students in grades 10

through 12 drop out of school; others leave before

reaching high school (202b). As of October 1989,

the status dropout rate among 16- to 24-year-olds—

i.e., the percentage of 16- to 24-year-olds reporting

themselves to be dropouts-was 12.6 percent (204a).

This means that about 4 million 16- to 24-year-olds

in October 1989 were without a high school diploma

or certificate and were not attending school.7 Dropout rates for blacks, Hispanics, and Native AmeriThe proportion of U.S. students who graduate

from high school has increased dramatically in the

last century. In 1989, the graduation rate (defined as

the percentage of 9th graders in 1985 who have been

graduated in 1989) was calculated to be 71.2 percent

(204b). Despite the improvements, dropping out of

s~g~c~lengti brought in several States (e.g., New Jersey, ‘Ikxas, Montan% and Kentucky) have rwendy res~t~ in court decisio~s- ‘oW

school financing systems because of disparities between spending in poor and wealthy school districts (107a). Similar chaUenges can be expected in the

future.

7Some high schml &opou~ ~vent~y em a ~gh sc,hool degree, ei~er by returning to school or by passing the tats of general educational

development (GED).
II-62 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

cans are higher than aggregate rates for the U.S.

population (202b) (see figure 4-2).

Relationships Between Adolescent Health

and School Adaptation

In the course of this assessment, OTA found that

school environments, academic achievement and

failure, and adolescent health are typically viewed as

discrete entities. If relationships between academic

achievement and failure and adolescent health are

considered, it is the impact of health problems on

academic achievement that is discussed, not the

reverse (e.g., 108a). The role of school environments

in promoting or impeding academic achievement

has been controversial (32a,103a,178). The role of

school environments in promoting adolescent

health, whether discretely or through academic

achievement, appears to be a recent concern and one

not yet fully recognized by many professional

educators (27,107b,147). This section reviews research that suggests that, just as adolescent health

problems can affect school adaptation,8 some indicators of school achievement have been found to affect

adolescents’ health, well-being, and ultimately, their

long-term economic productivity. After briefly addressing measures of school adaptation, the next

section reviews evidence for the impact of aspects of

school social environments and policies on school

adaptation and on adolescent achievement and

health. It is important to note that OTA knows of no

single study that has tracked in a systematic way the

impacts of school environments on school adaptation and health, and the feedback loops that must

occur among these elements (see figure 4-3). It is

difficult, of course, to disentangle the effects of the

academic achievement and health of students attending a school from other aspects of the school

environment. 9 Thus, tentative inferences must be

drawn about many of the relationships among school

processes and adolescent outcomes.

Students’ adaptation to school can be measured

using a variety of indicators. Short-term indicators

of school adaptation include school attendance,

school grades, participation in extracurricular activiFigure 4-2—High School Dropout Rates in the

United States, 1989a b

Percentage of dropouts among

individuals ages 16 to 24

36 --–— --- -.--—

33%

24;

I

154%

126% 12 4%

12

0

911

Total U S Central White

cities

13.8%

Black Hispanic c

aDropoutrates shown inthisfigure are status dropout rates (the proportion

of individuals of a speeified age who are not enrolled in school and have

not finished high school at any given point in time) among individuals ages

16 to 24 as of October 1989.

%hedata on whiehthisfigure is based are Current Population Survey data

from the U.S. Department of Commerce, Bureau of the Census.

cHispanics may be of any race.

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Education, Office of Educational Researeh and improvement, National Centerfor Education Statistics, Dropout Ratesin

the United States, NCES 90-659 (Washington, DC: September

1 990).

ties, and being retained in grade. Short-term indicators of school adaptation are sometimes predictive of

school dropout. One highly predictive short-term

indicator is retention in grade (70,1 12). After social

class controlled for ability, being retained in grade

(and therefore being overage for that grade) is the

best predictor of school dropout (68a).

As shown in table 4-1, studies have found that

dropping out of school and other indicators of poor

school adaptation are associated with adolescent

health outcomes that include substance abuse, delinquency, and adolescent pregnancy and childbearing10 (l,14,62,84a,85,137,210). Furthermore, the

lack of a high school diploma seriously jeopardizes

adolescents’ future economic and social well-being

(216). The consequences are particularly adverse for

poor and minority students (14,81a,198). Having a

BFor ~ ~ysis of adolescent school loss (i.e., absences) occurring as a result of illness, see ch. 6, “Chronic Physical Illnesses: Prevention and

Services, ‘‘ in this volume.

Wor example, a school in which many students are routinely absent, or hang around school but skip classes, or are violent in school, can have a

deleterious impact on teachers and administrators (e.g., they may come to feel powerless and depressed), who in turn have an impact on the more

well-behaved students. Environments such as these are commonly observed but have rarely been systematically researched (72a).

l~e relationship ~~~n school dropout and adolescent pregnancy and school dropout is complex. For further discussion see ch. 10, “Adolescent

Pregnancy and Parenting: Prevention and Services, ” in this volume.
Chapter 4—Schools and Discretionary Time . II-63

Figure 4-3—Possible Relationships

School Adaptation, and

1

Individual academic

factors

_~ ● Abilit y

I ● Effort

School environment s

and policies

●

●

●

●

●

●

Tracking

M;;;m;; competency

Standardized tests

School transitions

Parental involvement

MuIticultural

cu rr icu Ium

Among School Environments,

Adolescent Health

Individual academi c

o u tco mes

, ● Achievement v. failure

A

● Promotion v. retention

in grade

1

● Graduation v. dropout I

‘/ ‘

t D

high school

SOURCE: Office of Technology Assessment, 1991.

diploma, even with a poor achievement

record, significantly improves labor market participation (216), although poor achievement may have

other negative consequences (84a,137). High school

dropouts are more likely to be unemployed or

underemployed than high school graduates and are

half as likely to hold white collar jobs as high school

graduates are (216). Because they are less likely to

be employed or to have jobs with good career

prospects, high school dropouts are more likely to be

poor and to experience the health and other disadvantages associated with poverty (e.g., substandard

living conditions, poor nutrition, diminished access

to health care services). Their children are also likely

to experience disadvantage.

11 For society as well as

dropouts, dropping out of school has high costs. The

societal costs include not only lost productivity and

increased social welfare costs but more intangible

costs associated with poverty and lack of education

among certain segments of society.

Adolescent health

outcomes

. Delinquency

● Pregnancy

● Self-esteem

According to some observers, high dropout rates

and high rates of retention in grade are one indication of the failure of schools to meet their students’

educational or social growth needs (81a). This

failure seems particularly apparent in schools serving largely poor, racial, and ethnic minority adolescents, and adolescents in central cities. Unfortunately, dropout rates are typically reported by

population groupings based on race, and not by

school or community. Reporting measures of school

adaptation in this way makes it difficult to disentangle school environment effects on dropout and

retention in grade from the influence of other factors

(e.g., family economic need). National data suggest

that socioeconomic status and race/ethnicity are

related to students’ school adaptation, as measured

in terms of retention in grade and school dropout (see

table 4-2). An analysis of data from the High School

and Beyond Survey using a composite family

socioeconomic status index (including family income, parental education, and other factors) found

1 l~e heal~ and o~er effec~ of growing up poor are complex and not fully understood. SW Ch. 18, “Issues in the Delivery of Services to Selected

Groups of Adolescents, ” in Vol. III.
Table 4-l-Evidence for the Relationship Between School Adaptation and Adolescent Health

Studya

Indicator of school adaptation Adolescent health

Berlin and Sum, 1988 (High School and Beyond

survey data)

W.T. Grant Foundation, 1988 (national survey

data)

Young, 1983

Hispanic Policy Development Project, 1989

(review of the literature)

Fagan and Pabon, 1988

Garbarino and Asp, 198”

Gottfredson, 1988

McPartland, Colderon, and Braddock, 1987

Academy for Educational Development, 1989

Pallas, Natriello, and McDill, 1987

Dropout

School dropout.

Dropout rates.

Dropout status.

Dropout and low-achieving graduates.

Lack of high school diploma and poor academic

achievement.

Male dropouts.

Other Indicators

More years of school.

Poor school grades, limited educational

attainment, special education placement,

being retained in grade, poor attendance.

Poor school grades.

Lower than average academic performance,

school dropout.

Participation in extracurricular activities.

Associated with adolescent pregnancy and parenting; high rates of

subsequent poverty and unemployment; skill deficits. Situation

getting worse for blacks-in 1973, 14 percent of black male

dropouts reported no earnings, as compared with 43 percent in

1984.

Associated with higher rates of adolescent pregnancy.b

High school dropouts are far more likely to be underemployed or

unemployed than high school graduates; employed dropouts are

half as likely to hold white collar jobs as are high school graduates.

Decreased likelihood of enrolling in postsecondary education;

increased levels of welfare receipt; higher unemployment rates.

Associated with early Childbearing.b

Weak social attitudes, more drug problems, and more delinquency

among dropouts than among high school graduates.b Male

dropouts are far more likely to be involved in criminal behavior

than their in-school Peers.c

Positively associated with enhanced quality of child care offered to

one’s own children and with political competence; negatively

associated with criminal activity.

Associated with juvenile delinquency.c

Associated with school property violence.

Associated with adolescent pregnancy.b

Correlates, particularly for academically marginal students, with

academic progress, heightened self-expectations, reduced

frequency of delinquency, and increased persistence in schools.

aFutl ~tat~m are listed at the end of this chapter.

%he relationship between school dropout and adolescent pregnancy is discussed inch. 10, “Pregnancy and Parenting: Prevention and Services,” in this volume.

CFor a d~ssion of adol~nt delinquen~, See ~. 13, ‘lDelinque~y: prevent~n and servkss,” h th.~ VOIUnle.

SOURCE: Office of Technology Assessment, 1991.
Table 4-2-National Data on the Relationship of Students’ Race/Ethnicity and Socioeconomic Status to School Adaptation

Studya Adolescent health outcomes

Aspira, 1983 (cohort study)

Tobier, 1984 (survey of adults)

National Assessment of Educational Progress, 1990

(large data set on the reading ability of students)

U.S. Department of Education, 1987 (national survey data

collected from schools)

Neckerman and Wilson, 1987 (U.S. Bureau of the Census data

collected retrospectively as self-reports from adults)

Rumberger, 1987 (U.S. Department of Education national survey

data from 1984)

Barrow and Kolstad, 1987 (High School and Beyond survey data)

Berla, Henderson, and Kerewsky, 1989 (review of the literature)

New York City dropout rates exceed 68 percent for blacks and 80 percent for Hispanics.

In 1985,32 percent of New York City’s white adults had fewer than 4 years of high school, as compared

with 39 percent of blacks and 57 percent of Latinos.

Students in general are better readers in the 1980s than they were in the 1970s, although no discernible

changes occurred between 1984 and 1988; blacks and Hispanics made improvements during the

period of 1971 to 1988-nearly all 13- and 17-year-olds can read basic material; however, the

mean reading profile of black and Hispanic 17-year-olds remains only slightly better than white

13-year-olds.

In 1986, among 18- to 19-year-olds, 13 percent of white males, 11 percent of white females, 15 percent

of black males, 15 percent of black females, 29 percent of Hispanic males, and 24 percent of

Hispanic females were classified as dropouts.

National dropout rate is 27 percent; central city dropout rate is 42 percent; dropout rate in poverty areas

in central cities is 54 percent. In poor neighborhoods-+ defined as over 50 percent living below the

poverty line-dropout rates vary: in Anaheim, California, for instance, the dropout rate is 75

percent; in poor neighborhoods in Madison, Wisconsin, the dropout rate is 20 percent; in poor

neighborhoods in New York City, the dropout rate is 58.5 percent.

In 1972, national dropout rate was 22.8 percent; in 1984, dropout rate was 29.1 percent; New York State

dropout rate was 25.3 percent in 1972 and 37.8 percent in 1984; New York State estimates that

62 percent of Hispanics drop out, and 53 percent of blacks drop out.

The dropout rate among students from the lowest socioeconomic quartile is about 22 percent; the

dropout rate among students from the highest socioeconomic quartile is about 7 percent. The

relationships between socioeconomic variables and dropout rates often differ substantially

between the sexes and among white, black, and Hispanic students.

By age 15,25 percent of all students have been held back once or more. By age 11,44 percent of black

males, 26 percent of black females, 38 percent of Latino males, and 32 percent of Latino females

have repeated one grade.

at%ll citations are listed at the end of this chapter.

SOURCE: Office of Technology Assessment, 1991.
II-66 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

that the dropout rate among students from the lowest

socioeconomic quartile was about 22 percent, whereas

the dropout rate among students from the highest

socioeconomic quartile was about 7 percent (l0a).

Blacks and especially Hispanics have considerably higher rates of retention in grade and school

dropout rates than white non-Hispanic adolescents,

especially in urban areas (7,175,198,203). As shown

in table 4-2, Berla and colleagues report that by age

11, 44 percent of black males, 26 percent of black

females, 38 percent of Latino males, and 32 percent

of Latino females have repeated at least one grade

(12). As noted above, 13,8 percent of black 16- to

24-year-olds, 33 percent of Hispanic 16-to 24-yearolds on average, and 15.4 percent of 16- to 24-yearolds living in central cities report not having a high

school education (the so-called status dropout rate)

(figure 4-2). It is notable that dropout rates in central

cities are higher than in the United States as a whole,

and dropout rates in cities with a high proportion of

minorities are about one and a half times greater than

the overall dropout rates (148).

Overview of the Effects of Specific Factors on

School Environments and on Adolescent Health

The next several sections of this chapter examine

evidence regarding the effects of the following

factors on adolescent health:

●

●

●

●

●

●

●

●

specific academic policies (e.g., use of minimum competency tests, use of other standardized tests, tracking of students by achievement

levels),

school size,

school decisionmaking policies and orientation

to punishment,

arrangements for school transitions,

class size,

teacher behaviors,

school policies regarding cultural diversity, and

parental involvement in schools.

As discussed below, school academic policies

that emphasize raising achievement levels through

means such as standardized testing and school

policies that implicitly or explicitly track students by

achievement level may have some positive effects

on high-achieving students but generally have been

found to have detrimental effects on academically

marginal, low-income or minority adolescents. Especially for low-income or minority students, school

environments that emphasize these practices are

likely to affect adolescent health by diminishing

self-esteem, increasing psychological symptoms,

and segregating adolescent friendships (89,188).

These policies have been found to be associated with

low levels of academic achievement and increased

rates of retention in grade and school dropout among

academically marginal low-income and minority

students (84,89,1 10,1 17).

School size has often been found to be related to

student attendance levels, levels of participation in

extracurricular activities, and reported sense of

responsibility (74,168). Large school size--e. g.,

more than 1,000 students-has been associated with

adverse adolescent health outcomes, even when

location (e.g., urban, rural) and social class or

minority composition of the school is controlled for.

These include increased rates of a range of behaviors

including vandalism, drug selling, theft, and violence (74,137,203) and elevated rates of school

expulsions, disciplinary transfers, and school suspensions, which are indicators of delinquency (127,133).

Some studies have found larger schools to have

higher rates of retention in grade and dropout

(127,168). In contrast, some studies have found that

school size has no effect on academic achievement

(178), a measure of school adaptation that is related

to health outcomes (table 4-2).

Some school decisionmaking and other processes

have been associated with high dropout rates and

delinquent behaviors (84, 137,158,178). Adolescents

in schools where students, teachers, and parents

collaborate in school decisionmaking and other

processes tend to have higher rates of attendance,

fewer behavioral problems, and higher levels of

academic achievement (84,137,178). Some studies

have found that students in schools with a punitive

orientation are more likely to be violent and express

feelings of alienation (178).

The timing and nature of transitions to different

levels of schooling also have been found to influence

adolescent health. In general, school transitions that

occur in the 7th and 10th grades seem to cause the

most difficulties (18,22, 169). Such transitions seem

to have the most detrimental effects on females and

may also negatively affect low-income students

(1 1,18). During school transitions, some adolescents

show diminished levels of self-esteem, school participation, and academic achievement (18,22,169).

These effects are influenced by the number of
Chapter 4—Schools and Discretionary Time . II-67

teachers adolescents are exposed to and the size of

their classes (22,15 1).

As discussed further below, the evidence on the

effect of class size on student achievement is

somewhat ambiguous. It does appear, however, that

small classes are beneficial to academically marginal students.

Teachers are likely to be influential in mediating

the effects of school environments on adolescent

health and well-being. Of course, school environments are likely to have a large influence on

teachers’ attitudes and behaviors. For example, a

school’s orientation towards punishment, its decisionmaking strategies, the school’s physical conditions, and work demands have been found to affect

teachers (9,40,144). When teacher practices are

substantially controlled by administrative decisions,

teachers are more likely to have low levels of morale

and job satisfaction, and high rates of absenteeism

(9,40). In schools that emphasize shared decisionmaking, teachers have better attitudes about their

students, higher levels of morale and satisfaction,

and are more likely to successfully implement and

maintain new practices (24,40,45 ,72,122, 194). Teachers that use cooperative teaching strategies (e.g.,

team teaching) foster adolescent health through their

effects on achievement, cross-racial friendships, and

lower levels of delinquency (75,141 ,178). Working

conditions and administrative policies that affect

teachers’ behaviors (e.g., absenteeism) and teachers’

attitudes (e. g., morale, attitudes toward students)

and evidence for the effects of teacher behaviors on

adolescent health are discussed below.

School policies that ignore racial and ethnic

differences in their social arrangements and curriculum may have adverse consequences for students’

social development and academic achievement (72).

It could be argued that minorities are forced to

choose between their own culture and their academic

and professional development when schools sensitivities, and resultant curricula and activities, do not

reflect the cultural diversity of their members. In

schools that lack a multicultural perspective, minority students are likely to develop negative attitudes

about their ethnicity or oppositional cultural forms

(e.g., consider “being smart’ to be “acting white”)

(43,102,157a). Schools with bilingual programs

have been found to enhance minority students’

levels of academic achievement (43).

Finally, it appears that adolescent students’ levels

of achievement are enhanced by parental expectations of achievement and parental presence in

schools (25,35,70,73,195).1 2

Evidence for the Effects of Specific Academic

Policies on Adolescent Health

Among the school reforms of the 1980s were

efforts to raise academic standards by increasing

course requirements for graduation and by using

standardized testing or minimum competency tests

(MCTs), Another approach that some schools have

used is separating students by achievement levels—

also known as academic tracking.

Using Standardized Testing and Other Practices To Raise Academic Standards-Since 1980,

45 States and the District of Columbia have changed

requirements for earning high school diplomas,

primarily by increasing the course units required to

graduate (166). The length of the school day has

been changed (or changes have been recommended)

in 13 States and the District of Columbia, And in 12

States, the teaching career ladders have been

changed. Increases in requirements have been found

to place additional responsibilities on teachers and

lengthen the school day without additional support.

Available evidence suggests that such policies

have had some adverse consequences, especially for

academically at-risk students. Increased course requirements diminish time for participation in extracurricular activities, participation which particularly

for marginal, poor and minority students, enhance

academic progress and reduce delinquency. Pallas

and colleagues found that an increase in course

requirements was associated with increased alienation among marginal students who seem to be most

attached to courses outside the core curriculum

(164). Unfortunately, Pallas and colleagues noted,

teachers in the schools where increased course

requirements were required were seldom given the

support they needed to reach academically marginal

students. Raising standards was therefore an empty

gesture, tending to push low-achieving students out

of school.

12For f~er discussion of parents’ influence on adolescents’ hdth, see ch. 3,“Parents and Families’ Lnfluence on Adolescent Health, ” in this

volume.
II-68 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 4-4 also suggests that the use of standardized testing and MCTs have adverse consequences

for marginal students. One study found that standardized testing is practiced in larger schools where

there are more marginal students and tends to result

in curricula that conform to the test (138). Several

studies have found that, although standardized

testing has small positive effects on high-achieving

students, students in schools where such testing is

used are more likely to be retained in grade

(84,138,185). Educators generally agree that promoting adolescents who are not ready to be promoted will not be beneficial to their health unless

they receive additional support to learn the skills

they lack (71), but many educators have voiced

concerns that standardized testing has the capacity to

further marginalize disadvantaged students (209,213).

Similar, yet more pronounced, are the effects of

the recent national shift toward the widespread use

of MCTs. In 1989, 24 States used MCTs for

remediation, 12 for promotion, and 24 for graduation

(91). According to Haney and Madaus, the recent

national shift toward the use of MCTs has had

profound and devasting consequences for students’

academic performance (91). The use of MCTs has

been linked to increased rates of retention in grade

and school dropout in school districts that use MCTs

(91). Some evidence suggests that dropout rates may

be disproportionately high for at-risk (e.g., black and

bilingual) adolescents (91,110). MCTs may also

have adverse psychological consequences (e.g.,

apprehension, diminished self-esteem) for some

students.

To sum up, school academic policies that emphasize raising achievement levels by increasing courses,

using standardized testing, or using MCTs can

adversely affect academically marginal students

through increasing rates of retention in grade and

increasing rates of school dropout.

Tracking Students by Achievement LevelsPolicies used to track students by achievement level

range from the use of selective criteria for entry into

schools which parents can “choose’ for their child,

district-wide stratification of public high schools,

heterogeneous course offerings, school intake policies, teacher-selected ability groupings, and differential access to school guidance counselors. Such

policies may be developed and implemented by

local school districts, by individual schools, by

teachers within schools, or by guidance counselors.

School districts that stratify their public schools and

use selective criteria for entry into ‘‘choice’ schools

foster differential ability groupings across schools.

Administrators who build in specialized courses,

and who admit a homogeneous intellectual mix of

students to schools are tracking within a school,

whereas teachers who create student ability groupings are tracking within their classes. Finally,

guidance counselors who devote more of their

resources to counseling academically tracked students about educational and vocational options

reinforce the existing system of tracking.

Schools that use student selection criteria typically receive a disproportionate share of district

resources (21 1). Furthermore, national data suggest

that schools that have a higher concentration of

at-risk poor and minority students receive fewer

resources for staffing and materials, and such

schools have been found to rely more heavily on

remedial and rote memory activities (143).

Tracking practices that skim the best students off

the top and place them in selective schools may not

only have adverse consequences for marginalized

schools but may also minimize overall achievement

records of entire school districts. In a longitudinal

analysis of adolescents attending nonselective

schools in London, Rutter and colleagues found that

the intellectual heterogeneity of students was strongly

associated with positive educational outcomes for

the entire school (178). Rutter and colleagues

concluded that schools need a substantial nucleus of

average- to above-average-intellectual-ability students in order to achieve schoolwide. Other researchers, examining schools with good academic

records, have found that most such schools restrict

or reject tracking, reinforcing Rutter’s conclusions

that heterogeneous ability groupings enhance school

achievement outcomes (79). Furthermore, schools

where school composition is skewed towards marginal students have been found to have disproportionately high rates of dropout and low rates of

achievement (21 1).

Tracking that occurs when teachers place students

into “ability groupings “ is sometimes rather arbitrary; criteria unrelated to the ability of students have

been demonstrated to have effects on the placement

of students into “ability groupings. ’ According to

Hallinan, for example, teachers often create a set

number of equally sized groups that assume that

student ability is equally distributed in their class-
Chapter 4—Schools and Discretionary Time . II-69

room (89). Students who are older when entering an

elementary school are more likely to be placed in the

highest ability groups, an observation suggesting

that advantages resulting from age and previous

experience play a role in determining ability groupings (89). Adolescents who are placed in low-ability

groups have been found to fall behind academically,

and students chosen for high-ability groups have

been found to achieve more than their peers of equal

ability who are not in high-ability groups (89).

Placement in ability groupings also seems to exert an

effect on adolescent friendships: students placed in

ability groups are less likely to have crossracial and

crossachievement friendships than students not

placed in ability groups (89,188). Minority students

may also come away from tracking with more

negative attitudes towards their own ethnic group.

For example, Iadicola ex amined the effects of

tracking across schools and found that Hispanics,

especially females, who attended schools with

higher rates of testing and higher numbers of ability

groupings were more likely to express negative

attitudes toward their ethnicity (102). Ingrained

social patterns of racial stratification seem to be

reinforced by institutionalized tracking practices

which only reinforce white students’ preferences to

bond with similar others.

Some studies have found that minority, poor,

rural, and vocationally tracked students report that

counselors do not play a significant role in their

future goals, whereas academically tracked students

report that they do (1 18,1 19). This situation may

sometimes result from academically tracked students’ greater initiative in contacting guidance

counselors, but it may sometimes result from

counselors’ seeking a greater role in counseling

academically tracked students. Evidence suggests

that in some situations, guidance counseling is more

directed to high-achieving students (1 18,119).

To sum up, tracking students by achievement level

is inequitable because academically tracked students receive better instruction, easier access to

counseling, heightened teacher expectations, better

peer evaluations and more interesting curricular

content than students in lower achievement groups

(155). Since there is evidence that ability groups are

sometimes based on arbitrary criteria (e.g., a student’s entry into selective “choice” school may

reflect the parents’ ability to negotiate or may be

determined in part by a student’s age) and because

the students in groups receive different school

resources, it can be argued that ability groupings

create differences in students’ academic achievement levels rather than minimize them. Students

marginalized by the tracking process achieve less

and drop out more than students in matched schools

that do not use tracking (155).

Available evidence suggests that a heterogeneous

mix of intellectual ability is associated with high

rates of overall school achievement. Thus, it can be

argued that minimizing the intellectual mix of

schools (i.e., tracking across schools) or offering

specialized courses to high achieving students and

remedial courses for low-achieving students (i.e.,

tracking within schools) may not responsibly serve

the majority of adolescents. Policies that place

students into homogeneous groupings may have

detrimental effects on the majority of adolescents’

academic achievement levels. Nonetheless, some

observers have concluded that tracking persists

because of fears about the effects of “untracked”

schools on the best students (37).

Evidence for the Effects of School Size

on Adolescent Health

In considering the differences between the effects

of large and small schools on adolescent health, it is

important to realize that size of school is confounded

with variables that include location (i.e., rural v.

urban), financing, and school-related processes.

Large schools are typically in urban, often more

socially disorganized, settings than small schools

with a high density of low-income students. These

schools often receive less money or receive money

with restrictions on how it can be utilized (25). Large

schools are also often associated with more administrative staff, more centralized decisionmaking processes, and fewer opportunities for teachers and

students to participate in school policymaking (40,168).

Furthermore, large schools have been found to have

more rigid and compartmentalized roles, more

complexity in their communication patterns, larger

class sizes, more institutionalized tracking, and

punitive and controlling disciplinary orientations

(25,27,75,85,163,203). Finally, the students attending large schools may be different from students

attending small schools. For example, more students

attending large schools (i.e., minority, lower income, and poorer students) may confront problems

with health, housing, language, welfare, and academic difficulties (24).
11-70. Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

*

.- .+-

Photo credit: April Saul/Education Week

Many large urban schools serving socioeconomically

disadvantaged students lack the combination of

features that promotes adolescents’ health

and well-being,

A longitudinal study in England by Rutter and

colleagues found no relationship between school

size and students’ academic achievement (178), but

numerous other investigators have found correlations between large school and adverse academic

and health outcomes, especially for marginal, poor,

and minority students (27,74,75,1 18,130,162).

Large school size has been correlated with high

levels of alienation among students and teachers

(24,25), with high delinquency rates, high suspension rates, low attendance rates, and high dropout

(27, 133,137,168). Small schools have been found to

have lower levels of vandalism, less anomie, and

lower levels of victimization (74).

Although small schools seem to be beneficial for

all students, they appear to be most beneficial for

academically marginal low-income and minority

students (27,75, 130, 162). School size seems to

affect social cohesion, participation in school activities, sense of responsibility, and interactions with

faculty (168). Small schools offer greater social

cohesion and intimacy and Garbarino found marginal students to be four times more active in small

schools than in large ones (74). Large schools tend

to have more diverse curricula and more tracking,

and such schools may tend to marginalize adolescents with relatively poor academic achievement

records (see discussion above).

To sum up, small schools seem to be associated

with better academic and health outcomes for

adolescents than large schools. Furthermore,

school size appears to differentially matter most to

academically marginal low-income and minority

students. Larger schools are associated with negative academic outcomes (i.e., increased rates of

retention in grade and school dropout), as well as

delinquency (i.e., higher rates of drug selling, theft,

vandalism), behavioral problems (i.e., higher rates

of expulsions, suspensions, and disciplinary transfers), and lower rates of participation in extracurricular activities and fewer interactions with faculty.

It may be that the health outcomes of adolescents

attending schools of different sizes are particularly

influenced by the impact that size of school has on

shaping school-related processes. Possibly school

size is only important because it shapes a wide array

of school processes. If that is the case, simply

changing the size of the school without attending to

all of the associated factors (e.g., less funding,

increased bureaucracy) would, in all likelihood, be

futile. In the next section, the effects of schoolrelated processes that have sometimes been associated with school size are examined for their impact

on adolescent health.

Evidence for the Effects of School Decisionmaking

and Other Processes on Adolescent Health

There is limited evidence regarding the relationship between school processes and adolescent health

outcomes. Rutter and his colleagues were among the

first investigators to systematically examine the

relationship between processes that occur within

schools and student outcome variables (178). They

devised a composite school process measure which

reflected the degree of emphasis on academic

achievement, the extent to which courses were

planned and taught by teams of teachers, the

availability of incentives and rewards for student
Chapter 4—Schools and Discretionary Time ● II-71

performance, and the degree of encouragement that

adolescents were given to participate and take

responsibility for themselves and for others. In a

longitudinal study in England, Rutter and colleagues

found that such processes improved adolescents’

academic achievement and school attendance rates

and minimized behavioral problems and delinquency.

Some investigators have examined the relationship between the decisionmaking process used by

school administrators and school staff and adolescent health.13 McPartland and colleagues found that

schools where students participate in decisionmaking have lower rates of vandalism, and students

report enhanced communication (137). Gottfredson

and colleagues found that the schools where students, teachers, administrators, and parents have

access to the decisionmaking process tend to have

reduced rates of delinquency (84). Furthermore,

schools that have poor teacher-administration cooperation and where teachers report lack of administrative soundness tend to have higher dropout and

delinquency rates and more discipline problems

(84).

Some investigators have found a relationship

between a school’s orientation towards punishment

and adolescent health. They have found that schools

that frequently use punishment and that focus on

control tend to have high rates of school victimization and increased rates of disciplinary problems and

that students who attend those schools often report

feeling alienated (84,178). Optow has argued on

theoretical grounds that schools that underreact to

school-based violence (e.g., ignore) or overreact to

school-based violence (e.g., inflict excessive punishment) make it difficult for adolescents to develop

trusting relationships with adults from whom they

can learn to control their aggressive impulses (158).

To sum up, available evidence suggests that some

school processes-+. g., relying on team teaching

efforts, encouraging students to participate in deci -

sionmaking and relying more on rewards and

positive incentives for student performance than on

punishment--improve students’ academic achievement, school attendance rates, and are associated

with reduced rates of delinquency, dropout, school

victimization, and reported alienation among Stu -

dents.

Evidence for the Effects of

on Adolescent Health

School transitions are

mentary school to either

School Transitions

changes from an elejunior high or middle

school and changes from junior or middle school to

high school. Figure 4-1 illustrates the common ways

that school transitions have been organized in the

United States, The most common school configuration is kindergarten through 6th grade (elementary

school), 7th through 9th grade (junior high school),

and 10th through 12th grade (high school) (204).

Another common configuration is kindergarten

through 8th grade, followed by 9th through 12th

grade. Yet another common configuration is kindergarten through 4th grade, 5th through 8th grade

(middle school), and 9th through 12th grade.

Whether looking at evidence of retention in grade,

suspensions, schoolwide victimizations, or academic achievement, several studies suggest that

seventh grade is often a difficult year, especially

when it corresponds to the frost year out of elementary school. In a 1988 analysis of Philadelphia’s

grade reorganization, Pugh compared seventh and

eighth graders in junior high schools (schools

configured grades 7 through 9) with seventh and

eighth graders in middle schools (schools configured grades 5 through 8 or grades 6 through 8) (169).

The seventh and eighth graders in junior high

schools—i.e., students who underwent school transitions in the seventh grade-had substantially more

suspensions (35 v. 23 percent) and retentions in

grade (15 v, 8 percent), had lower rates of attendance, and on achievement tests adjusted for socioeconomic status scored 12.9 points lower than the

seventh and eighth graders in middle schools did.

The Pugh analysis is consistent with other analyses

(72a).

Blyth and colleagues conducted a 5-year longitudinal study of 594 white adolescents from the 6th

through 10th grades (1974-79) in 18 schools in

Milwaukee (18). Some of the students attended

schools configured kindergarten through grade 6,

grades 7 through 9, and grades 10 through 12 and

others attended schools configured kindergarten

through grade 8 and grades 9 through 12 (18). Blyth

and colleagues interviewed the students in grades 6,

7, 9, and 10. They looked at the students’ global

self-esteem, grades, achievement tests, and particiIWhe effects of school d~isiowtig policies on teachers’ attitudes and behaviors are examined in a separate seCtiOn of tis chapter ~low.
II-72 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

pation in extracurricular activities. Blyth and colleagues found that seventh grade female students in

schools where transitions occurred in the seventh

grade were more likely than female students in

schools configured kindergarten through grade 8 to

have drops in grade point average, self-esteem, and

rates of participation in extracurricular activities.

Seventh grade male students in schools where

transitions occurred in the seventh grade similarly

had lower grade averages than seventh grade male

students in schools configured kindergarten through

grade 8. Male self-esteem was not affected by school

transitions. Adolescent males’ rates of participation

in extracurricular activity decreased in the seventh

grade when they changed schools, but their rates of

participation ultimately returned to the base level;

the rates for females never returned to their base

level.

Becker found that students from the lowest

income groups scored higher on achievement tests in

elementary schools than adolescents from the same

background in middle schools, suggesting that

low-income groups fare better with elementary

school structures than with middle school structures

(11).

In an attempt to understand why school transitions

cause difficulties for adolescents, some investigators

have examined how different school arrangements

mediate the effects of school transitions on adolescent health. Braddock and other investigators have

found that schools where adolescents change classrooms for different content areas are associated with

the majority of problems at transition (11,18,22).

Braddock and colleagues found that seventh grade

students appear to be most academically productive

in schools where they interact with two or three

different teachers rather than with six or seven (22).

Reviewing the evidence and building on developmental theories of adolescents, Eccles and Midgley

found that structures and practices in middle or

junior high schools are not suited to the developmental needs of early adolescents (57a). They argue that

size differences, tracking practices, competitive

motivational strategies, controlling teacher behaviors, using a lecture format and the absence of

opportunities for students to practice autonomous

behaviors all conflict with adolescent development.

These investigators also found that transition effects

(e.g., student attitudes about school) are mediated by

changes in the school and classroom environment

such that negative attitudes were associated with

schools that were not developmentally appropriate.

To sum up, available research on school transitions is limited, but some evidence suggests that

school transitions are associated with increased

rates of suspension, retention in grade, and decreased levels of achievement, attendance, self-

-esteem, and participation in extracurricular activities. Female students seem to be particularly adversely affected by transitions that occur in the

seventh grade. The research that has been conducted

to date suggests that there may be better and worse

developmental moments for shifting from one

school to another; the experience of transition may

in and of itself be traumatizing; and some school

transitions may conflict with adolescents’ developmental needs (72a). In addition, some research has

shown that adverse effects can be ameliorated by

specific changes in school environments such as

prolonged contact with a single teacher rather than

multiple classes and teachers (27).

Evidence for the Effects of Class Size on

Adolescent Health

The evidence on the relationship between class

size and adolescent health is somewhat difficult to

interpret. In 1986, Robinson and Wittebols compiled

a comprehensive review of the literature on class

size and achievement for the Educational Research

Service (174). Their review of 22 studies published

from 1950 to 1985 found that 50 percent of

kindergarten through grade 3 studies, 38 percent of

the grade 4 through grade 8 studies, and 18 percent

of the grade 9 through 12 studies indicate that small

classes have a positive effect on student achievement. Robinson and Wittebols concluded that available research fails to show that small classes have a

positive effect on high school students’ achievement

levels generally.

According to Fine, a class size of 15 to 20 seems

to be substantially more productive when dealing

with low-achieving students than a class size of 35

(72a). In high schools in which students are educationally disadvantaged, classes of 35 reinforce what

Goodlad and others have written about-passive

downtime will constitute upwards of 85 percent of

most secondary classroom instructional practices

(83). McNeil argues that such teaching is a structurally created characteristic of large schools and

oversized classes (82).
Chapter 4—Schools and Discretionary Time ● II-73

To sum up, it appears that class size may have

differential impacts on students in different grade

levels. At the high school level, class size may have

more impact on academically marginal students

than on average students. Improved classroom size

may be a necessary but not sufficient condition for

improved academic achievement of academically

marginal students (72a).

Evidence for the Effects of School Environments on

Teachers’ Attitudes and Behaviors

Studies examining the relationship between

school environments and teachers’ attitudes and

behaviors are summarized in table 4-3. These studies

relate contextual factors (e.g., working conditions,

location, size) and teacher involvement in decisionmaking practices with teachers’ attitudes and behaviors.

Corcoran and colleagues, analyzing national

school and teacher survey data, report that many

U.S. educators-specially urban secondary school

teachers-experience poor working conditions (40).

According to Corcoran and colleagues, poor working conditions reported by educators include substandard facilities, a lack of space, inadequate

classroom materials, large classes, a lack of influence in decisions, and concerns about safety. These

conditions are associated with high absenteeism,

low effectiveness, low morale, and low job satisfaction. Moos found that teachers on whom work

demands are high tend to rely more on rote teaching

methods (143).

Various school reforms have been investigated by

researchers as sources of influence on teacher

behaviors (see table 4-3). One wave of reforms has

emphasized “standards’ and monitoring teacher

behaviors in public schools. Bachrach and colleagues have characterized schools that operate

under these reforms as schools organized around

controlling teachers’ activities, centralized decisionmaking, and rendering the curriculum ‘‘teacherproof” (9). A more recent series of reforms, often

called ‘‘restructuring, has emphasized bringing

teachers into policy and decisionmaking processes.

National survey data indicate that teachers in

urban and other schools where incentives and school

policies are determined largely by school administrators report being more suspicious, feeling more

contempt, having higher rates of absenteeism, expePhoto credit: Sharon Knarvik

Teachers’ morale, sense of commitment, and other

attitudes and behaviors that can be expected to improve

the school environment for adolescents are enhanced

by school reforms emphasizing collaborative and

inoperative relations within schools.

riencing lowered morale and feelings of powerlessness, and being distrustful of administrators (9). The

majority of these teachers also experienced problems with inadequate instructional time, receiving

minimal feedback from administrators, and the

extensive use of standardized tests (9,40). Furthermore, teachers in schools where decisionmaking is

centralized express a desire to be given a greater

voice in decisionmaking and to have more communication with administrators (9).

School reforms emphasizing collaborative and

cooperative relations within schools have been

found to increase teacher satisfaction, successful

implementation and maintenance of new practices,

morale, sense of ownership and commitment, while

they tended to decrease rates of absenteeism (9,24,

40,194). Furthermore, educators who reported having a substantial say in shaping policy also report

more positive views of adolescents and more optimism that they can make a difference in the

adolescent’s academic accomplishments (72a).

To sum up, there is clear evidence that teachers

are negatively affected by poor working conditions

and administrative policies that centralize decisionmaking and use narrow authority structures. Teachers’ attitudes and behaviors that can be expected to

improve the school environment for adolescents are

enhanced by a collective and cooperative school

environment.
Table 4-3-Evidence for the Relationship of Various School Environments to Teachers’ Attitudes and Behaviors

Studya School environment Adolescent health

. . Poor working environment

Corcoran, White, and Walker, 1988 Urban schools where teachers expressed concerns

(national school and teacher survey about substandard physical renditions, lack of

data) space, resources, safety, and classroom size.

Schools in which teachers are required to use

standardized testing.

MOOS, 1985 Schools where very high work demands are placed

on teachers.

Bachrach, Bauer, and Shedd, 1986

(national survey of teachers)

Pallas, Natriello, and McDill, 1989

Bryk, Lee, and Smith, 1990

Bachrach, Bauer, and Shedd, 1986

Fine, 1984

Bryk and Driscoll, 1988

Centralized decisionmaking with little Input from

teachers

Schools in which policies and incentives are made

by administrators.

Schools are currently organized around controlling

teachers’ activities, centralized decision making

and rendering curriculum “teacher-proof.”

Majority of teachers experience problems with

instructional time, problems receiving feedback

from administrators.

School social climate perceived as positive.

Positive school climate.

Increased administrative control and narrowing of

authority of teachers.

Centralized decisionmaking in schools.

Schools in which teachers’ classroom policies are

controlled.

Teachers’ perception of influence in shaping policy.

Collaborative environment with teachers

involved in decisionmaking

Schools that have collaborative relationships

between teachers and administrators and

schools that focus on cooperative processes.

Poor working renditions related to absenteeism, low effectiveness, low

morale, and low job satisfaction for teacher--especially for urban

secondary school teachers.

Teachers report that standardized tests are a threat to their

professionalism.

Teachers in such schools tend to rely more on rote learning teaching

methods.

Teachers who report having minimal input to decisions concerning their

working conditions and incentives had higher rates of absenteeism

and lower morale.

Teachers are alienated, tired, and feel powerless.

Teachers’ perceptions of mean ability of students in their classroom were

positively related to perceived school social climate (regardless of the

actual ability levels of their students).

Positive school climate is positively related to the extent to which there

seems to be a shared sense of purpose among teachers-goal

consensus.

Teachers expressed that they did not feel apart of the school community

and that people did not listen to their ideas (alienation).

Teachers report being more suspicious, feeling more contempt, having

deteriorated morale, and being distrustful of administrators; teachers

indicate that they should be given a greater voice in decisionmaking;

teachers reported dissatisfaction with communications with

administrators.

Teachers have higher rates of absenteeism and lower reported morale.

Educators who saw themselves as powerless tend to view adolescents

they work with as beyond help; educators who report having

substantial say in shaping policy also report more positive views of

adolescence and more optimism about making a difference.

Teachers report increased satisfaction; decreased rates of absenteeism.
Table 4-3-Evidence for the Relationship of Various School Environments to Teachers’ Attitudes and Behaviors-Continued

Studya School environment Adolescent health

Stevenson, 1987 Collective and cooperative school climate. Teachers report enhanced sense of ownership, more successful

implementation of new practices.

Lifton, 1988; Dade County Public School, Schools restructured to give teachers more input Preliminary evidence that teacher morale, commitment, willingness to

1988 (preliminary evidence from into decision making. continue teaching are enhanced.

teacher surveys in restructured

school district)

Corcoran, White, and Walker, 1988 Small schools, with high levels of teacher influence Teachers in such schools expressed more positive attitudes towards

(national school and teacher survey and with staff cohesion. students.

data)

aFUll citations are listed at the end of this chapter.

SOURCE: Office of Technology Assessment, 1991.

●
II-76 . Adolescent Health-Volume II Background and the Effectiveness of Selected Prevention and Treatment Services

Evidence for the Effects of Teacher Behaviors on

Adolescent Health

Limited evidence suggests that the behaviors of

teachers and students are interconnected. Educators

using team teaching (where teachers share responsibility for a group of students either within or across

schools) affect adolescent health in a positive way.

Furthermore, teachers in schools with centralized

decisionmaking, where there is little coordination

between the efforts of teachers and school administrations, are more likely to use authority and

coercion as part of their instructional style, which

also affects adolescent health.

Studies have found that adolescents who have

teachers that use team teaching have increased levels

of academic achievement and are more likely to

develop interracial friendships (24,124,141). Team

teaching approaches also have been associated with

decreases in student dropout, delinquency, and

suspension (75,178). Further, the use of coercive

techniques by teachers has been associated with

lowered self-esteem among students and increased

frequency of classroom disruption (137). Students

who report that they are treated disrespectfully by

their teachers report higher rates of feelings of

alienation and school victimization (85). Furthermore, in schools where coordination between teachers and principals is poor, adolescents are more

likely to have high discipline and criminal problems

(133).

Evidence for the Effects of School Policies

Regarding Cultural Diversity on Adolescent Health

It has been argued that “social education” in

which students come to learn about and respect

critically and creatively their own ethnic and racial

heritage is important so that adolescents can generate strategies for managing difference as difference,

not as deficits (73). It also has been argued that

schools as they are currently organized do not

educate students about ethnic diversity and students

are, therefore, more likely to form stereotypes and

have their racial and other biases reinforced (69,73).

There is currently considerable debate—and limited

evidence—about how to celebrate, rather than disparage, cultural diversity (58a).

Research that has examined the effects of schools

on racial and ethnic minority adolescents’ health

outcomes14 suggests that there are insidious school

processes that differentially affect minorities. For

example, when schools ignore ethnic differences in

their social arrangements and in their curriculum,

there are consequences for minority adolescents

related to academic achievement and the degree of

attachment to their own ethnic group. Iadicola

compared schools that differed with respect to the

degree of Hispanic cultural influence on the curricula and the percentages of non-Hispanic white and

Hispanic students. Iadicola found that Hispanic

students in schools with a high degree of nonHispanic white cultural influence were more likely

to express lower levels of attachment to their own

group (102). It could be argued that schools in

low-income communities that do not embrace cultural differences are structured so that Hispanic

students are forced to ‘‘make a choice’ ‘—between

self and family and between personal development

and community involvement (102). Obgu has argued that racial stratification and classroom materials that reflect the perspective of whites with little or

no acknowledgement of minorities results in black

adolescents’ behaving in ways that undermine their

academic success (157a). Some studies suggests that

multicultural education and school-based collaborations with minorities in the community can improve

minority adolescents’ academic achievement (43,102).

In interviews with students and educators, Fine

found that students in integrated schools valued

differences between diverse groups as strengths, not

defects (70). In contrast, students in a fully segregated school learned stereotypes and had their racial

biases reinforced (70). However, there is still considerable confusion among teachers and others about

defining and implementing multicultural education

(58a). According to one informed observer, the

support that multicultural education needs will come

only from comprehensive policymaking and from

teachers who see differences among students as

reasons for ‘‘celebration’ rather than for handwringing (58a).

ld~e delivq of he~th ~d relatti services to racial and ethnic minority adolescents is discus~ in Ch. lg. “Issues in the Delivery of Services to

Selected Groups of Adolescents,” in Vol. III.
Chapter 4—Schools and Discretionary Time . II-77

Table 4+ Evidence for the Relationship of Parental Involvement in Schools to the School Environment

and Adolescent Health

Studya

Form of parental involvement School environment Adolescent health

Svec, 1986 (experimental study)

Bryk, Lee, and Smith, 1990

(review)

Fine, 1989; Fine and Phillips,

1990 (interviews with educators and with Iow-income parents of middle-school students)

Comer, 1988 (intervention among

3rd, 4th, and 5th graders in

schools in low-income districts in New Haven, Connecticut, and Maryland)

In experimental study, randomly

assigned high school drop

outs went to school with or

without parents to negotiate

reentry to school.

Parents expect achievement and

place importance on educational attainment.

Parents volunteer in schools.

Parent involved in professional

councils at school sites.

Decentralization (community amtrol) in New York City.

Parents’ presence at schools.

As part of a comprehensive

school intervention program,

parents work closely with

school administrators, teachers, a mental health specialist, and a nonprofessional

support person to meet the

emotional, social, psychological, and academic needs

of their children. Some parents work as classroom assistants, tutors, or aides;

some join the school’s governing body.

Principals are more sensitive to

community interests,

schools have more legitimacy

in the community, culturally

relevant curriculum is developed.

Especially with Iow-income students, parents’ presence

serves as a reminder to teachers that they need to be

concerned about the impact

of school on their students.

Relations between parents and

school staff improve. School

administrators, staff, and parents’ collaboration results in

increased organizational effectiveness.

More schools refused the dropouts who did not have their

parents with them.

Parental expectations are highly

and consistently related to

academic outcomes.

Parental volunteering is associated with positive outcomes,

especially for elementary

school students.

Intervention had no significant

influences on student academic achievement.

Intervention had ambiguous impact on student achievement.

Students whose parents question school policies are more

likely to receive fair treatment.

Preliminary evidence suggests

intervention improved reading, language, and math

scores. Behavior problems

declined.

aFull citations are listed at the end of this chapter.

SOURCE: Office of Technology Assessment, 1991.

Evidence for the Effects of Parental Involvement in

Schools on Adolescent Health

Research on parental involvement has been limited until recently to national surveys that focus on

traditional forms of involvement by parents. Investigators have examined the effects of parental expectations, parental volunteering, and parental presence

in schools and have generally found-especially

when research findings are related to local school

districts-that parental involvement is beneficial to

adolescents (see table 4-4).

Probably the most thoroughly documented effect

that parents have on adolescent health is related to

their expectations that their children will achieve. A

review by Bryk and colleagues noted that studies

consistently find that parents who expect their

children to achieve and who place importance on

educational attainment affect their levels of academic achievement (25). Although not as well

documented, evidence suggests that adolescents are

also positively affected by the presence of their

parents at school—whether at school to volunteer, to

serve as advocates for their children, or simply to be

present (25,70,73,195). The importance of parental
II-78 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

involvement is recognized in Comer’s comprehensive school interventions, first implemented in

New Haven, Connecticut, elementary schools, and

now being implemented in more than 50 schools

around the country, including 2 middle schools and

a high school (35) (see box 4-A).

In a recent review, Bryk and colleagues noted that

parental involvement on professional councils at

school sites in Salt Lake City had no significant

influence on student academic achievement (25).

These investigators also described a study of community control in New York City. This evaluation

found that parental choice had an ambiguous effect

on student achievement (25).

Summary: School Influences on Adolescent Health

Although it is limited, of variable methodological

quality, and difficult to conduct, available research

strongly suggests the importance of school environments on academic achievement and on adolescents’ health. Studies in the last 20 years provide

contrast to earlier studies that led many to believe

that schools make little difference (32a, 103a). These

earlier studies have been criticized because they

focused mainly on a limited measure of attainment

and examined a very narrow range of school

variables (175a). According to Rutter’s studies in

England, and a host of studies in the United States

reviewed in this chapter, social variables account for

much of the variation between schools, and hence

some of the variation in adolescent health (175a).

Generally, school policies found to have adverse

effects on the minority, low-income, academically

marginal students include MCTs without the addition of academic supports, academic tracking, large

school size, punitive orientation, little support during transitions between levels of schooling, and lack

of cultural diversity and appreciation of racial and

ethnic differences. School policies generally found

to have positive effects on adolescent health include

participatory decisionmaking, parental involvement

in schools, and a combination of other process

variables (178). Effects of the school environment

on adolescent health are often mediated through

teachers’ attitudes and behaviors and through adolescents’ academic achievement, most prominently

retention in grade and school dropout. The most

compelling evidence suggests that improving

schools to benefit adolescents requires a combination of approaches. This combination can be summarized as a school that is a small, comfortable,

safe, intellectually engaging, and emotionally intimate community (72a). Transitions are minimized,

and when they must occur, they are managed with a

view toward meeting the developmentally appropriate needs of adolescents. Teachers are encouraged

to initiate and develop new programs that are

sensitive to the diversity of their students. The

curriculum responds to individuality as well as to

differences, while developing a common knowledge

base among students in a particular school. Teacher,

parent, and student participation in decisionmaking

is encouraged. Unfortunately, this combination of

features characterizes few schools, particularly those

public schools serving socioeconomically and educationally disadvantaged students, many of whom

are racial and ethnic minorities.

Box 4-A reviews selected promising interventions that attempt, at least in part, to address the

shortcomings of many contemporary American

schools.

Major Federal Policies and Programs

Related to Education

As discussed elsewhere in this Report, Federal

programs related to education are primarily the

responsibility of the U.S. Department of Education.ls The U.S. Department of Labor also has some

responsibilities in this area.

U.S. Department of Education

In 1989, the U.S. Department of Education had a

budget of approximately $22 billion and was responsible for 187 programs spanning six different offices

(see figure 4-4). The U.S. Department of Education

does not administer educational programs targeted

specifically to adolescents but includes adolescents

as part of the school-aged population. It is impossible to determine total expenditures on adolescents,

because U.S. Department of Education funds are

distributed to State and local educational agencies

that determine their own priorities.

The U.S. Department of Education’s priorities

include increasing educational services to econom15s= ch. 19, “me Role of F~eral Agencies in Adolescent Heal@” k VO1. HI.
Chapter 4—Schools and Discretionary Time . II-79

Box 4-A—Innovative Approaches to Improving American Schoolsl

In recent years, promising interventions in schools have been tested and found to demonstrate beneficial effects

on adolescent health through their effects on adolescents’ levels of academic achievement, school persistence,

attitudes toward school, self-esteem, and confidence. These interventions, discussed further below, are generally

of two major types:

● interventions that are focused on improving individual learning and preventing selected heal t

associated with school failure (e.g., adolescent pregnancy and parenting); and

. interventions that are focused on changing school and/or community environments.

Interventions focused on individual learning and preventing selected health problems associated with school failure

include peer tutoring interventions; cooperative learning interventions; summer learning interventions; and

interventions that provide incentives and supports to students to graduate and go on to college. Interventions focused

on improving school environments include the School Development Program developed by Yale child psychiatrist

James Comer and also include some school-linked health centers (SLHCs). Examples of these two major types of

interventions that have undergone some evaluation and seem to show some promise are discussed below. Also

discussed below is the ‘comprehensive school/community health’ model, which is drawing considerable attention

from researchers and policymakers who are concerned about the health of U.S. adolescents (27,107b,108b,147),

Promising Interventions Focused on Improving Individual Learning and Preventing Selected Health

Problems Associated With School Failure

As noted above, interventions that focus on improving the skills of low-achieving students through means that

do not involve academic tracking include peer tutoring interventions, cooperative learning interventions, summer

learning interventions, and, most recently, interventions that provide incentives and supports to students to graduate

and goon to college. Several interventions that offer a more intensive focus on individual students than can typically

be found in the large public schools that are attended by many minority, poor, and academically at-risk adolescents

are discussed below. All of the interventions discussed below have undergone at least some preliminary evaluation

in terms of outcomes for adolescents and appear to hold some promise for enhancing adolescents’ adaptation to

school.

Peer tutoring interventions-Peer tutoring means using older or same age students to work individually with

students to teach a particular content area. Peer tutoring strategies emerged from concerns about how educators can

deal creatively with 35 students or more, engage students in appreciating rather than depreciating peer differences,

and promote active participatory learning among students. Generally, peer tutoring appears to be an effective

approach for adolescents. Some studies have found peer tutoring to be less costly than computer-assisted instruction,

to enhance levels of academic achievement beyond those found in conventional classes, and to be beneficial for

tutors and tutees (31,97,121).

Cooperative learning interventions-Teachers using cooperative learning strategies create groups where

each student has exclusive knowledge of a topic and where the students need to work together as a group to create

a final product. This strategy often stimulates interdependency among students. Cooperative learning appears to

satisfy many educational ends simultaneously (104,206). Cooperative learning enables heterogeneous groups of

students to work across ability levels, thus reducing the need to track students. It encourages students to participate

actively as teachers and as learners with their peers. It facilitates empathy across and within racial, ethnic, and ability

groups, and it shifts the questions of absolute authority away from teachers.

In elementary schools, cooperative learning strategies tend to enhance students’ academic achievement,

teaching instruction, and students’ sense of empathy (6,152). Investigators have sought to document the effects

of cooperative learning on achievement in secondary schools. One analysis of 27 selected studies involving 37

comparisons of cooperative v. control learning strategies concluded that over two-thirds of the studies favored

cooperation (207). Math and language arts seem to be the curricular areas most amenable to positive effects of

cooperative learning.

Summer learning interventions--Particularly for socioeconomically disadvantaged students, summers are

typically a time of enormous educational regress. Heyns argues that schools that provide educational interventions

IEvi&~ce on preschool interventions W nOt be Men uP in this c~Pter.

Continued on next page
11-80. Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 4-A—Innovative Approaches to Improving American Schoolsl-Continued

during the summer to low-income and academically disadvantaged students can and do reduce disparities in the

academic skills associated with the background characteristics of children and adolescents (99).

The Summer Training and Education Program (STEP) is an intervention designed to help reduce dropout levels

among poor and educationally deficient youth by focusing on two factors that are closely associated with dropping

out of school: poor academic performance and adolescent parenthood (184a). STEP targets low-income 14- and

15-year-olds who are performing below grade level in either reading or math and offers them two consecutive

summers of remediation, life skills instruction and work experience, and various support services (e.g., counselor

advocates and group meetings) during the intervening school year. The goal of STEP is to reduce participants’

summer learning losses, increase their reading and math skills, increase their graduation rates, and decrease their

pregnancy and parenting rates.

A national evaluation of STEP managed by the Philadelphia nonprofit corporation Public/Private Ventures is

comparing STEP participants’ outcomes to outcomes for a control group of students in the federally funded Summer

Youth Employment and Training Program (who received remedial education and a summer job but no other support

services) (184a). Preliminary results from the evaluation indicate that STEP minimized participants’ academic

losses over the summer.2 Furthermore, STEP increased participants’ reading and math scores and increased their

knowledge of contraception (184a). Preliminary findings regarding STEP’s impact on dropout rates among

participants are consistent with the hypothesis that STEP reduces dropout behavior but are based on small numbers

and are not statistically significant. Firm conclusions about STEP’s long-term effects on participants will have to

await the completion of the research in 1993.

Interventions to provide incentives and support for adolescents to graduate and go on to collegeEugene Lang’s celebrated I Have a Dream (IHAD) Project is perhaps the best known of these types of interventions.

The IHAD project began when Lang promised to pay college tuition fees for a class of sixth-graders then preparing

to graduate from his elementary school alma mater (99a). Lang realized quite quickly, however, that while a tuition

guarantee was essential, if IHAD students were to graduate, they would need considerable additional social and

academic support. The basic features of all IHAD projects have come to include “a sponsor,3 a tuition guarantee,

a project coordinator,4 and additional support services [for students (e.g., tutoring, cultural enrichment)]” (99a).

IHAD student participants are known as “Dreamers” (99a).

The publicity surrounding Lang’s project helped it become the formal prototype for many similar

programs--140 by summer 1990, at a total cost in private funds of $50 million, according to a 1991 report by

Public/Private Ventures (99a). Evaluating the effectiveness of IHAD projects is difficult, however, both because

IHAD sponsors have been reluctant to allow formal research (99a,207a) and because individual IHAD and similar

projects (207a) vary considerably within the basic framework

Public/Private Ventures obtained permission from the Greater Washington IHAD Foundation to evaluate its

IHAD Projects, most of which were begun in the 1988-89 school year.5 It is too early to tell whether the Greater

Washington area projects will be effective in achieving their ultimate objective of high school graduation and

2S= Ch. 10, ~qwm arid Pmaing: Prevention and services, “ in this volume for further discussion of the national evaluation of

STEP,

3sponsors ~ b indiviws WhO guarautee the college tuition and provide financial support for other aspects Of ~prO@tS. Conk@

between sponsors and IXwunms are tiequent, but according to Public/Private Ventures’ evaluation “they am valued by both groups” (99a).

Personal conwt seemed to be centml to the meaning sponsors derived tim KIWl support, as opposed to more anonymous forma of charity

(99a). Comments by Dreamers suggested that “some Dreamers develop commi tmcnt to IHAD’s [achievement] goals as a way to reciprocate

sponsors’ geamrosity (99a).

4-*@ ~b~~v~ v~~s, “h) II?httiotip with tie P@=t ~

is a Dreamer’s crucial link to the IHAD program”:

“Project c “ oorbatm qresent a continuous stable source of support for these youth. Unlike teac~ project monlinators provide a havea in

the midst of a school environment that can be indifferent or competitive.. .Pmject coordinate advocate for Dmamera within a school and

leverage t@Wkmal maourcc& such as tutoring, tX@S or concrete assistance during emcxgmcies. Tky ean and do drive youth to SISWO1, thus

improving att~and bring in parents for teacher consultations, thus kmasing !mmntal involvement” (9%). M@q ~form strong

emo?iond mdmEnts to project coordinators. However, contacts with project Coordmatom are voluntary d vary among Studaltls and project

. CodmWrs. Project Coordinator are not formally -iated with the Studlmts’ ScMols.

5= ~Wva&v~evaluation is Iknded by a private foundation (99a). Tkious supportem back the 8 classes now overseen by

the Greater w “ aabmgbn IHAD Fmmtadon. An initial sponsor formed the cheater wUllh@On IIMD Foundation and convcaed a class in 1987.

sponsors as of s- 1990 irwluded individual benefactors (three *); pairs of bu8ir&ss executives (three classes); a group of

professional athletes and abusincas executive (one claas); and two churches (one class) (99a).
Chapter 4—Schools and Discretionary Time . II-81

college entry (99a).6 However, Public/Private Ventures’ preliminary 1-year review of three of the Washington area’s

IHAD projects, based on interviews with 14 of the Dreamers and project coordinators, found that IHAD was a

“promising” intervention (99a). In its l-year review, Public/Private Ventures found that:

● the IHAD intervention had targeted and reached very disadvantaged youth;

. the timing of the IHAD intervention (at the end of fifth or sixth grade-the beginning of junior high or middle

school entry) was “developmentally propitious”;

● the IHAD model seemed to have a positive effect on Dreamers’ attitudes towards education, and

. the IHAD intervention provides adult relationships (i.e., sponsors, project coordinators, mentors7

) that are

meaningful to youth (99a).

On the other hand, Public/Private Ventures expressed concern that “support services, especially tutoring, are

necessary program components, but are provided unevenly’ (99a). It also noted that enrichment activities (e.g., a

summer program for Dreamers) and incentive awards are inconsistently delivered within each school and among

schools. Project coordinators were found to be overburdened and in need of help in gaining access to social services

for their students (99a). Public/Private Ventures found that the “inconsistency of the services is probably inevitable

within the present Foundation structure’ and that “the quality of Foundation-wide activities, such as the summer

school, is worrisome” (99a). The evaluators recommended additional oversight by the Greater Washington IHAD

Foundation’s board of directors to improve these aspects of the program.

IHAD raises an interesting public policy dilemma (99a). According to Public/Private Ventures, the benefits

of IHAD may derive from IHAD’s private sponsorship:

IHAD’s unique contribution may be exclusive to the private sector: an association with a wealthy and even

famous benefactor. This benefit can have immense repercussions for a youth from a poverty background: a sudden

change of luck, intermittent reminders of a special status, and a long-term commitment by a distant and powerful

advocate. Publicly funded interventions can probably never deliver this sense of a special connection, or elicit the high

expectations that youth-and some school officials-attribute to sponsors (99a).

Nonetheless, it may be that many of the elements of IHAD--the project coordinator who provides a haven for

adolescents in a competitive and often hostile school environment, tutoring, the link to intensive social and academic

support services, guaranteed college tuition--an be reproducd in school and community settings using public

funds.

Promising Interventions Focused Largely on Changing School and Community Environments

While some interventions focus on improving the school adaptation of selected individuals, other interventions

focus largely on changing school and sometimes community environments, although they may “build in”

individually focused attention (e.g., 35). The primary purpose of interventions focused on changing these

environments is to make schools (and, sometimes, communities) more health-promoting environments for

adolescents. One of the most frequently cited of these approaches to improving school environments is Comer’s

School Development Program (35). In addition, proponents of SLHCs often view SLHCs as a means of integrating

a health perspective into a school, as well as a way to deliver health and other nonacademic services to individual

adolescents (141a).8 These approaches come under the general rubric of “comprehensive school health”

(107b,108a), establishing the school as a health-promoting environment (27), or school/community linkages to

promote adolescent health (147).

Comer’s School Development Program—A longitudinal study of an intervention developed by Yale

University child psychiatrist James Comer provides strong evidence that creating a collaborative dynamic between

educators and parents, as opposed to the traditional social service bureaucratic relationship, markedly advances both

6A news ~icIe rep~~ mixed results for the initial Eugene Lang class in New York City (152b).

7Mentors Wme provided by 11-IAD at only one of the schools. IKI thiS school, apprOXbt@ 30 emPloYf$es of the spo~ors’ comP~Y

“adopted” two Dreamers each: “They phone the Dreamers, wrote them letters and attended company-sponsored trips and dinners with

them. . .Addit.iorud contacts could be initiated if either the mentor or the youth desired [and they often were]” (99a). Public/Private Ventures’

evaluation notes that mentors were sometimes frustrated by the differences in values between the mentors and the Dreamers, and that one mentor

recommended @aining for mentom and matching youth with mentors from similar backgrounds (99a). Interventions using mentors to prevent

specific adolescent health problems are discussed in other chapters in this volume; there are no evaluations of such interventions available.

s~e role of sLHcs in health services delivery are discussed further in VO1. I of this Repo~ SWWMr-y and Policy Options, and inch.

15, “Major Issues in the Delivery of Primary and Comprehensive Health Services to Adolescents,” in Vol. III.

Continued on next page
II-82 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 4-A—Innovative Approaches to Improving American Schoolsl-Continued

organizational responsiveness to students’ personal needs and students’ academic work (35). Unlike some current

educational reforms which focus on instruction and curriculum, the Comer intervention is based on the

understanding that “many kinds of development, in social, psychological, emotional, moral, linguistic, and

cognitive areas, are critical to future academic learning” (35).

The Comer intervention, also known as the School Development program, seeks to overcome what Comer

terms “a basic problem underlying the schools’ dismal academic and disciplinary record: the sociocultural

misalignment between home and school” (35). For many black and Hispanic children whose parents have had a

traumatic social history, Comer suggests, education must do more than teach the basics (127a). It must also address

students’ emotional, social, and psychological needs (127a). The School Development Program has three goals: 1)

to induce parents to participate in the school’s life; 2) to force school administrators, teachers, and other staff to share

authority in managing the school; and 3) to bring guidance counselors, mental health professionals, and teachers

into a team that meets regularly to combat behavior problems (127a). A school governance and management team,

consisting of parents and teachers, the principal, a mental health specialist, develops a comprehensive school plan

covering academics, social activities (e.g., potluck suppers to teach children social skills and enable parents to meet

teachers), and special programs. A mental health team assigns a member to work with a child who is having

difficulty and tries to identify whether some school process is contributing to the behavior. Parents are also

encouraged to become classroom assistants, tutors, or aides.

The Comer process has already been adopted by more than 100 schools in nine districts in eight States (127a).

In the schools where Comer’s programs are being implemented, the evaluation data for at-risk students are very

encouraging. In the two New Haven elementary schools where the program was implemented, behavioral problems

in the schools declined and math and reading scores climbed. Similar results were achieved, from 1985 to 1987,

in 10 predominantly black schools involved in the Comer program in Prince Georges County, Maryland (35). A

more rigorous evaluation of the Comer intervention in Prince Georges County is being developed.

School-linked health centers 9—As discussed further elsewhere in this Report, SLHCs vary in the services

they offer. Comprehensive SLHCs (and comprehensive community-based centers for adolescents) are centers that

aspire to provide health services that address the range of problems that many adolescents face: care for acute

physical illness, general medical examinations in preparation for involvement in athletics, mental health counseling,

laboratory tests, reproductive health care, counseling for family members, prescriptions, advocacy, and coordination

of care. The more comprehensive of the centers may also offer adolescents additional services, such as educational

services, vocational services, legal assistance, recreational opportunities, child care services and parenting education

for adolescent parents. The defining feature of a comprehensive Service center for adolescents is the extent to which

the center attempts to be responsive to the specific needs of adolescents by, for example, offering free care or using

sliding-fee schedules for payment, evening and weekend hours of operation, confidentiality of services, and staff

members who are knowledgeable about and committed to adolescents. OTA has concluded that SLHCs are the most

promising recent innovation to improve U.S. adolescents’ access to health and related services. Although there is

as yet little systematic evidence that SLHCs for adolescents improve health outcomes, there is clear evidence that

such centers can improve adolescents’ access to the health and related services that adolescents are most likely to

need.

In the opinion of many observers, however, SLHCs are not just a site for delivering health services to

adolescents. SLHCs can be a means of integrating a health perspective into a school and making schools more

health-promoting environments. They can provide health services to faculty, provide linkages with health

professionals and services outside the school building, serve as a source of referral and consultation for teachers and

students, and make health-promoting suggestions to school administrators. Perhaps as a consequence of this

perspective on SLHCs, some evaluations of SLHCs have focused on whether the presence of an SLHC improves

the health of the entire student body in a school, not just the users of clinic services (e.g., 107c). However, it is as

yet difficult to make judgments about the ability of SLHCs to improve school environments and so influence the

health of entire student bodies: there have been few evaluations and those that have been conducted are

9See Vol. I of thiS Report, SWWM ry and PolicY Options, the “Report Brief,’ and ch. 15, “Major Issues in the Delivery of Rimary and

Comprehensive Health Services to Adolescents,” in Vol. III.
Chapter 4—Schools and Discretionary Time . II-83

methodologically weak hence, findings concerning impact are mixed. 10 Most important, however, evaluations have

not formally evaluated whether SLHCs have become fully integrated into schools.

The comprehensive school/community health model-An increasing recognition that there are inherent

limitations to what individuals, the traditional health care system, schools, and social services can do on their own

to promote and improve adolescent health has led observers to recommend more comprehensive and integrated

approaches. Evaluations of SLHCs (see above) by Kirby and others have pointed to the need for additional

integration of SLHCs into schools and communities (e.g., 2a,107c). In their review of the provision of mental health

services in SLHCs, for example, Adelman and Taylor suggested that SLHC-based mental health services take a

more preventive orientation, in part by becoming better integrated into the daily life of a school (2a). Kirby and his

colleagues suggested that SLHCs develop communitywide programs involving parents, youth-serving agencies,

religious and other community leaders, and the media (107c).

One approach to integrating school and community programs offered by Kirby makes the community the center

of the effort: programs are subject to community control and programs are overseen by a “child health council”

(107b). Because schools are the one institution regularly attended by most young people ages 5 to 16, however,

Kirby suggests that ‘schools represent the public institution with the greatest opportunity for playing an important

role in improving the health of most youth” (107b). According to Kirby, a comprehensive school/community health

program at the school level:

● includes health instruction, school health services, other school activities, and a reinforcing school

environment;

● integrates special programs for parents and includes adult mentors; and

. has linkages with health and youth-serving agencies, churches, businesses, and local media (107b).

Thus, schools are the central locus of efforts to promote and improve adolescent health, but they are not expected

to act alone (see also 27,147).

As pointed out by Kirby and others (107b,147), the implementation of comprehensive school/community

health programs has been impeded by the failure to resolve some important issues. Key issues include resistance

by schools to adopting additional responsibilities and a lack of formal evidence that integrated school/community

programs are more effective than more segmented efforts (107b). Recently, however, a sense of urgency about

adolescent health and achievement has stimulated many learned observers, including those in the education

community, to come out in support of a greater role for schools in improving adolescent health (e.g., 27,147). The

analysis in this chapter (and throughout this Report) strongly suggests that a key to improving adolescent

health would be to encourage the view of schools as environments that can either promote or impede

adolescent health, rather than merely as settings in which to place additional responsibilities, such as the

delivery of additional “programs,” without providing additional supports.

1OSW ch. 15, “~jor Issues in the Delivery of Primary and Comprehensive Health Services to Adolescents,” in VO1. ill.

SOURCE: Office of Technology Assessment, 1991.

ically and educationally disadvantaged children. For The Office of the Assistant Secretary for Elethe past two decades, the primary Federal vehicle for

helping schools meet the educational needs of

educationally disadvantaged children (i.e., children

performing below their appropriate grade level,

children of migrant workers, children with physical

disabilities, and neglected or delinquent children

under State care) has been grant programs authorized by Chapter 1 and administered by the Office of

the Assistant Secretary for Elementary and Secondary Education.

mentary and Secondary Education has one of the

largest appropriations in the U.S. Department of

Education, approximately $6.6 billion in fiscal year

1989. Although the proportion of funding allocated

to adolescents cannot be precisely determined,

major programs that provide adolescent-related

efforts include the following:

. Chapter 1 grants to provide financial assistance

to State and local educational agencies to meet
E

Figure 4-4--U.S.

Chief of Staff ~-

1

I Executive w

Secretary of

1

Secretary I I Educatio . n

~

I ——

I Executive Assistant I

Private Education +

~

Counsel I

~

Deputy Under

i Secretary fo r

I Planning, Budget,

and Evaluation

— .

—

I

1 [

Assistant Secretary I I Assistant Secretary

for Elementary I

for Postand Secondary ~ Secondary

Education Education

I

–+-—

1

I

L

Inspector General

—. .-~

(

,

(

I

Deputy Unde r

I Secretary for

Management ,

—

! ,

l—

I

.———

)

I 1 Assistant Secretary

I

for Educational

I

, i Research and

I

Improvement

I

I

I

I

~--”

Deputy Under

Secretary for

Intergovernmental and

Interagency Affairs

i -

I Assistant Secretar y

——~

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=Fjijjq

Education

~1w!K

Languages Affairs , 1

SOURCE: U.S. Department of Education, organizational chart, Washington, DC, Sept. 15, 1989.

●
Chapter 4—Schools and Discretionary Time . II-85

●

●

●

●

the special educational needs16 of disadvantaged children and adolescents;17

education of homeless children and youth, as

authorized by the Stewart B. McKinney Homeless Assistance Act;

Indian education programs, as authorized by

the Indian Education Act of 1988;

training for elementary and secondary school

teachers in math and science, as authorized by

the Dwight D. Eisenhower Mathematics and

Science Education, Hawkins-Stafford Amendments of 1988; and

drug abuse education and prevention coordination in States and communities, as authorized

by the Drug-Free Schools and Communities

Act of 1986.

Chapter 1, Title I of the Elementary and Secondary Education Act, provides Federal assistance for

State and local programs of education for disadvantaged U.S. pupils at all levels, from prekindergarten

through secondary school (202a). The fiscal year

1989 appropriation for Chapter 1 was $4.6 billion,

making this program the largest program of aid to

elementary and secondary education in the United

States.

Chapter 1 was initially authorized as Title I of the

Elementary and Secondary Education Act in 1965

(202a). In 1988, Congress reauthorized the Chapter

1 program, again as part of the Elementary and

Secondary Education Act, in the Augustus F.

Hawkins-Robert T. Stafford Elementary and Secondary School Improvement Amendments of 1988

(Public Law 100-297) (202a). The 1988 law, better

known as the Hawkins-Stafford Act, made a number

of changes in State and local educational agency

programs of Chapter 1.18 Among other things, the

Hawkins-Stafford Act provided for the following:

● incentives to enhance accountability and improve performance—the Hawkins-Stafford Act

contained several provisions aimed at evaluating the performance of individual pupils,

schools, and local educational agencies served

●

by Chapter 1 and at providing Federal assistance to improve this performance. The law

specifies that if an individual pupil participates

in Chapter 1 for a year without academic

improvement, the local educational agency

must consider changing the services provided

to that pupil. If the aggregate performance of

pupils in a school fails to improve over 1 year,

the local educational agency must develop a

program improvement plan. It is important to

note that the law allows State and local

educational agencies a great deal of flexibility

in setting the standards to which they are to be

held accountable.

programs to increase parental involvement in

the education of Chapter 1 participants—The

law requires local educational agencies to

implement procedures ‘of sufficient size, scope,

and quality to give reasonable promise of

substantial progress toward achieving the goals’

of informing parents about the Chapter 1

program, training parents to help instruct their

children, and consulting with parents. The

agencies are required, among other things, to

develop written policies for parental involvement in planning and implementing Chapter 1

programs, to convene an annual meeting of

parents, and to provide program information

and an opportunity for regular meetings for

parents if the parents so desire. The law gives

general guidance and lists numerous examples

to illustrate the types of authorized parental

involvement activity that would allow local

educational agencies to meet their responsibilities--e.g., parent training programs, the

hiring of parent liaisons, the training of school

staff to work with parents, the use of parents as

tutors or classroom aides, and parental advisory

councils-but it leaves local educational agencies with about the same level of flexibility in

the area of encouraging parental involvement

as they had before. Thus, it remains to be seen

16F~er~ ~uppo~ for ~ ~Pi~ edu~tj~n’ 1 ~rogmunder fiblic ~w 94142, tie Education of tie Handicapped Act, as amended, is not discussed

in thiS chapter. Sm ch. 19, “The RoIe of FederaI Agencies in Adolescent Health” in Vol. III, and ch. 11, “Mental Health Problems: Prevention ~d

Services, ‘‘ in this volume.

17N0 age bre~do~ we av~lable for c~ent fiding of ~pter 1. However, in he 1987-88 school year, 21 percent (1,037,127) Of the pOpllhtiOn

served were students in grades 7 through 12 in both public and private schools, with funding for these adolescents totaling $3.8 billion.

lg~~~ucatio~ ~gencypmgms of @ptm 1 ~present abut 90 percent of Chapter 1 tiding (202a). Chpter 1 Iocal edu~tiotd agency gr~ts

are calculated by the Federal Government on a county basis. State education agencies receive the aggregate funds for counties in their States, then allocate

the county amounts to individual local educational agencies.
II-86 ● Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

what impact the new provisions will have on

the actual level of parental involvement.19

programs for secondary school pupils and

school dropouts—The Hawkins-Stafford Act

devoted substantial attention to establishing

programs specifically for compensatory education of secondary school students. Although

local educational agencies have always been

authorized to use Chapter 1 funds for secondary

school students, Chapter 1 services have historically been focused on pupils in kindergarten

through sixth grade. In 1985-86, for example,

about 88 percent of all Chapter 1 basic grant

participants were enrolled in kindergarten

through grade 6, while only 5 percent were in

grades 10 through 12. Two different titles of the

Elementary and Secondary School Education

Act, as amended by the Hawkins-Stafford Act,

provide authorizations for programs of school

dropout prevention and secondary school basic

skills improvement: Title VI and Title I,

Chapter 1, part C.

—Title VI contains l-year demonstration grant

authorizations under the School Dropout Demonstration Assistance Act of 1988 and the

Secondary Schools Basic Skills Demonstration

Assistance Act of 1988. The former act authorizes demonstration grants to local educational

agencies for dropout prevention and reentry

activities both within schools and in cooperation with community organizations and businesses.

20 Dropout prevention and reentry activities may include services to address poor

academic achievement, work-study programs,

services intended to improve student motivation and the school learnin g environment,

remedial services to youth at risk of dropping

out, occupational training, educational programs offering jobs or college admission to

students who complete them, summer employment, etc. The fiscal year 1989 authorization

for this program to address school dropout

programs was $50 million; the appropriation

was $21.7 million (202a) .21 22 The Secondary

Schools Basic Skills Demonstration Assistance

Act authorizes a program of national demonstration grants to local educational agencies for

activities to help educationally disadvantaged

secondary school students attain grade level

proficiency in basic skills and learn more

advanced skills. The grants may be used to

initiate or expand compensatory education

programs for secondary school students or

dropouts, transition-to-work activities in cooperation with the private sector or communitybased organization, and use of secondary students as tutors of other educationally disadvantaged pupils. The fiscal year 1989 authorization

for this program was $200 million; however, no

funds were appropriated for the program. In

fiscal year 1990, the frost year of funding, just

under $5 million was appropriated for the

program (202b). According to the U.S. Department of Education, basic skills programs can

continue to be carried out through Chapter 1

basic and concentration grants and the School

Dropout Demonstration Assistance Act.

—Title I, Chapter 1, part C established a longer

term formula grant program of State grants to

secondary schools for basic skills improvement

plus dropout prevention and reentry. In general,

funds will be allocated to States in proportion

to the Chapter 1 basic grants their schools

receive .23

l~e Haw~.Stafford Act authorized on a demonstration basis, in the Even Start progrrun, support for projects that provide basic education for both

educationally disadvantaged children ages 1 through 7 and their parents who reside in was of relatively high poverty concentration. This program is

intended to provide geneml basic education to parents and to increase their involvement in helping to instruct their children (202a). It may have the

potential to benefit adolescent parents.

mAt lat fine other U.S. Department of Education programs and three U.S. Department of Labor programs may help schools that have dropout

programs. For information about these programs, which range from large grant programs (e.g., Chapter 1 and the Job Training Partnership Act programs)

to small programs explicitly focused on helping students complete school, see the March 1990 Congressional Research Service issue brief entitled ‘High

School Dropouts: Current Federal Programs’ (202b). That publication notes that little is known about the extent to which the available programs actually

help students complete school (202b). It also notes that because the fragmentation of programs maybe confusing to orga.nhtions working with dropouts,

greater coordination may be desirable. OTA’s discussion of the general problem of fragmentation in Federal programs for adolescents is presented in

ch. 19, “The Role of Federal Agencies in Adolescent Health, ” in Vol. Ill of this Report.

zlTi~e w ~so rquimd tie Secm- of ~ucation to es@blish a s~~d deffition of the term ‘ ‘school dropout. ’ Such a deffition W&S publishd

in the Federal Register on May 10, 1988, p. 16667 (202a).

~As of M~h1990, fisc~ yea 1988 ~d 1989 appropriatio~ for~e School Dropout Demo~~tion Assistance Aclhad provided 2 JW.WS Of aSSiSlilIl~

to 89 projects in 31 States and the District of Columbia (202 b). Evaluations were not yet available.

~AU of these c~ges Me discussed at 1ength ~ a J~u~ 1989 Congressio@ Re~mch Service report entitled “Education for Disadvantaged

Children: Major Themes in the 1988 Reauthorization of Chapter 1“ (202a).
Chapter 4—Schools and Discretionary Time . II-87

U.S. Department of Labor

Within the U.S. Department of Labor, the Employment and Training Administration is the agency

most directly supporting activities affecting adolescents. In program year 1989, funding for youth was

estimated to account for 58 percent ($2.2 billion) of

the budget. Employment and Training Administration projects for youth typically focus on adolescents

and young adults ages 16 and over. The Employment

and Training Administration supports employment

and training programs for economically disadvantaged youth under the 1982 Job Training Partnership

Act. Three programs authorized under Titles II-A,

II-B, and IV of the Job Partnership Training Act

support the provision of services to high school

dropouts and potential dropouts ages 14 or 16 to 21

(202b),

Title II-A provides training grants for disadvantaged adults and youth to States, which pass on 78

percent of the funds to local service delivery areas

for training of people who are economically disadvantaged or face other barriers to employment (e.g.,

lack of a high school diploma) (202b). Local service

delivery areas must spend 40 percent of the funds for

youth ages 16 to 21. States must use a portion of their

education set-aside (8 percent of the total grant) for

literacy training, dropout prevention, and school-towork transition programs. The fiscal year 1990

appropriation for Title H-A was $1.7 billion.

Title II-B provides Summer Youth Employment

and Training grants for low-income youth to States,

which pass on funds to service delivery areas for

summer on-the-job training, work experience, and

supportive services for disadvantaged youth ages 16

to 21 (202 b). At local option, 14- and 15-year-olds

may also be served. Local service delivery areas’

plans must include assessments of participants’

reading and math skills and describe available

remedial education activities. The fiscal year 1990

appropriation was $699 million.

Title IV authorizes various federally administered

programs affecting adolescents, such as Job Corps

and programs designed for Native Americans and

migrant workers (202 b). Job Corps, a joint venture

between the U.S. Department of Labor, private

corporations, and nonprofit organizations, provides

employment and training in primarily residential

centers for severely disadvantaged adolescents and

young adults ages 16 to 21. The U.S. Department of

Labor provides funding for the centers, which

totaled $741.8 million in program year 1989, and

corporations and nonprofit organizations organize

and manage the centers under a contractual agreement. In program year 1989, there were 100,000

participants in Job Corps. After completing the

program, 66.9 percent of the participants were

placed in jobs and 16.7 percent went on for further

education.

Title IV also establishes funding for research,

which is administered by the Division of Research

and Demonstrations in the Office of Strategic

Planning and Policy Development. One of the

primary goals is to address the problem of unemployed youth or those at risk of becoming unemployed. Specific programs include grants to integrate Federal, State, and local services; to investigate patterns of youth achievement; to link school

and employment with apprenticeships; to evaluate

demonstrations providing alternative education to

at-risk youth; and to analyze interagency demonstrations. In one recent year, there were 35 such research

projects underway, and the average cost per project

was approximately $275,000.

Under the Employment and Training Administration’s Office of Work-Based Learning, the Bureau of

Apprenticeship and Training administers various

apprenticeship programs authorized by the National

Apprenticeship Act of 1937. Federal staff from the

Bureau of Apprenticeship and Training, as well as

State personnel in some States, assist in providing

technical assistance to the apprenticeship programs,

which are sponsored by industry. The average age of

most apprentices is about 29, and about 17 percent

of apprentices are between the ages of 16 and 22.

There is one type of apprenticeship program designed specifically for adolescents. The School-toApprenticeship Program, which makes up less than

1 percent of all apprenticeship programs, provides

adolescents with the opportunity to attain valuable

job skills in an apprenticeship when they are high

school seniors (101).
II-88 . Adolescent Health-Volume //: Background and the Effectiveness of Selected Prevention and Treatment Services

Adolescents’ Discretionary Time24

Neither researchers, policymakers, nor even parents know a great deal about how U.S. adolescents

use their time when they are not in school or engaged

in basic maintenance activities (e.g., eating, sleeping). A number of questions remain to be answered.

For instance, how many hours per week do adolescents typically spend in discretionary activities?

Where do they engage in such activities? With

whom, if anyone, are such activities shared? Furthermore, does the use of adolescents’ discretionary time

vary by age, race, gender or other cultural, ethnic, or

demographic factors?

Despite the paucity of systematic data on the

topic, it is virtually certain that the physical, social,

and behavioral development of U.S. adolescents is

shaped, at least in part, by experiences that occur

during their discretionary time. Hence, it is likely

that the constructive and creative use of discretionary time will enhance adolescents’ prospects for

healthy development. Toward this end, future policies regarding adolescent development must be well

informed by knowledge about the past, present, and

potential uses of discretionary time.

Given the large “amounts of time that adolescents

devote to highly structured activities (such as

schooling and homework) and essential maintenance activities (such as eating, sleeping, and

personal hygiene), their discretionary time probably

constitutes the most abundant and flexible resource

that exists for the provision of health-enhancing

programs. Studies have shown that recreational and

leisure activities, as well as work activities, can

provide adolescents with opportunities for experiences of mastery and competency (103); creativity

and self-expression (50); self-improvement and

self-definition (125); self-fulfillment and personal

meaning (50); enhancement of character and personality (103); testing oneself in competition (106);

development of interpersonal and social skills (103);

and, the development of autonomy (50). Leisure and

work activities also can contribute to social experimentation and recognition (125); improved physical

health (17); an increased sense of freedom (50);

identification with positive role models and mentors

(66); companionship and improved relationships

with others (50); and, of course, entertainment and

relaxation (132). Research has shown that leisure

and work activities which involve the attainment of

specific goals (59) and meaningful goal-directed

activity (65,129) are positively related to important

developmental variables such as self-esteem, positive affect, and life satisfaction.

For a number of reasons, U.S. adolescents today

probably spend much less time with their parents

and families than in previous years. The reasons

include the breakdown of two-parent families due to

separation and divorce (29,77); the deterioration of

extended family relationships as a result of high

rates of geographic mobility and urban migration

(76); the rapid entry of mothers into the work force

(216) and the concurrent emergence of numerous

‘‘latchkey’ children who are unattended after

school (192); high incidence of parental substance

abuse and mental illness, and parents’ attendant

inability to exert positive socializing effects upon

their children (68); decreased family size and,

therefore, fewer siblings who are available to

socialize youngsters (16,29); and, fiscal exigencies

which constrain the availability of funds for afterschool programs (128).

According to some observers, U.S. adolescents

have become increasingly separated from adults,

have fewer adult responsibilities, and communicate

less frequently with adults. Indeed, one study

indicates that relatively few adolescents ask their

parents for advice about such basic concerns as jobs,

college, school problems, sibling problems, health

or diet, drinking, sex, trouble with other adolescents,

and drugs (154). To the extent that adolescents spend

less time with their parents, their development is

likely to be shaped less frequently and less influentially by parents and more often by peers or others

with whom adolescents come into contact during

their “free” time or by parental surrogates and role

models who appear on television or elsewhere.

Some observers suggest that the relative isolation of

adolescents from adults has helped to bring about

‘‘adolescent rolelessness" (153). Others contend

that adolescents’ insulation from “the real business

of life” produces apathy, self-hatred, boredom,

loneliness, meaninglessness, and acute feelings of

frustration (46).

a~s ~tion draws substantially from a paper entitled ‘‘How Can Society Contribute to M-@d Use of Adolescents’ Spare Time,” prepared

under contract to OTA by Ronald Feldman (66a).
Chapter 4—Schools and Discretionary Time ● II-89

Given the central role of discretionary time in

adolescent growth and development, it is unfortunate that relevant research concerning this topic is

very limited. Such research is essential to better

comprehend how adolescents use their discretionary

time and how we can devise appropriate policies and

programs to promote health-enhancing uses of

discretionary time.

How Do U.S. Adolescents Spend Their Time?

Results from the Monitoring the Future/High

School Seniors Survey, which surveyed a nationally

representative sample of about 17,000 U.S. high

school seniors, indicate that U.S. adolescents consider discretionary and leisure activities to be of

great importance (8). Seventy percent of the high

school seniors who were interviewed in 1986 stated

that it was either “extremely important” or “quite

important” to have “plenty of time’ for recreation

and hobbies. This was the highest25 percentage

reported in the survey’s 10-year history. In considering the attributes of preferred jobs, 78 percent of the

1986 high school seniors regarded more than 2

weeks of vacation as “pretty important” or “very

important, while 83 percent deemed it “pretty

important’ or ‘very important’ that their job afford

‘‘a lot of time for other things in life. Both figures

were higher than at any other time in the survey’s

history.

A review by Easterlin and Crimmins further

substantiates that a significant shift has emerged in

the leisure aspirations of American adolescents

during the decade from 1976 to 1986 (55). Among

14 life goals studied, the goal with the greatest

increase in importance to adolescents in the decade

from 1976 to 1986 was “having lots of money.” The

1986 adolescent respondents considered it much

more important than their counterparts a decade

earlier to own such items as a vacation house, at least

two cars, and a recreational vehicle. Although in

both 1976 and 1986 these goals were exceeded in

importance by other goals, including ‘‘a good

marriage and family life, ” the foregoing goals rose

most in importance and were integrally related to

high valuations of leisure time.

Perhaps the most systematic study of American

adolescents’ use of time was a study by CzikszentTable 4-5-Where Adolescents Spend Their Timea

Home (41%)

Bedroom . . . . . . . . . . . . . . . . . . . . . . . . .

Living room . . . . . . . . . . . . . . . . . . . . . . .

Kitchen . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yard or garage . . . . . . . . . . . . . . . . . . . .

Dining room . . . . . . . . . . . . . . . . . . . . . . .

Basement . . . . . . . . . . . . . . . . . . . . . . . . .

Bathroom . . . . . . . . . . . . . . . . . . . . . . . . .

School (32%)

Classroom. . . . . . . . . . . . . . . . . . . . . . . .

Miscellaneous locations . . . . . . . . . . . . .

Cafeteria . . . . . . . . . . . . . . . . . . . . . . . . .

Halls . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gym . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Student center . . . . . . . . . . . . . . . . . . . . .

Library . . . . . . . . . . . . . . . . . . . . . . . . . . .

School grounds . . . . . . . . . . . . . . . . . . . .

Public (27%)

Friends’ home . . . . . . . . . . . . . . . . . . . . .

At work . . . . . . . . . . . . . . . . . . . . . . . . . . .

Automobile . . . . . . . . . . . . . . . . . . . . . . . .

Other public areas . . . . . . . . . . . . . . . . .

Store or cafe . . . . . . . . . . . . . . . . . . . . . .

Street . . . . . . . . . . . . . . . . . . . . . . . . . . .

Park . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Walking . . . . . . . . . . . . . . . . . . . . . . . . . .

Indoor recreational facility . . . . . . . . . . .

Church . . . . . . . . . . . . . . . . . . . . . . . . . .

Bus or train . . . . . . . . . . . . . . . . . . . . . . .

~he data shown in this table were derived from a study of 75 adolescents

who for a l-week period carried an electronic pager and were buzzed

frequently during thedayand asked torecordtheiraetivities (see text). The

data here are based upon 2,734 weighted self-reports. Each percentage

point is equivalent to approximately 1 hour per week spent in the given

location or activity.

12.9%

8.9

8.1

4.1

3.3

2.2

1.6

19.8

2.3

2.2

2.0

1.9

1.3

1.2

0.8

5.4

5.3

3.8

3.0

2.8

2.0

1.7

1.5

0.8

0.8

0.4

SOURCE: Adapted from M. Csikszentmihalyi and R. Larson, 5eing

Adolescent: Conflict and Growth in the Tmnage YWS (New

York, NY: Basic Books, 1984).

mihalyi and Larson published in 1984 (44). These

investigators utilized an innovative research procedure in which 75 adolescents were asked to carry an

electronic pager and a pad of self-report forms for 1

week. At a random moment within every 2-hour

period, a signal was sent to the pager and the

adolescent was instructed to complete a self-report

form about his or her activity at that time. Despite

sampling limitations, this study did provide an

overview of 75 adolescents’ daily experience.

As shown in table 4-5, the investigators found that

the sampled adolescents spent 41 percent of their

time at home, 32 percent at school, and 27 percent in

locations such as fiends’ homes, work or parks (44).

Much (nearly 40 percent) of the time these adolescents spent at school was spent in places other than

2S~~~ it ~~o@ttit pla~ing ~ ~gh “~~e on le~ rime M- ~r ~nrernpor~ ~O]e~en~ me ltiernow ~hey were iIl ptis~ it iS illlpollilllt

to compare adolescents’ attitudes towards leisure time to those of adults. A sumey recently reported in the Washington Post found that many private

sector executives considered vacations crucial to their psychological and physical well-being (215a).

2$}7-!).1(; – !)] --- i (Jl, :{
11-90. Adolescent Health-Volume II Background and the Effectiveness of Selected Prevention and Treatment Services

the classroom (e.g., miscellaneous locations, cafeteria, halls, gym). Time spent in these locations

frequently afforded opportunities for unstructured

social interaction with peers.

As shown in table 4-6, the sampled adolescents

spent 40 percent of their time in discretionary

activities such as socializing, watching television,

reading, and engaging in sports or games (44). They

spent approximately 31 percent of their time in daily

maintenance activities such as chores, errands,

eating, traveling from one place to another, sleeping,

and personal care (e.g., grooming, dressing and

bathing). Finally, they spent 29 percent of their time

in activities that the investigators characterized as

‘‘productive,’ primarily studying, classwork, or

jobs and related activities. Even though the sampled

adolescents devoted more time to self-selected

discretionary activities than to maintenance or

productive activities, it is probable that the researchers’ estimates of the subjects’ discretionary time are

low. The reason is that data were not collected

during such prime leisure periods as Sundays,

weekdays after 11 p.m., and the summer.

If one considers the sampled adolescents’ leisure

time (see table 4-6), one finds that the greatest

proportion of this was spent in socializing; the

adolescents spent one-sixth of their waking hours

socializing. In addition, the sampled adolescents

reported engaging in conversation while studying,

watching television, and eating. In total, therefore,

the sampled adolescents probably spent about onethird of their day conversing with others. Hence,

conversation was by far the single most prevalent

activity in the sampled adolescents’ lives. The next

largest amount of leisure time, after that spent

socializing, was spent in watching television. The

sampled adolescents spent much smaller proportions of their leisure time in essentially solitary

activities such as reading, thinking, and listening to

music or in activities that typically involve friends

and peers such as sports and games or arts and

hobbies. Altogether, more than one-half of the

adolescents’ discretionary time was spent in social

interaction with others and in activities that adults

often consider to be of secondary importance. In

terms of sheer amount of time, peers were by far the

greatest presence in the sampled adolescents’ lives.

In the late 1970s, Farley conducted a related study

with 129 Canadian adolescents who ranged between

10 and 17 years of age (60). Information regarding

Table 4-6-What Adolescents Spend

Their Time Doinge

Leisure activities (40%)

Socializing. . . . . . . . . . . . . . . . . . . . . . . .

Watching television . . . . . . . . . . . . . . . . .

Miscellaneous . . . . . . . . . . . . . . . . . . . . .

Reading (nonschool) . . . . . . . . . . . . . . .

Sports and games . . . . . . . . . . . . . . . . .

Thinking . . . . . . . . . . . . . . . . . . . . . . . . .

Arts and hobbies . . . . . . . . . . . . . . . . . .

Listening to music . . . . . . . . . . . . . . . . . .

Maintenance activities (31%)

Chores and errands . . . . . . . . . . . . . . . .

Eating . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Transportation . . . . . . . . . . . . . . . . . . . . .

Rest and napping . . . . . . . . . . . . . . . . . .

Personal care . . . . . . . . . . . . . . . . . . . . .

Productive activities (29%)

Studying . . . . . . . . . . . . . . . . . . . . . . . . . .

Classwork . . . . . . . . . . . . . . . . . . . . . . . .

Jobs and other activities . . . . . . . . . . . .

16.0?!

7.2

4.6

3.5

3.4

2.4

1.5

1.4

14.3

5.6

4.9

3.2

3.2

12.7

12.0

4.3

~hedata in this table were derived from a study of 75 adolescents who for

a 1-week period carried an electronic pager and were buzzed frequently

during the day and asked to record their activities (see text).

SOURCE: Adapted from M. Csikszentmihalyi and R. Larson, Being

Adolescent: Conflict and Growth in the T-nqge Y-s (New

York, NY: Basic Books, 1984).

the daily activities of 129 adolescents was collected

by recall of a sequential record of every activity that

lasted at least 15 minutes. Aside from weekday

school attendance, passive leisure was the activity

grouping that clearly emerged as the most widespread on both weekdays and Sundays. Nearly 90

percent of the adolescents devoted some time each

day to passive leisure activities. On the average, the

adolescents in this study spent 2 to 3 hours per day

passively. Nearly three-quarters of this time was

accounted for by television watching. Low levels of

participation were recorded for such activities as

working away from home, cultural or educational

activities, and organizational activities. Only 18

percent of the respondents participated in adolescent

organizations, and an even lower percentage (12

percent) took part in church activities. Nevertheless,

100 percent of the subjects who participated in

adolescent organizations or church activities regarded these organizations as ‘‘important’ or “very

important. ‘ ‘

Related research further supports the observation

that a great deal of American adolescents’ time is

spent watching television. Some studies indicate

that more than 70 percent of U.S. adolescents watch

television daily (105) and that adolescents spend up

to 25 hours per week watching television (145,191).

Hispanic adolescents may watch television for as

many as 30 hours per week (87). Home-based video
Chapter 4—Schools and Discretionary Time . II-91

games and televised music videos are of increasing

interest to American adolescents (42,135). While

some critics regard these leisure time activities as an

“addiction” (189), the effects of such activities

depend upon a wide range of variables such as the

extent of peer and parental involvement and the

substantive content of the videos. Rigorous research

concerning the effects of these activities is virtually

nonexistent.

Schneller conducted a 1988 study of adolescents’

discretionary activity based on diaries logged every

half hour from the close of school until bedtime

(179). This study found a negative correlation

between television viewing and activities such as

participation in social or cultural events, adolescent

movement activities, excursions, and outdoor games.

Selnow and Reynolds’ 1984 study of 184 sixth,

seventh, and eighth graders similarly found a negative correlation between television viewing and

membership in school, church, and musical groups

(182). The authors concluded that extensive television viewing entails ‘‘opportunity costs” that preclude other forms of valuable activity. Adolescents

who view greater amounts of television are less

likely to take advantage of the social learning

opportunities that can be provided by group membership.

The optimum amount of solitary activity is likely

to vary in accord with the unique needs of each

adolescent. For more mature adolescents, increased

time alone generally is associated with better adjustment. Although some adolescents do not regard the

experience of being alone as particularly pleasant,

those who spend at least a moderate amount of time

alone-that is, about 30 percent of their waking

hours-appear to be better adjusted than others

(108). Hence, being alone for reasonable periods of

time may serve a constructive developmental function for adolescents (42,1 15).

In comparison with younger children, adolescents

tend more often to be alone or with peers during the

after-school hours (192). Some studies have shown

that adolescents spend up to 10 hours per week at

video arcades (149) and shopping malls (4).26 As

children are increasingly left to fend for themselves,

parents fear about their children’s safety (62).

Among other things, they express concern about

after-school injuries, excessive television viewing,

being kidnapped, and sexual abuse (98). Concurrently, they worry that their adolescent children may

not be utilizing their discretionary time in a way

which contributes to more effective social, emotional, and behavioral development.

Alternatives for the Constructive Use of

Adolescents’ Discretionary Time

As discussed elsewhere in this Report,27 since at

least the early 1900s, a number of extrafamilial

youth-serving agencies and, to some extent, other

entities (e.g., schools, municipal recreation centers)

have developed to enhance adolescents’ access to

health-enhancing alternatives for occupying their

discretionary time. Just as there has been little

systematic research on how, where, why, and with

whom adolescents spend their discretionary time,

there has been little systematic research into the

nature, quality, and effectiveness of existing alternatives for the constructive use of adolescents’ discretionary time. Nonetheless, as discussed below, many

of these entities have attempted to base their

programs on research on adolescent development

and the prevention of problem behavior. Views on

the basic requirements of programs to promote

healthy adolescent development are discussed below,

as are several typical programs and, when available,

evaluations of their effectiveness. Perhaps because

adolescents’ discretionary time has not been a

central focus of research or policy development,

several issues about the nature of these alternatives

have yet to be resolved. These issues are raised in the

next section of this chapter.

Basic Requirements of Alternatives for the

Constructive Use of Adolescents’

Discretionary Time

According to Kerewsky and Lefstein, a number of

factors are of particular importance in the design of

effective and developmentally appropriate programs

for adolescents (107).28 Such factors include selfexploration and definition, meaningful participation, positive interaction with peers and adults,

~Subst~ce abuse problems among U.S. adolescents are discussed in ch. 12, ‘‘Alcohol, Tobacco, and Drug Abuse: Prevention and Services,’ in this

volume.

ZTS= ch. 2, “What Is Adolescent Health?’ in t.his vOIUme.

Z8CWent ~der~~dings of the developrnen~ ne~s of adol~cents me discussed ti ch. 2, “What Is Adolescent Health?’ in this volume.
II-92 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

physical activity, competence and achievement, and

structure and clear limits. Kerewsky and Lefstein

suggest that effective programs for adolescents

ought to be characterized by the following “nonnegotiable” criteria: they must have a clearly defined

mission; be responsible to the local community; be

safe and clean; and be caring, enjoyable and

supervised. Moreover, they must meet at least once

weekly in the after-school hours, be locally based,

and be available during vacations. Several other

criteria are regarded by Kerewsky and Lefstein as

‘‘negotiable —that is, desirable under ideal circumstances but hardly expected in all instances

(107). Specifically, programs should be accessible

both physically and financially; include parent

participation and provide in-service training for

staff; and have a means of assessing the results. And,

to the extent possible, programs should not overlap

with local organizations and should proceed upon

the basis of interagency collaboration. A variety of

adolescent programs meet many, if not all, of these

criteria.

Lefstein and Lipsitz assert that appropriate and

effective program alternatives for adolescents must

take place in environments that offer realistic

expectations for adolescents, caring relationships

with adults, and diverse opportunities for constructive and enjoyable activities with peers (120).

Costello suggests that adolescents must acquire

four important capacities that are essential for

well-functioning adults: 1) physical vitality, 2) the

ability to sustain caring relationships, 3) resourcefulness, and 4) social connectedness (41). Toward these

ends, adolescent development programs should

enable adolescents to engage in physical and mental

activities which are adequate to accomplishing the

tasks of everyday life. They should promote adolescents’ sense of self-worth and the well-being of

others in the family and the community. They should

promote adolescents’ ability to seek and sift information, apply practical knowledge, and improve

one’s cognitive and social skills. And, they ought to

strengthen adolescents’ sense of affiliation with a

social community, which validates the adolescents’

personal identity, provides support and services, and

requires contributions in turn.

The available literature suggests the efficacy of

basing program design efforts on a developmental

perspective regarding adolescents (66a). Adolescents mature at varying rates. Both developmental

and programmatic needs may differ considerably in

accord with such factors as the participants’ gender,

race, socioeconomic status, and ethnicity (107).

Moreover, the quantity, quality, and operational

features of programs for adolescents can be expected

to vary in accord with the nature of the respective

communities in which they are located. The accessibility and utility of adolescent development programs necessarily are shaped by such factors as the

community’s financial resources, geographic location, and demographic composition.

The available literature reveals many ways for

American adolescents to spend their discretionary

time. These may be either formally organized,

informally organized, or unorganized (66a). Several

types of programs are discussed further below.

Youth-Serving Organizations

Many youth-serving programs are sponsored by

national organizations that are funded primarily by

the independent sector. One tabulation indicates that

more than 300 national youth organizations operate

with chapters of varying size throughout the United

States (61). Two of the largest national organizations

are the Boy Scouts and the 4-H Clubs, each with a

membership of over four million youth in 1986. The

membership in these and seven other major youth

organizations (Girl Scouts of America, Boys and

Girls Clubs, Young Men’s and Young Women’s

Christian Association, Camp Fire, and Salvation

Army) totaled 17 million in 1980, representing over

one-third of all elementary and high-school age

youths (1 13).

Long established agencies dominate the adolescent service field. In 1983, for example, the Boy

Scouts of America had a 1983 membership equal to

15.9 percent of all American males 7 through 16

years of age (19). Between 1972 and 1983, however,

the number of Scouts and Explorers in the organization declined by 22 percent, from 2,405,220 youth to

1,867,982 (19). From 1984 through 1988, by contrast, some youth organizations experienced increases in membership--e.g., the Boys Clubs29 (+2

percent), Girl Scouts (+8 percent), Boy Scouts (+16

% order to more accurately reflect its membership, the Boys Clubs of America recently changes its name to the Boys and Girls Clubs of America.
Chapter 4—Schools and Discretionary Time ● II-93

percent), Girls Clubs30 (+25 percent), and Camp Fire

(+48 percent). Concurrently, however, there was a

decline in the youth membership of the YMCA and

YWCA (60).

In recent years, the Boy Scouts, Girl Scouts, the

Salvation Army, and related organizations have

progressed substantially beyond their original missions. They have established a variety of new

programs including after-school programs for latchkey children, problem-solving programs for minority youths, and programs that help parents to

promote ethical decisionmaking on the part of their

children. Some organizations have devised highly

targeted programs for special populations such as

runaways and neglected or abused adolescents.

Within the private sector, the Boys and Girls

Clubs of America is the major nationwide organization with a primary focus on direct service for

disadvantaged youths. In 1983, the Boys Clubs

served about 1.2 million youth (20). Of these, 61

percent ranged in age from 11 to 18 years, 75 percent

were from families with annual incomes under

$12,000,30 percent from families that receive public

assistance, 51 percent from minority families, and 46

percent from single-parent households (20). Data

from 1988 indicate that the membership of the Boys

and Girls Clubs of America has remained stable with

1.285 million members at 1,100 facilities across the

Nation (21). However, the proportion of 11- to-l 8-yearold members declined from 61 percent in 1983 to 53

percent in 1988.

Boys and Girls Clubs’ programs focus on abroad

range of concerns including citizenship and leadership development, health and fitness, adolescent

employment, delinquency prevention, and the promotion of talent in sports and the arts. The Boys and

Girls Clubs have developed curricula for youth

programs in a number of areas, including health

promotion, delinquency prevention, adolescent employment, citizen and leadership development, alcohol abuse prevention, and education for family life.

The Girls Clubs of America (now Girls Inc.)

experienced an increase in membership from 200,000

in 1984 to 250,000 in 1988 (81). It also experienced

in increase during the same period in the proportion

of black, Hispanic, and Asian members (from 44

percent to 50 percent). However, only 29 percent of

Girls Club members range in age from 12 to 18 years

(81). Among the Girls Clubs’ innovative programs

are AIDS education, a pregnancy prevention programs, Friendly Persuasion (a program for substance abuse prevention), and Operation SMART

(science, math, and relevant technology).

As Wynn and colleagues have noted, adolescents

can participate in a wide range of programs offered

by independent sector organizations. There are

career groups such as Junior Achievement; characterbuilding organizations such as the Boy Scouts;

political groups like Young Democrats and Young

Republicans; veterans’ organizations such as the

Sons of the Veterans of Foreign Wars; hobby groups

such as Junior Philatelists of America; and, ethnic

groups like the Ukranian Youth Organization and

Indian Youth of America (205). In the absence of

adequate surveys, however, few systematic data are

available regarding the total number of adolescents

who participate in privately supported youth organizations. It is especially difficult to ascertain the

membership of such private organizations as high

school fraternities, sororities, and local social clubs.

A number of studies have reported beneficial

effects as a result of program participation in

national youth-serving organizations. In 1987, Ladewig and Thomas found, for instance, that former

4-H members attained higher levels of education

than nonparticipants and, as adults, were more likely

to be involved in civic activities and political

organizations (114). Likewise, a large-scale survey

of high school seniors by Hanks found that adolescents’ participation in voluntary organizations was

related to subsequent voting behavior and involvement in political campaigns (92).

Community Service Programs

Approximately 4,000 adolescent community service programs are in existence in the United States

(18 1). The programs include more than 50 full-time

youth service corps, 550 campus-based service

programs, 3,000 school-based service programs, at

least 50 service corps and programs that are organized by local communities, and Federal service

programs overseen by ACTION.

Cities are particularly active sponsors of youth

service programs. Thus, for instance, the City

~(j~ls clubs of America is now known as Ghk hlc.
II-94 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Volunteer Corps of New York City (CVC), with an

annual $8 million budget, has pioneered volunteer

efforts in human service delivery. It has established

a program for high school adolescents who work

full-time in the summer and part-time during the

school year. In 1988, CVC instituted a small

program for students already in college, offering

summer stipends and bonuses for one and two

semesters of part-time Corps work. About 600 CVC

volunteers work on projects in city parks, building

rehabilitation, centers for retarded adults, nursing

homes, and schools. Every 3 months, the participants change projects so that they can have a variety

of environmental and human service work experiences during a l-year period. CVC also offers

completion incentives: $2500 for those who complete 1 year of service, or $5000 toward college for

those who choose to resume their studies (210).

Adolescents who participate in community service programs can obtain a variety of benefits. A

survey of a random sample of participants in projects

sponsored by young volunteers overseen by the

Federal program ACTION found that the young

participants intended to continue volunteer service

both in school and as adults and, also, that they

would encourage others to volunteer (2). Moreover,

adolescent participants have reported gains in understanding community service, ability to work with

others, development of career objectives, willingness to learn, and reduced need for supervision.

Calabrese and Schumer’s study of ninth grade

participants in a 20-week school community service

program showed reduced levels of alienation, isolation, and discipline problems (26). Likewise, in a

study of 11- to-17-year-old volunteers in community improvement projects, Hamilton and Fenzel

found that participants developed positive attitudes

toward social responsibility for needy people and a

commitment toward continued volunteer work (90).

Participants also developed vocational and interpersonal skills and gained greater knowledge of themselves and others.

School-Based Programs

Schools typically are accessible and often-used

sites for adolescent development and adolescent

service activities. Peer counseling and peer tutoring

programs are among the most successful and visible

programs that have been offered in schools. Such

programs often are reported to yield a wide range of

benefits both for the tutees and the tutors (48,80,

111,1 16). Reported benefits include gains in tests of

ego and moral development (32). Adolescents in

such programs have been employed as counselors

(49), trainers (126), therapists for the remediation of

behavior disorders (33), and peer mediators. In one

New York City school, administrators reported that

a peer mediation program cut the suspension rate in

half (52).

Many school-based programs address adolescent

problems primarily on a reactive basis, but some

school systems also have initiated a wide range of

community service programs that are essentially

proactive and preventive in nature. Following extensive deliberations, the Carnegie Council on Adolescent Development recommended that adolescent

community service be part of the core program in

middle school education (27). The Carnegie Council

on Adolescent Development observed that students

can volunteer to work in such diverse settings as

senior citizen centers, nursing homes, soup kitchens,

child care centers, parks, and environmental centers.

Assistance for such programs can be provided by

institutions of higher education. The Early Adolescent Helper Program of the City University of New

York, for example, has involved hundreds of students from 17 New York City middle and junior high

schools in educational enrichment and adolescent

service activities (27).

Significant benefits for adolescents have been

identified by many studies of school-based programs. Thus, Conrad and Hedin’s study of 4,000

students in experiential educational programs reported that the students showed improvements in

self-esteem, moral reasoning, personal and social

development, attitudes toward adults, and involvement in the community (36). Similarly, Hanks and

Eckland’s study of 1,627 high school sophomores

found that participation in school-based extracurricular activities is associated with later educational

attainment and with participation in adult voluntary

organizations (93). Related studies have shown

participation in extracurricular activities to be associated with higher educational goals (190), subsequent educational attainment (159), occupational

attainment and income (160), and participation in

voluntary organizations and the political process

(161). The studies do not allow any firm conclusions

about causality.
Chapter 4—Schools and Discretionary Time . II-95

Photo credit: Ron Larson/Youth Service America

Some studies suggest that participation in extracurricular

activities can keep adolescents in school and

enhance their academic progress.

Municipal Recreation Centers

Numerous adolescent development programs have

been established at municipal recreation centers

throughout the Nation.

As noted by Lefstein and Lipstiz, for example, the

Arlington County (Virginia) Recreation Division

operates neighborhood centers that offer planned

activities and drop-in programs for adolescents

(120). A Junior Jamboree program is conducted on

alternate Saturdays which offers arts and crafts,

sports, cooking, field trips, and health information

for 12- to 15-year-olds (120).

Similarly, the Concord (California) Recreation

and Human Services Division has created a Department of Leisure Services which operates a city-wide

recreation program at elementary schools, intermediate schools, high schools, and local community

centers (120). The Department of Leisure Services

has established a variety of adolescent Services

Target Programs for low-income neighborhoods

where parents cannot afford to pay for special

out-of-school activities for their children. Besides

offering an extensive array of games, sports, and

special interest classes, the program seeks to help the

participants to build social skills and to experience

a world other than their own impoverished neighborhoods by means of parties, excursions out of the

neighborhood, and other events. After 1 year of

programming that included recreation, counseling,

and employment, juvenile crime decreased in three

target neighborhoods by 31 percent, 63 percent, and

69 percent, respectively (120).

A unique collaborative program with the private

sector has been established by the East Oakland

(California) Youth Development Center (120). The

center sponsors a comprehensive program that offers

job skills development, basic skills tutoring, counseling, and recreation. Over 1,000 adolescents ranging in age from 10 to 21 years are registered as

members (120). While the City of Oakland invested

$350,000 in community development funds toward

initiation of the program, the Youth Development

Center was launched largely by means of an

aggressive fundraising campaign conducted by the

Community Affairs Department of the Clorox Company. The Clorox Company contributed $247,000

toward construction of the center, pledged $50,000

annually for program operation, and initiated an

endowment campaign aimed at matching the company’s own gift of $1.5 million. Since the Center

opened, 25 foundations and more than 70 corporations have contributed finds for its operation (120).

Churches and Synagogues

There is a great need for ample and diverse

family-based activities that are attractive to adolescents. Churches and synagogues are among the

foremost institutions that can offer such activities on

a regular basis.

Some of the most extensive family-oriented

programs have been devised by the Church of Jesus

Christ of Latter Day Saints (Mormons) (197). The

Mormon church promotes “wholesome recreation”

as a part of its religious creed by setting aside 1

weekday evening as a “Family Activity Night”

(197). Families are free to choose the activity that

they desire but are encouraged to engage in varied

and challenging activities that appeal to all age

groups. The church makes available a comprehensive Family Resource Manual which identifies

family enrichment activities (e.g., first aid, food

storage, and home repairs) as well as physical,

cultural, social and intellectual activities. Each

church parish has a small activities committeetha t

helps families to develop their own activities.

Information about exemplary programs is disseminated to other such committees on a yearly basis.

Churches and synagogues also have sponsored a

wide range of community service programs (120)

and family camps for parents and their children.
II-96 ● Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Some of these have introduced programming g that

teaches or reinforces selected family and societal

values (96), while others have concentrated on

sports, skills development, or cultural and educational learning such as was introduced by the

Chautauqua movement (58).

Other Alternatives

Various innovative alternatives for the constructive use of adolescents’ discretionary time have been

developed by a wide range of agencies at the

national, regional, and local levels.

One innovative alternative is a family recreation

program, known as “Together Is Better,” that has

been introduced nationally by the Canadian Parks

and Recreation Association (95). This program

emphasizes a high degree of interaction among

family members. Examples include family picnics,

group hikes, and family games. Information kits

about activities such as kite-making, backyard

camping, hiking, and tracing family trees are distributed nationally. A major marketing campaign gives

the overall program a central focus and creates high

visibility.

The U.S. Air Force’s Community Action Program

sponsored a Youth Services Camping Program for

boys in the State of Michigan, that brought together

590 14- to 17-year-old low achievers, predelinquents, expelled or suspended students, and wards of

the court (201). The Youth Services Camping

Program emphasized vocational opportunities,

health care, recreation, fellowship and leadership.

The behaviors and self-concepts of all categories of

the boys participating improved substantially (201).

A suburban community center achieved similar

results by integrating small numbers of antisocial

adolescents into activity groups with prosocial

adolescents (67). Innovative adolescent development programming can occur at community centers

and neighborhood agencies sponsored by religious

organizations, fraternal associations and other

groups. Revitalized efforts at these sites and others

can capitalize upon major adolescent development

resources that have been underutilized in recent

decades.

Public libraries are important, but often overlooked, sites for adolescent development programs.

Some libraries offer creative opportunities for adolescents to provide support across generations including service as storytellers for young children

and as ‘‘computer tutors’ for children and adults

(172). They also offer programs for consolidating

academic and reading skills, learning practical life

skills such as budget planning and hunting safety,

and exploring social or emotional issues that are

relevant to adolescence (215).

Finally, paid jobs constitute an important resource

for the constructive use of adolescents’ discretionary

time (3). As are other alternatives, paid jobs are

likely to be most beneficial when they engage

adolescents in meaningful tasks, bring them into

regular contact with adults and responsible peers,

and provide fair and adequate remuneration for the

services that are provided (183). Special care must

be taken to ensure that adolescents do not devote

excessive amounts of time to paid jobs and thereby

forgo opportunities to keep up with their schoolwork

or to take part in other growth-enhancing activities

with their peers and family (193).

Major Issues in the Elaboration of HealthEnhancing Alternatives for the Use of

Adolescents’ Discretionary Time

A number of major issues must be addressed if

significant improvements are to be made in the

quantity, quality, and diversity of health-enhancing

alternatives for America’s adolescents. These pertain both to key barriers that impede the development of innovative programs and to a variety of

unanswered questions that must be resolved, at least

in part, if significant advances are to be made.

Counterproductive Theories of

Adolescent Development

Adolescent services, and the misperceptions upon

which they often are based, have evolved largely

from theories of adolescent deviance (199). These

formulations view adolescents, particularly those

from low-income households, as essentially deviant

or potentially deviant. From this standpoint, adults

must guide adolescents along a fairly narrow path

toward adulthood and they must correct and constrain those who stray. Given the prevalence of this

perspective, programs are most likely to be funded

when they can claim the capacity to combat a

particular deviancy such as drug use, vandalism, or

delinquency. Proactive and preventive programs are

less likely to attract the financial support that they

deserve.
Chapter 4—Schools and Discretionary Time . II-97

Correspondingly, agencies that serve adolescents

sometimes tend to overreact to incidents of adolescent deviance that are depicted by the mass media.

This can lead them to emphasize programs that are

essentially reactive rather than proactive. It also

reinforces the stereotype of ‘‘adolescents as deviants’ on the part of the public, policymakers, and the

adolescent service community. The result is a highly

fragmented service delivery system, increased barriers to the elaboration of holistic service delivery

programs, and heightened activity by entrepreneurial

agencies that may design their programs more to

reflect the availability of public funds than the

serious needs of the community.

Categorical Funding Sources

The specialized funding that has been promoted

by single-purpose advocacy groups, legislative committee systems, and narrowly targeted adolescent

service bureaucracies make the delivery of comprehensive adolescent services all but impossible. The

ability of both public and private agencies to plan

coherent adolescent services is often undermined by

the rigidity of Federal, State, and local categorical

funding requirements and by the tendency to formulate narrowly targeted contracts in response to

specific problems that come to the public’s awareness (135). Legislative committee systems used to

formulate public policies and programs often tend to

conceptualize adolescents categorically as drugusers, runaways, adolescents in need of job training,

or in terms of similarly constraining definitions that

overlook the fact that a single adolescent may have

multiple needs. 31 In the real world, the same

adolescent is often a dropout, a drug abuser, a mother

or a father, in need of mental health care, and

unemployable in the local labor market-a fact that

politicians, grantmakers, service providers, and even

families sometimes fail to recognize (51,199).

Categorical conceptualizations have led to the

haphazard growth of specialized direct service

agencies and provided little opportunity or incentive

for programs to cooperate, coordinate, or engage in

systematic long-term planning of comprehensive

adolescent programs.

Another problem is that public and private funds

for adolescent programs tend to be awarded on a

short-term basis. But, when funds are doled out for

only 1, 2, or 3 years at a time, it is virtually

impossible to plan coherent long-term programs and

to develop initiatives that seek to sustain or expand

hard-won gains. It also is difficult to retain talented

staff who may have more secure jobs waiting

elsewhere. Inordinate staff attention must be directed constantly toward the acquisition of financial

resources. A patchwork quilt aggregation of poorly

interrelated and inadequately integrated programs

may emerge from a myriad of funding sources.

Moreover, counterproductive competition can occur

on the part of agencies who might otherwise benefit

from a collaborative and collegial relationship. Time

spent in school and time spent in discretionary

(nonschool, nonmaintenance) activities constitute

large segments of an adolescent’s life. Outside the

family and home,32 school buildings and personnel,

and peers and adults in community settings (including the media) constitute important and influential

environments for adolescents. This chapter reviewed shortcomings in many of these settings and

ways in which these environments can be improved.

Public Support v. Private Support

A fundamental issue in the provision of adolescent development programs pertains to the optimum

mix between public support and private support.

Private auspices may be highly effective for the

creation and sustenance of such programs. Yet there

are communities that do not have the resources—

whether in funds or in leadership--to support the

development of an infrastructure which is sufficient

to create and maintain an array of programs.

Key questions regarding this issue have been

articulated by Wynn and colleagues (215). If the

provision of community supports for adolescent

development programs ought to be through voluntary efforts, where can resources be found to sustain

them at an adequate level? Should a quasi-public

corporation or organization be created to assist in

stimulating and sustaining community support? Or,

should government play a more active role in the

provision of community supports? Might we actually need to create a social care and community

31~e problem ~fmultiple ~omitt= juri~dlction~ ~ con~ess ad tie fi~en~tionof Fede~ progr~s for adolescents is discussed in ch. 19,

Role of Federal Agencies in Adolescent Heal@” in Vol. III.

Jzpments ad fmi1i6~ ~uences on adolescent healti are reviewed in ch. 3, ‘‘Parents and Families’ Influence on Adolescent He~th, ’ ~d elsewhem

in this volume.
II-98 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

support system like our educational system or health

care system to foster the development of adolescent

programs? How can government effectively support

the informal, voluntary, and associational nature of

many existing and potential forms of community

support? And, would government bring with it rigid

formulas or bureaucratic approaches that are antithetical to the existence of community supports?

An overview of Federal expenditures for children

and adolescents indicates that only a scant portion of

governmental resources is devoted to nonschool

developmental programs.33 In 1980, for instance, the

greatest percentages of Federal outlays for children

and adolescents were for income maintenance programs (35.5 percent), nutrition (19.4 percent), education (16.5 percent), health (8.4 percent), employment (6.4 percent), housing (5.3 percent), and

community development (5.2 percent). A relatively

small percentage was allocated for child care (2.4

percent), juvenile justice (0.6 percent), or recreation

(0.3 percent). Moreover, U.S. Government expenditures for recreation declined steadily, from 0.5

percent of the domestic Federal budget in 1964 to

only 0.3 percent in 1980 (34). In Britain, by contrast,

youth work receives approximately 1.5 percent of

the national budget (215). The scant attention

directed toward recreation and leisure programs for

U.S. adolescents is reflected at the State level as well

as the Federal level. Of 56 States, territories, and the

District of Columbia participating in the 1982 White

House Conference on Children and Youth, only 6

treated recreation and leisure as a major concern in

their statewide conferences (205).

New York City sponsors a Youth Bureau that is

responsible for planning, implementing, and monitoring development and delinquency prevention

programs for adolescents. The Youth Bureau contracts with community-based organizations to provide services for youth. The community-based

programs with which the Youth Bureau contracts

typically provide recreational, educational, counseling, cultural enrichment, and vocational services.

There were 582 such contract agencies in fiscal year

1989 with a budget of $30.7 million (134). Altogether, the agency’s budget averages less than $16

per adolescent in New York City.

Common Infrastructure v. Adolescents

as a Special Case

A strong case can be made for the provision of

special finding and program initiatives designed

expressly for adolescents. Indeed, a sound investment in adolescent development programs can be

expected to yield highly beneficial long-term outcomes for society as a whole. Adolescents who are

properly challenged, motivated, and trained are

likely to develop into mature and responsible

parents, breadwinners, and citizens.

Nevertheless, alternative strategies for funding

and program development also can be considered. It

has been suggested, for instance, that programs can

be devised which are based upon the common needs

of varying at-risk populations. By this formulation,

the provision of community supports can be thought

of not as categorical responses to a separate and

independent adolescent population but as ways in

which communities can assist a broad range of

individuals with common interests and needs (215).

Thus, efforts to convey information about health and

educational resources, provide transportation services for isolated or dependent individuals, or implement mutual assistance programs can be organized

across age groups rather than by means of a single

age category. Systematic study of the relative

advantages and disadvantages of these approaches

and others would be useful.

Adolescent Development, Recreation,

or Employment?

In an era of limited resources, it is essential to

ascertain what proportions of available funds can be

allocated optimally to initiatives that aim, respectively, at adolescent development, recreation, employment, or other goals. The guidelines for this task

will be determined largely by the particular subpopulations of adolescents under consideration. Thus,

adolescents from economically impoverished families or neighborhoods may benefit relatively more

than other adolescents from programs that offer job

skills training or employment opportunities. Nevertheless, the goals of adolescent development, recreation, and employment need not be mutually exclusive. Many types of programs can progress toward

all three objectives albeit in varying respects and at

differing rates.

33M Ovewiew of F~e~ expenditures on adolescents is preSentd in cb. 19, ‘‘The Role of Federal Agencies in Adolescent Heal@” in Vol. III.
Chapter 4—Schools and Discretionary Time . //-99

Extent of Adult Involvement and Supervision

Adult involvement may be necessary in the design

or supervision of especially complex or demanding

programs and for programs that are geared primarily

toward younger adolescents. To the extent possible,

though, adolescents themselves should be actively

engaged in the design and operation of their own

programs. In some cases when adults are involved,

professional training may be desirable. Such training

may be particularly important for the design and

implementation of programs that require extensive

expertise in administration or for programs that

serve large numbers of seriously disturbed adolescents. Graduate training in adolescent work and the

related helping professions has proven beneficial in

programs for such high-risk populations as antisocial adolescents (67) and adolescents whose parents

are mentally ill (68). Clearly, however, adult volunteers can contribute safely and cost-effectively to the

vast majority of programs that aim to promote

health-enhancing activities on the part of adolescents. A more concerted effort to involve adult

volunteers may be needed. Because some of the

adolescents and institutions’ volunteers may be

dealing with may present serious obstacles, it will be

important to provide appropriate support and referral

networks to adult volunteers.

Differing Needs for Differing

Adolescent Populations

Fairly little is known about the differing developmental needs of particular groups of adolescents.

Patterns may or may not be similar in varying

subcultures. Increased peer-group orientation and a

growing interest in group activities during early and

middle adolescence has been observed concurrently,

for instance, in England (187), Australia (78), and

the United States (67). Yet, a crosscultural study of

school dropouts has shown that Australian and

American adolescents who quit secondary school

use their leisure time in different ways (15). Australian school leavers typically spend their extra time in

sports and recreation. By contrast, American dropouts report more visiting, loafing, and problem

behaviors. The investigators posit that these differences reflect the differential structuring of available

activities for adolescents in the two societies rather

than national differences in leisure preferences.

They suggest further that some of the deleterious

consequences that are presumed to follow from

dropping out in America reflect the daily social

experiences of dropouts in this country more than

the act of quitting school.

Cultural and subcultural variations often are

evident in the use of discretionary time by adolescents. Hispanic adolescents, for instance, devote

more time than white non-Hispanic adolescents to

television viewing (87). White adolescents are more

likely to have paid jobs than black adolescents (66a).

Yet these variations also may reflect such factors as

the decreased availability of two-parent families for

certain categories of adolescents, more dual-career

couples, reduced employment opportunities, and

diminished community availability of leisure alternatives such as public libraries, after-school programs, and for-profit or nonprofit youth service

agencies. A study of Chicago neighborhoods has

shown, for instance, that in areas where the median

family income is below $25,000, the average number of children per each available public library is

twice the number of children in areas with higher

family income (196). More than twice as much

money was spent per child on libraries in the more

affluent neighborhoods.

Adolescent programs can profitably bring together adolescents from differing social, cultural and

behavioral backgrounds. The most dramatic examples in this regard pertain to programs that integrate

adolescents with behavioral problems into groups of

‘‘normal” peers in classroom or recreational settings (23,39,47,88,170,217). Peer-based ‘‘therapy”

programs for adolescents typically have been regarded as failures when interventions were attempted solely in groups comprised of antisocial

peers and at institutions denoted primarily as correctional or mental health settings (13,109,131,214).

The latter tend to be unnecessarily stigmatizing. In

contrast, experimental evidence suggests that antisocial adolescents are more likely to achieve behavioral gains when they are treated among prosocial

peers and when the interventions are offered in

nonstigmatizing environments such as community

centers (67).

Adolescents’ needs may also be different at

different times of the day. OTA observes that more

programs and facilities are available during the day,

but not at night or on weekends when adolescents

may have little to do. Some communities have setup

Friday night dances, midnight basketball sessions,

and the like, but these seem to be the exception rather

than the rule. Often, administrative convenience
II-100 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

rather than adolescent need seems to be the determining factor in program development.

National Youth Service

Since the days of the post-Depression Civilian

Conservation Corps (CCC), there has been debate in

this country concerning the desirability of a national

youth service. The factors that are regarded as

important to the success of the CCC ought perhaps

to be considered as criteria for the evaluation of

future proposals concerning a national youth service

(57). First, the CCC was operated with a clear sense

of purpose, namely, conservation work and economic support, as opposed to purely adolescent

development objectives. Second, the CCC emphasized productivity. Third, many CCC projects were

highly visible to surrounding communities and to the

country at large. Fourth, local communities had a

voice in projects undertaken by the CCC. And, fifth,

each CCC camp made distinct contributions to the

local economy.

New models of national youth service have been

endorsed by groups such as The Commission on

Work, Family and Citizenship of The William T.

Grant Foundation (210), advocacy organizations

such as the Coalition for National Service (56), and

the public in general, who favor voluntary service by

a ratio of better than seven to one (56).

Because of the size, visibility and vast impact of

any form of national youth service, public acceptance of such an initiative will depend upon the

answers to a variety of questions. These are likely to

be based not only on economic considerations but on

philosophical and political ones as well. To cite but

a few: Should a national service program be

mandatory or voluntary? Should it be in lieu of

military service or in addition to it? Should it be

during high school or afterwards? Should it offer

economic incentives to the participants or not? What

is the preferred length of service? Will participants

necessarily replace employed adult workers? What

should be the respective roles of federal and local

authorities? And, what are the relative economic

costs and benefits?

Few of these questions can be answered definitively. Yet, several key considerations are worth

noting. With regard to financial costs and benefits,

for example, a study of the California Conservation

Corps by Public/Private Ventures estimates $1.34 in

benefits for each dollar spent in the program (210).

A second study suggests that the proportionate

benefit is even higher, to wit, $1.60 in public benefit

for each dollar spent by the Corps (210). The Job

Corps has been similarly evaluated. Analyses have

shown that the Job Corps increases earnings, enables

its graduates to be employed longer, and helps many

to goon to full-time study (210).

From 1934 through 1939,90,000 acres of land in

the Capitol Forest in Washington State was reforested by the CCC at an approximate cost $270,000

(101). In 1981, the acreage was harvested, and the

timber value was placed conservatively at $7,000

per acre, or $630,000,000. Examples such as this

dramatize not only the fact that significant financial

benefits can accrue from large-scale youth service

programs but also that planners and politicians must

calculate their relative benefits on along-term basis.

They must act upon the same principles of ‘delayed

gratification’ that are regarded as so essential to the

development of healthy adolescents.

Revitalization and Reinstitution of Social Service

Agency Programs

In the past several decades, much of the Nation’s

organizational infrastructure for adolescent development programs has deteriorated. Traditional social

service agencies such as neighborhood houses and

community centers have increasingly relocated to

affluent suburban areas; they have employed nonprofessional and volunteer personnel more readily

than professionals; and they reduced the quantity

and quality of their programs for adolescents (200).

Nevertheless, neighborhood houses, community centers, and other social service agencies can constitute

excellent settings for leisure and community service

programs for adolescents of all ages. Many observers believe they may be more productive sites for

helping high-risk adolescents than conventional

types of treatment organizations (68). The developmental gains that are achieved by adolescents in

such settings can be readily generalized to their

natural environments and can be achieved on the

basis of expenditures that may be as much as 80

percent lower than for comparable intervention

programs in mental health or juvenile justice settings

(67).

A significant revitalization of social service

agencies would require a major infusion of Federal,

State, and local support. Among other things, funds

will be necessary to train professionals and volunteers and perhaps construct or renovate facilities in
Chapter 4—Schools and Discretionary Time ● II-101

Photo credit: Youth Service America

Revitalized social service agencies could work to develop

volunteer opportunities that strengthen intergenerational

connections among adolescents and adults from different

social and economic backgrounds.

high-need areas. Revitalized social service agencies

could explore new ways to involve adolescents in

instrumental tasks as well as in purely recreational

activities. They could sponsor nonprofit or for-profit

adolescent-operated enterprises and can provide

seed money, technical assistance and supervision.

They can work with schools to develop leisure

counseling centers and can develop volunteer opportunities that strengthen intergenerational connections among adolescents and adults from different

social and economic backgrounds. They also could

establish funded positions for adolescents to serve as

apprentice-level adolescent workers.

Recent Federal Initiative: National and Community

Service Act of 1990

In 1990, Congress passed a law designed to

enhance opportunities for national and community

service for all U.S. citizens, particularly the disadvantaged. This law, the National and Community

Service Act of 1990 (Public Law 101-610), authorizes Federal financial assistance for a number of

voluntary service programs, including programs for

in-school and out-of-school adolescents. In presenting the rationale for the legislation, the senatorial

authors of the legislation argued in part that (S. 1430,

101st

(1)

(2)

(3)

(4)

(5)

(6)

Congress, 2d session):

service to the community and the Nation is a

responsibility of all citizens of the United

States, regardless of the economic level or age

of such citizens;

citizens of the United States who become

engaged in service at a young age will better

understand the responsibilities of citizenship

and continue to serve the community into

adulthood;

serving others builds self-esteem and teaches

teamwork, decisionmaking, and problemSolving;

the 70,000,000 youth of the United States

who are between the ages of 5 and 25 offer a

powerful and largely untapped resource for

community service;

conservation corps and human service corps

provide important benefits to participants and

to the community;

the Volunteers in Service to America Program is one of the most cost effective means

of fighting poverty in the United States. . .

Many of the activities and program requirements

authorized by the National and Community Service

Act of 1990 (Public Law 101-610) are particularly

relevant to adolescents.

Title I of the National and Community Service

Act of 1990 establishes a National and Community

Service State Grant Program. Several subtitles of

Title I are relevant to adolescents:

--Subtitle B. School-Aged Service (Seine America; The Community Service, Schools and

Service Learning Act of 1990).34 This subtitle

provides Serve America grants to States or

local applicants for service-learning programs

~’<To ~ ehgible to remive a grant [under Title I, Subtitle B], a S@te. . shall prepare and submi~ to the Commission [on National and Community

Service, established under section 190 of the act], an application. . including a description of the manner in which. . economically and educationally

disadvantaged youths, including individuals with disabilities, youth with limited basic sldlls or learning disabilities, and youth who are in foster care,

are assured of service opportunities” (S. 1430, Title I, Subtitle B, Sec. 113).
11-102. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

for students,35 community service programs,

and adult volunteer programs. For the latter two

programs, dropouts and other out-of-school

youth (individuals under age 27 who have not

completed college or the equivalent and who

are not in school) are target participants and

recipients. Serve America grants will be administered by the Commission on National and

Community Service established under Subtitle

G (202b).

-Subtitle C. American Conservation and Youth

Corps (American Conservation and Youth

Service Corps Act of 1990)-This authorizes

grants to States, Indian tribes, local agencies, to

the Secretary of Agriculture, to the Secretary of

the Interior, or to the Director of ACTION for

the creation or expansion of full-time or summer youth service programs focusing on conservation and human services. Full-time youth

service programs are intended for 16- to 25-yearolds, and the summer youth service programs

are intended for 15- to 21-year-olds. The law

requires that participants’ educational levels be

assessed and that participants be provided with

appropriate education and training. Priority for

services must be given to participants without

high school diplomas, and the program must

enable such participants to earn a diploma or its

equivalent. Arrangements may be made with

schools to upgrade literacy skills, obtain high

school diplomas or the equivalent, obtain

college degrees, or improve work skills. Youth

corps grants will be administered by the Commission on National and Community Service

(202b).

-Subtitle D. National and Community Service

(National and Community Service Act )-This

authorizes grants to States and Indian tribes for

the creation of full- and part-time national and

community service programs to address unmet

educational, human, environmental, and public

safety needs, especially those needs relating to

poverty. The programs will include full- and

part-time volunteers age 17 and older. National

and Community Service grants will be administered by the Commission on National and

Community Service (202b).

-Subtitle E. Innovative and Demonstration Programs and Projects-One part of this provides

for grants to States and Indian tribes for the

creation of innovative volunteer service programs. Section 165 authorizes a rural youth

service demonstration project. Projects may

include volunteer service involving the elderly

and assisted-living services performed by students, school dropouts, and out-of-school youth.

-Subtitle G. National Commission on National

and Community Service-This establishes the

National Commission on National and Community Service to administer Title I programs.

The Commission is to be composed of 21

members to be appointed by the President. The

Secretary of Education, Secretary of Health and

Human Services, Secretary of Labor, Secretary

of Interior, Secretary of Agriculture, and the

Director of ACTION shall serve as ex-officio

members of the Commission. Not later than

January 1, 1993, the President shall prepare and

submit to Congress a report containing recommendations for the improvement of the administration and coordination of volunteer, national, and community service programs administered by ACTION, the Commission on

National Service, and other Federal entities.

Congress authorized $56 million for Title I in fiscal

year 1991, $95.5 million in fiscal year 1992, and

$105 million for fiscal year 1993. In each of these

years, not less than 30 percent is to be allocated for

subtitle B, not less than 30 percent for subtitle C, and

not less than 30 percent for subtitle D. In each year,

Congress authorized $2 million for the National

Commission on National and Community Service.

Title II of the National and Community Service

Act of 1990 modifies a number of existing programs.

The following subtitles are relevant to adolescents:

-Subtitle B. Youthbuild Projects (amends the

Domestic Volunteer Service Act of 1973 (42

USC 4951 et seq)--This provides for the

Director of ACTION, in consultation with the

Secretary of Labor, to provide Federal grants

for Youthbuild projects. Such projects, which

involve constructing and rehabilitating housing

ss~e law defines service 1 earning as a method under which students learn and develop through active participation in organized service experiences

that meet actual community needs and that are coordinated in collaboration with the school and community; that is integrated into the students’ academic

curriculum; that provides students with opportunities to use newly acquired skills and knowledge in real life situations in their own communities; and

that enhances what is taught in school by extending student learnin g beyond the classroom into the community and helps to foster the development of

a sense of caring for others (Title I, Subtitle A, Sec. 101. Defdtions).
Chapter 4—Schools and Discretionary Time . II-103

and community facilities (e.g., youth recreation

centers, senior citizen centers, community

health centers) for low-income people, are

intended to provide economically disadvantaged young people with opportunities for

service to their communities and opportunities

to obtain education and employment skills. At

least 75 percent of the participants must be

individuals who are ages 16 to 24, economically disadvantaged, and high school dropouts

whose reading and math skills are at or below

the eighth grade level. Projects must provide

basic skills instruction and remedial education,

bilingual education for participants with limited English proficiency, and secondary education leading to a high school diploma or its

equivalent.

-Subtitle C. Amendments to Student Literacy

Corps (amends the Higher Education Act of

1965 (20 USC 1018)--This amends the act to

give priority in providing tutoring services to

educationally disadvantaged students receiving

services under Chapter 1 of Title I of the

Elementary and Secondary Education Act of

1965 and to, illiterate parents of educationally

or economically disadvantaged elementary

school students, with special emphasis on

single-parent households.

For Title II, Congress authorized $5 million for

fiscal year 1991, $7.5 for fiscal year 1992, and $10

million for fiscal year 1993.

While the total amounts authorized for programs

with a considerable emphasis on adolescents are not

very large, the National and Community Service Act

of 1990 does begin to address many of the concerns

about adolescent rolelessness and preparation for the

future expressed by numerous observers (160,330).

It is too early to judge the effectiveness of the

legislation in improving the lives of adolescents, but

Congress could encourage the newly established

Commission on National and Community Service

(also established by Public Law 101-610), to evaluate systematically the impact on adolescents in the

Commission’s report to Congress.

Conclusions and Policy Implications

Time spent in school and time spent in discretionary (nonschool, nonmaintenance) activities constitute large segments of an adolescent’s life. Outside

the family and home,36 important and influential

environments for adolescents include school buildings and personnel, and peers and adults in community settings (including the media). This chapter has

reviewed several shortcomings in many school and

other environments and suggested ways in which

these environments can be improved.

Although little systematic empirical research has

been supported, the studies that have been conducted

suggest that academic and health outcomes of

adolescent students are influenced by school environments. Overall, school environments that facilitate adolescent well-being take the shape of small

(fewer than 1,000 students in the school, and 15 to

20 per class), comfortable, safe, intellectually engaging, and emotionally intimate communities.

Transitions are minimized, and when they must

occur, they are managed with a view toward meeting

the developmentally appropriate needs of adolescents. Teachers are encouraged to initiate and

develop new programs that are sensitive to the

diversity of their students. The curriculum responds

to individuality as well as to differences, while

developing a common knowledge base among

students in a particular school. Teacher, parent, and

student participation in decisionmaking is encouraged. Unfortunately, this combination of features

characterizes few schools, particularly those public

schools serving socioeconomically and educationally disadvantaged students, many of whom are

racial and ethnic minorities. Instead, the larger, often

impersonal, schools that these students attend have

been found to be associated with higher rates of

retention in grade, suspensions from school, discipline and crime problems, lowered social cohesion,

more negative student attitudes, and greater student

passivity (including lower participation in school

activities, and less interaction with faculty).

Specific practices such as tracking and “teaching

to the test’ for minimum competency testing have

been associated with lowered levels of academic

achievement, retention in grade, and school dropout,

especially for low income racial and ethnic minority

36pacnts ~d f~liea$ ~uenceS on adolescent he~~ me reviewed inch. 3, ‘‘Paren@ and F~hes’ ~uen~ on Adolescent Health, ’ and elsewhere

in this volume.
//-104 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

students. Although school practices and policies are

rarely investigated for their direct links to adolescent

health and well-being, studies have shown that lower

grades are associated with violence toward school

property, other delinquency, and pregnancy. Students who are retained in grade school are more

likely to drop out of school before graduation. In

turn, school dropout is associated with high rates of

subsequent poverty and unemployment, underemployment, diminished earnings, and adolescent pregnancy and parenting.

Adolescents, particularly females, can be particularly harmed by the transition from elementary to

middle or junior high school grades, if such transitions are not handled well in the middle school

setting. The environment of the typical junior or

middle school adolescent has been found to clash

with early adolescents’ needs for autonomy, their

budding cognitive abilities to think at an abstract

level, their heightened needs for intimacy, and their

heightened self-consciousness.

Teachers’ attitudes and parental involvement are

critical links in the relationships between school

policies and environments and health outcomes for

adolescents. Teachers’ attitudes toward students

tend to be more positive in schools that are smaller,

use decentralized governance and participatory decisionmaking, and rely less on standardized testing.

Parental involvement in schools has been shown to

be related to increasing the responsivity and efficiency of schools and to fair treatment of students,

but the evidence on academic achievement is mixed.

Some interventions have yielded increased tolerance across racial groups and improvements in the

self-esteem or academic achievement of racial and

ethnic minorities; these interventions include exposure to persons of differing cultural backgrounds,

learning in mixed-ability groupings, a multicultural

curriculum, bilingual education, and school-based

collaborations with minority communities.

Much of adolescents’ time is spent away from

school. The scarce data that are available suggest

that sufficient opportunities do not exist for adolescents to spend their discretionary time in ways that

are attractive and satisfying, conducive to healthy

development, and acceptable to the adult community. The problem has been found to be worse in poor

than in middle-class communities.

The Federal share in funding for schools (6.3

percent of public school revenues in 1988) rose until

1980, when it began to fall again. Financial and

programmatic support for recreation and youth

service activities from Federal, State, and local

governments, and the private for-profit sector, has

been meager and fragmented. Federal support for

4-H clubs and, more recently, the National and

Community Service Act of 1990 (Public Law

101-610) is an exception.

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Part II:

PREVENTION AND SERVICES

RELATED TO SELECTED

ADOLESCENT HEALTH CONCERNS
PREVENTION AND SERVICES

RELATED TO PHYSICAL

HEALTH PROBLEMS
Chapter 5

ACCIDENTAL INJURIES:

PREVENTION AND SERVICES

Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Background on Accidental Injuries Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Sources of Data on Accidental Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Trends in the Incidence and Prevalence of Accidental Injuries Among Adolescents . . . . . . . . . 118

Injury Deaths and Death Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Health Survey Data on Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Injury-Related Health Services Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Specific Types of Injuries Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Motor-Vehicle-Related Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Drowning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

Accidental Firearm Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Sports and Recreational Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Factors Associated With Accidental Injuries Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . 126

Demographic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

Risk-Taking Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Stressful Life Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Consequences of Accidental Injuries Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Prevention of Accidental Injuries Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

Educational and Incentive Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

Driver Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

Incentives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

Combining Education and Incentives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

legislation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

Special Driver Licensing Restrictions for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...............134

Requirements for School Bus Safety Belts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

Automatic Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Treatment of Accidental Injuries Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

Major Federal Policies and Programs Pertaining to Accidental Injuries Among Adolescents . . . . 138

U.S. Department of Health and Human Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

Centers for Disease Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

Health Resources and Services Administration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

National Institute for Child Health and Human Development . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

U.S. Department of Transportation’s National Highway Traffic Safety Administration . . . . . . 139

U.S. Consumer Product Safety Commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Chapter 5 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Figures

Figure Page

5-1. Death Rates Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, by All Causes and

External Causes of Death, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

5-2. Death Rates for the Five Leading Causes of Death Among U.S. Adolescents

Ages 10 to 14 and Ages 15 to 19, 1970-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

5-3. Accidental Injury Deaths by Cause Among U.S. Adolescents Ages 10 to 19, 1984-86 . . . . . 121

5-4. Drowning Deaths Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19,

by Race and Gender, 1968-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

5-5. Motor Vehicle Accident Deaths Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19,

by Race and Gender, 1968-87.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

Tables

Table Page

5-1. Average Annual Accidental Injury Deaths and Death Rates Among U.S. Adolescents

Ages 10 to 14 and Ages 15 to 19, 1984-86 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

5-2. Top 14 Consumer Products Related to Accidents Leading to Hospital Emergency Room

Visits Among U.S. Adolescents Ages 10 to 18, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

5-3. Male-to-Female Ratios of Injury Deaths Among U.S. Adolescents Ages 10 to 14 and

Ages 15 to 19, by Selected Causes, 1984-86 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Chapter 5

ACCIDENTAL INJURIES: PREVENTION AND SERVICES1

Introduction

Broadly speaking, injuries to adolescents are of

two general types, accidental (or unintentional)

injuries 2 and nonaccidental injuries such as those

inflicted in suicide attempts or assaults.3 Accidental

injuries are responsible for more deaths to American

adolescents than any other problem, causing more

than half of all deaths to persons ages 10 to 194 (see

figure 5-l). In 1987, 55 percent of all deaths to

persons ages 10 to 19 were due to accidental injuries

(93). That year, 10,658 U.S. adolescents ages 10 to

19 died from accidental injuries (93). Many more

adolescents experienced accidental injuries that

caused visits to physicians’ offices or hospital

emergency rooms, temporary or permanent disability, restricted-activity and school-loss days, and

other problems. This chapter reviews information on

the problem of accidental injuries for U.S. adolescents, the factors associated with accidental injuries

among adolescents, consequences of accidental

injuries, and the effectiveness of different strategies

to prevent accidental injury. The chapter also

describes major Federal Government policies and

programs pertaining to accidental injuries.

Background on Accidental Injuries

Among Adolescents

Sources of Data

on Accidental Injuries

No single source of information provides comprehensive data on the cause, nature, and severity of

injuries among the U.S. population (58). Particularly

lacking are detailed data on injuries that do not result

in death.56

National data on injuries currently have to be

gathered from the National Center for Health Statistics in the U.S. Department of Health and Human

Services (DHHS), the National Highway Traffic

Safety Administration (NHTSA) in the U.S. Department of Transportation, and other sources. These

sources offer data that include:

● mortality data based on death certificates,

. national, population based, health survey data,

l~is chapter is based, in part, on a background paper on unintentional injuries prepared for OTA (66). O’IA, however, ties MI responsibtiity for

the use of information in this chapter, and for the use of the phrase “accidental injuries” rather than “unintentional injuries. ”

To make this Report more accessible to the lay reader and for other reasons, OTA has chosen to use the term accidental injury in this Report. The

term preferred by those in the injury prevention community, however, is unintentional injury (e.g., 66).-Those who prefer the term unintentional ti~

believe that the term accidental injury implies that injuries cannot be prevented, whereas the term unintentional injury implies that while an individual

may not have consciously intended to hurt him or herself, some action taken or not taken may have prevented the injury. Perhaps to overstate this

perspective somewhat all injuries are avoidable. The position that true “accidents’ do not wcur (i.e., by chance, entirely without cause) correctly brings

attention to injuries as a public health problem to which additional preventive interventions can and should be applied, but it seems to be unprovable.

Use of the term unintentional also may have the unfortunate effect of placing the onus of causation (and responsibility for precautions) exclusively on

the person who is injured, atthough in fact unintentional injuries may be caused unintentionally, by persons, organizations, or systems other than the

victim.

s~omtlonon adolescent suicide is presented in ch. 11, “Mental Health Problems: Prevention and S-ices,” in this volume. Information in

homicide among U.S. adolescents is presented inch. 13, “Delinquency: Prevention and Services, “ in this volume, and inch. 18, “Issues in the Delivery

of Services to Selected Groups of Adolescents, ’ in Vol. III.

4~e fwu~ of ~s OTA Report is on adoles~nts ages 10 ~ough 18. There is no single agr~d-upon deftition of ~olewents, however, ad much

of the data reported in this chapter is for individuals ages 10 through 19, because data obtained from the National Center for Health Statistics on causes

of death for adolescents are reported using age breaks of 10 to 14 and 15 to 19. Differences in Federat agencies’ deftitions of adolescence are discussed

inch. 19, “The Role of Federal Agencies in Adolescent HealtlL” in Vol. III.

fThere are relatively more data available on injuries related to motor vehicle crashes because of the efforts of the National Highway Tra.tlic Safety

Administration (NHTSA) and the Insurance Institute for Highway Safety, both of which have a mandate to study automobile injuries (47).

me Nationat Center for Heatth Statistics is currently working on merging and expanding its health care surveys (87a). Designed to include a patient

followup component and tinkage with the household interview survey, the new National Health Care Survey witl generate data that will permit analysis

of patient outcomes, the relationship between uses of health services and health characteristics, and the use of health care at the local level (87b). As

discussed further in app. C, “Issues Related to the Lack of Information About Adolescent Health and Health and Related Services, ” in Vol. I of this

Report (76a), oversarnpling of adolescents and their use of health services is also required to improve the Nation’s knowledge base about adolescent

health.

-11-117-
II-118 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

● health care services utilization data (e.g., hospital discharge abstracts, hospital emergency

room reports, and surveys of office-based

physicians), and

● traffic accident data (78).7

In addition to national sources of data on injuries,

there are a number of smaller, local or regional

studies that provide data on injuries. The generalizability of data from these smaller studies is limited.

In the aggregate, however, these studies do provide

some useful information about accidental injuries

among adolescents.

Trends in the Incidence and Prevalence of

Accidental Injuries Among Adolescents

Injury Deaths and Death Rates

Over time, the prominence of accidental and other

injuries as a cause of death for young people has

increased, in part because of the significant decrease

in the numbers of deaths associated with infectious

disease (78,88). Injury death rates for adolescents

ages 10 to 14 decreased from 23.6 deaths per

100,000 in 1950 to 16.3 per 100,000 in 1987, but the

rates for adolescents ages 15 to 19 actually increased

over the same period, from 55.6 deaths per 100,000

to 67.3 per 100,000 (65,93). Accidental injury death

rates for adolescents declined between 1970 and the

mid-1980s. But between 1986 and 1987, they

leveled off for 10- to 14-year-olds and increased for

15- to 19-year-olds (see figure 5-2).

In 1987, approximately half of all deaths-and

more than two-thirds (70 percent) of injury deathsamong U.S. adolescents ages 10 to 19 were due to

accidental injuries (see figure 5-1 and table 5-l). The

percentage of injury deaths that are accidental

changes during adolescence. In 1987, for example,

79 percent of injury deaths among adolescents ages

10 to 14 were accidental, but 69 percent of the injury

deaths for adolescents ages 15 to 19 were accidental.

Figure 5-l-Death Rates Among U.S. Adolescents

Ages 10 to 14 and Ages 15 to 19, by All Causes and

External Causes of Death, 1987

Deaths/100,000

100 1 I

I 84.6

80

60

4 0

2 0

0

1

All causesb All injuries’

Ez

46.2

Accidents

Ages 10

Ages 15

Ages 10

to 14

to 19

to 19

10.3

1.5

Suicide Homicide

Cause of death

aAlthough this OTA Report focuses on adolescents ages 10 to 18, the *ta

here are for $year age groups and therefore fndude 19-year-olds.

b~All causes~~ ind~es inju~es and diW=es. The rates at ~~h muses of

death other than injuries oceursintheadolescent population are relatively

small-e. g., malignant neopfasms, the next highest cause of death after

injuries, occurs in 10- to 19-year+ids at a rate of 3.7 per 100,000

adolescents ages 10 to 19.

C“AII injufies” includes acd&n@ suicide, homidde, and other ki@ieS.

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Services, Public Health service,

Centers for Disease Control, National Center for Health Statistics, unpublished 1987 mortality rates, Hyattsville, MD, 1990,

Health Survey Data on Injuries

Data on injuries available from the National

Health Interview Survey8 (NHIS) conducted by the

National Center for Health Statistics in DHHS

indicate that each year about 30 percent of U.S.

children and adolescents ages 5 to 17 experience an

injury (92), NHIS does not provide separate breakdowns for accidental and intentional injuries.

Data from the 1988 NHIS indicate that injuries

accounted for 18 percent of restricted-activity days9

reported for adolescents ages 10 to 18 in 1988 (93).

Adolescent males had more injury-related restrictedactivity per 100 adolescents than adolescent females.10

7Sever~ Fede~ souces of &h on physical health of U.S. adolescents are described ti box 6-B ~ ch. 6 “Chronic Physical Illnesses: Prevention

and Services, ‘‘ in this volume.

8~e N~o~ H~~ ~temiew s~ey cofl~@ data on c~~en ~d adoksc~ts up to age 17 from thek parerl@ USUatly theh 1110~.

9As d~j~ by tie N~tjO~ H~~ ~t~i~ s~ey co~uct~ by D~s, a res~icted-activi~ &y is my by on which ii person CUt

her usual activities for more than one-half day because of an illness or an injury. Restricted-activity days are unduplicated counts of bed-disability days,

work-loss days, and school-loss days, and other days on which a person cuts down on his or her usual activity (92).

1OS= ~ble 6-5 in ch. 6, ‘‘chronic Physical Illnesses: Prevention and SeWices, “ in this volume for data on restricted-activity days associated with

injuries.
Chapter 5—Accidental Injuries: Prevention and Services . II-119

Figure 5-2—Death Rates for the Five Leading Causes of Death Among U.S. Adolescents

Ages 10 to 14 and Ages 15 to 19, 1970-87

Adolescents ages

Deaths/100.000 population

70

60

50 ‘

I

I

4 0

30 ‘

20’k1 0 ’

I

Oi

1970

10 to 14

. .

.- Accidents and adverse

effects

&

Mallgnant neoplasms

f. Major cardiovascular

problems

‘“Y SuIclde

. . Homicide and legal

i n te rve nt ion

. .

.,

k -* ii . ---%:xb”-4-=+ -.. –– -

1975 1980 1985 1987

Adolescents ages 15 to 19

Deaths/100,000 population

7 0

40

30

1 ‘-- +4

20 “

‘s2 -—~

,

——.. +: ‘ I .

Accidents and adverse

effects

Malignant neoplasms

Major cardiovascular

problems

Suicide

Homicide and legal

intervention

.7 — —

0 ------- .–~——.——— ~—1 ..— .-—— - J

1970 1975 1980 1985 1987

SOURCE: Office of Technology Assessment, 1981, based on U.S. Department of Health and Human Services, Public Health Service, Centers for CXsease

Control, National Center for Health Statistics, Vifa/ Statistics of the Urrited States 1970, Vo/. //-tWorta/ify (Washington, DC: U.S. Government

Printing Office, 1974); U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for

Health Statistics, Vii%/ Statistics of the United States 1975, Vol. /Morfa/ify (Washington, DC: U.S. Government Printing Office, 1979); U.S.

Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Centerfor Health Statistics, Viti/StatMcs

of the United States 1980, Vo/. //-hforta/ity, Pub. No. (PHS) 85-1101 (Washington, DC: U.S. Government Printing Office, 1985); U.S. Department

of Health and Human Services, Public Health Servics, Centers for Disease Control, National Center for Health Statistics, Vita/Statistics oftfre United

States 1985, Vo/. //-hforta/ity, Pub. No. (PHS) 88-1102 (Washington, DC: U.S. Government Printing Office, 1987); and U.S Department of Health

and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1987 mortality data,

Hyattsville, MD, 1990.

School-loss days are a subset of restricted-activity Injury-Related Health Services Utilization

days (92).11 NHIS data indicate that injuries were According to data from the 1985 National Amburesponsible for 8.5 percent of school-loss days latory Medical Care Survey conducted by the

associated with acute conditions among adolescents National Center for Health Statistics in DHHS, some

ages 10 to 17 in 1988 (93).12 Again, adolescent 8,177,000 visits to private office-based physicians’

males had higher rates of school-loss days associ- offices by adolescents ages 10 to 18 in 1985 were for

ated with injuries than adolescent females. a diagnosis of injury or poisoning, accounting for

1 IA~ defined by tie Nati~~ He~~ ~tcwlewSmey conducted by DHHS, a schoo/./oss day is my &y on w~ch a ctil(j did not attend school fOr

at least half of his or her normal school day because of a specific illness or injury (92). School-loss days are determined only for children 5 to 17 years

of age, beginning in 1982.

IZSW table 6.6 in ch. 6, ‘‘~onic Physical Illness: Prevention ~d services,‘‘ in this volume for data on school-loss days associated with injuries.
11-120. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 5-l-Average Annual Accidental Injury Deaths and Death Rates Among

U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, 1984-86

Ages 10 to 14 Ages 15 to 19

Rate Rate

Deaths (per 100,000) Deaths (per 100,000)

Vehicle-related:

Motor vehicle occupant . . . . . . . . . . . . . . . . . . . . . . 458 2.69 3,770 20.18

Drivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 0.33 2,094 11.21

Passengers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402 2.36 1,676 8.97

Motorcycles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 0.51 639 3.42

Pedestrians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294 1.72 515 2.76

Bicycles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 1.28 142 0.76

Other &vehicle unspecified . . . . . . . . . . . . . . . . . . 203 1.19 1,526 8.17

Other:

Drowning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 1.64 566 3.03

Firearms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 0.99 248 1.33

Fires/burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 1.02 238 1.27

Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 0.23 143 0.77

Other accidental . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324 1.90 752 4.02

Total accidental . . . . . . . . . . . . . . . . . . . . . . . . . . . .2,248 13.18 8,537 45.69

SOURCES: U.S. Department of Commerce, Bureau of the Census, Current Popu/atiorr Reports, Series P-25, No.

I&W, Estimates of the Population of the United States by Age, Sex, and Race: 1980 to 1986 (Washington,

DC: U.S. Government Printing Office, 1987); U.S. Department of Health and Human Serviees, Public

Health Serviee, National Center for Health Statistics, Vita/ Statistics of the United States, Vo/urne //,

1984-1986 Morta/ity, Parf A (Washington, DC: U.S. Government Printing Office).

16.3 percent of adolescents’ visits to physicians’

offices (89).13 Presumably, many adolescents with

injuries are treated at home, in clinics, by athletic

trainers, or in emergency rooms. Data from hospital

emergency rooms on visits associated with a range

of consumer products are discussed below (79,80,

81). 14

The National Hospital Discharge Survey, also

conducted by the National Center for Health Statistics within DHHS, reports that in 1987 injuries and

poisonings together were the most frequent reasons

for adolescents’ hospitalizations (91).15 In 1988,

injuries and poisonings accounted for approximately

31 percent of hospitalizations of adolescent males

ages 10 to 14 and 42 percent of hospitalizations of

males ages 15 to 18 (91). The percentage of

hospitalizations due to injuries for adolescent females that year was lower; injuries accounted for

approximately 26 percent of hospitalizations of

10- to 14-year-old females and 9 percent of hospitalizations of 15- to 18-year-old females. It is not possible

to distinguish accidental from nonaccidental injuries

in hospital discharge data (91).16

Specific Types of Injuries Among Adolescents

Information on the causes of fatal injuries to

adolescents is available from the Vital Statistics

System of the National Center for Health Statistics

in DHHS. As shown in figure 5-3, about threefourths of accidental injury deaths among U.S.

adolescents ages 10 to 19 in 1984 to 1986 resulted

from vehicle-related accidents (99,100,101). Deaths

from vehicle-related accidents include deaths among

drivers and passengers in cars, all-terrain vehicles

(ATVs), and bicycles. Drowning is also a significant

cause of accidental death among adolescents, ac13sw @bIe 6.3 inch. 6, “ChrOniC Physical Illnesses: Prevention and Services, “ in this volume for data on office visits to physicians associated with

injury and poisoning. The National Ambulatory Medical Care Survey does not provide a breakdown of visits by type of injury (i.e., accidental or

intentional), Furthermore, the number of visits for injwy is undoubtedly higher than the number of individual patients, making a count of individual

adolescents difficult.

lds~ ~tion below endued “Speci.flc Causes of Injury Among AdOleS03M%”

15s= ~ble 6-2 in ch. (j, “ChmniC Physical Illnesses: Prevention and Services, ” for data on hospital discharges associated with injuries among

adolescents.

16More ~mplete ~omtionon me diWoses involv~ in adolmmnts’ visi~ to physici~s’ OffiCXX and hospitalizations Cm bC fo~d in ch. 6,

“Chronic Physical Illnesses: Prevention and Services,” in this volume.
Chapter 5—Accidental Injuries: Prevention and Services .11-121

Figure 5-3-Accidental Injury Deaths by Cause

Among U.S. Adolescents Ages 10 to 19, 1984-86

Vehliclesa 7,85

‘=..,. Other 1,076

r

‘\

> Falls 182

Fires/burr

Firearms

7 Drowning Z#

IS 412

417

846

aThis ~tegory includes deaths among drivers, passengers, and pedestri-

ans; and includes ears, trucks, all-terrain vehicles, motorcycles, bicycles,

and other and unspecified motor vehicles. Differences by type of vehiele

and age are reported in table 5-1.

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Services, Public Health Service,

National Center for Health Statistics, Vtia/Statistics of the United

Sfates—Vo/. //, Morta/ity (Washington, DC: U.S. Government

Printing Office, various years).

counting for nearly 8 percent of accidental injury

deaths (see figure 5-3). Other important causes of

accidental injury deaths among adolescents are

firearm accidents, fires/burns, and falls.

Comprehensive national data on nonfatal accidental injuries are not available. Neither NHIS nor

the National Hospital Discharge Survey nor the

National Ambulatory Medical Care Survey obtains

information on the causes of such injuries.

One source of cause-specific data on health

services utilization related to injuries is the U.S.

Consumer Product Safety Commission’s National

Electronic Injury Surveillance System, conducted in

U.S. emergency rooms (80). This survey is limited,

however, in that it excludes motor vehicles and

firearms from its purview. Data from a review by the

U.S. Consumer Product Safety Commission of the

top 20 leading consumer products associated with

accidental injuries resulting in emergency room

treatment for adolescents ages 10 to 18 in 1988

reveals that the vast majority of such injuries are

associated with recreational activities (see table 5-2)

(80). Among the leading categories of products are

those involved in basketball, football, baseball,

skateboarding, wrestling, roller skating, or bicycling. Injuries are reported both for organized and

informal activities (80).

Photo credit: Education Week

Sports, including organized sports, are a leading cause of

nonfatal injuries among adolescents. According to data

from the U.S. Consumer Product Safety Commission’s

surveillance system, football accounted for nearly 236,000

visits to hospital emergency rooms in 1988.

Local studies provide additional information about

the causes of nonfatal injury to adolescents. In a

statewide study in Massachusetts,17 sports injuries

accounted for the greatest number of injuries in

adolescents ages 13 to 19 that resulted in medical

treatment (32). This study estimated that

1 in 14 adolescents ages 13 to 19 required hospital

treatment for sports injury and 20 percent of these

injuries were from football (32). The authors suggest

that because of the methodological limitations of

their study, these figures should be considered

minimal injury rates.

A more detailed discussion of motor-vehiclerelated injuries, drowning, firearm-related injuries,

and injuries associated with sports and recreational

activities (e.g., football, bicycling) is presented

below.

Motor-Vehicle-Related Injuries

National data indicate that vehicle-related injuries

are the leading cause of accidental injury deaths

among U.S. adolescents ages 10 to 19. Fatal motor

vehicle injuries account for the largest proportion of

17~S S~dy ~ollect~ ~~ on fa~ ad no~a@ ~tentio~ injfies to a s~ple of over 5,()()() children ~d adoltiwnts ages O to 19 h Massachusetts

over a l-year period as part of the Massachusetts Statewide Childhood Injury Prevention Program Surveillance System (32). Adolescents ages 13 to 19

made up about half of the sample.

?!)? -!ld(; — !) 1 — – .-I (J1, :\
//-122 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 5-2—Top 14 Consumer Productsa Related to

Accidents Leading to Hospital Emergency Room

Visits Among U.S. Adolescents Ages 10 to 18,

1988

Number of

emergency

Consumer product room visits

Basketball.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244,166

Organized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81,176

Informal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26,850

Not specified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136,140

Football . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .235,853

Organized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110,253

Informal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28,174

Not specified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97,426

Bicycles or accessories . . . . . . . . . . . . . . . . . . . . . . . . . . . 182,031

Baseball . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109,920

Organized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47,463

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62,457

Stairs or steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102,297

Knives, not elsewhere classified . . . . . . . . . . . . . . . . . . 57,774

Soccer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54,820

Organized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27,025

Other.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27,795

Skateboards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50,095

Floors or flooring materials . . . . . . . . . . . . . . . . . . . . . . . . 46,846

Nails, screws, carpet tacks, or thumbtacks . . . . . . . . . 43,600

Doors, not specified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41,738

Ceiling and walls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37,301

Roller skating (activity, apparel or equipment) .,.... 31,729

Wrestling (activity, apparel, or equipment) . . . . . . . . . 30,990

aThe U.S. Consumer Proctucts safety Commission keeps track of injuries

associated with activities that involve the use of consumer products,

although every injury is not directly caused bythe product. Theydo not

collect dataon accidents involving motor vehicles orfirearms.

SOURCE: U.S. Consumer Product Safety Commission, unpublished 1988

data from the National Electronic Injury Surveillance System,

1989.

fatal vehicle-related injuries among U.S. adolescents, especially 15- to 19-year-olds (table 5-1).18

Drivers ages 16 to 19 represent only 6 percent of

licensed drivers but account for 13 percent of all fatal

motor vehicle crashes (110). Adolescent drivers are

at greatest risk of becoming involved in a motor

vehicle crash when they drive at night. Although

adolescent drivers do only 20 percent of their driving

at night, they suffer more than half their crash

fatalities during nighttime hours (42,123). In 1988,

half of all fatal crashes involving drivers ages 15 to

17 took place between the hours of 4 p.m. and

midnight (1 10).19 The nighttime fatality rates for

adolescent males exceed those for females by more

than two to one (122,123). Most motor vehicle

.

Photo credit: Bethesda Chevy Chase Rescue Squad

Drowning is the second leading cause of accidental injury

deaths for adolescents; black adolescent males are

particularly at risk.

crashes involving adolescents take place on the

weekend. In 1988, adolescent drivers ages 15 to 17

were most frequently involved in fatal crashes on

Fridays or Saturdays; 40 percent of fatal crashes took

place on one of these days. Another 16 percent took

place on Sunday (110).

Alcohol consumption is a risk factor for automobile crashes for persons of all ages, but it appears that

adolescents may be at even greater risk than adults

of becoming involved in a motor vehicle crash if

they drive after consuming alcohol (42). The National Highway Traffic Safety Administration (NHTSA)

in the U.S. Department of Transportation reports that

about half of the motor vehicle crash fatalities

among adolescents ages 15 to 19 are related to

alcohol, and about a quarter of fatally injured drivers

ages 15 to 19 are intoxicated at the time of their

accident (116). Interestingly, however, drivers ages

16 to 19 are less likely than older drivers (e.g., those

ages 20 to 24) to have consumed alcohol prior to

involvement in a crash. Furthermore, in alcoholrelated crashes, the average blood alcohol content is

lower for the fatally injured adolescent driver than

for the fatally injured adult driver (42,1 10). This

suggests that it takes less alcohol for the adolescent

driver to be at risk for a serious or fatal motor vehicle

crash (42,104,1 17,1 18).20

18B@-le ~d AT’v.~lat~ injfies are dismssed in the St?CtiOII below On SpOltS md ra~tio~ injuries.

lg~o~er 18 Pmcent of faM crashes took place between the hours of noon and 4 p.m. (1 10).

~sk factors, prevention and treatment for alcohol and other drug abuse are discussed in ch. 12, ‘‘Alcohol, Tobacco, and Drug Abuse: Prevention

and Services, “ in this volume.
c

.-o

Z

3

0. 0

n

Chapter 5—Accidental injuries: Prevention and Services .11-123

100

80

60

F

Figure 5-4-Drowning Deaths Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19,

by Race and Gender, 1968-87

10-14 years

40

20

[

-’-.,

1--- \

10

—

\4“ \

8

‘-— — -

6

.\—

4

2

1

0.8 I

0.6

0.4

0.2

I

------ \ /-- ~.,

‘. /’ \

\ /

,.- n, .“”, \ , \

,’\ \ , \

/’ ‘v ‘,/ \

\

/ \

., — — — ,

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.—

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0.1 ~

1 1 1 I 1 I

1968 1970 1975 1980 1985 1987

100

80

60

40

20

10

8

6

4

2

1

0.8

0.6

0.4

0.2

0.1

15-19 years

---- /{ ‘\ ---- / ‘ \ /

/ ‘. ‘s, / // \\ ,~. ‘. \ / ‘-’ \

,— — /\/A. _/\’\ 1’ -

\

\ /“\

& .— / >~, ,/ ‘\ z-~.~

\y—. / .’~

-L

1 1 1 1 1 1

1968 1970 1975 1980 1985 1987

Year Year

White male — — — Black male

.— —. — White female -------- Black female

SOURCES: 1968-85 data: U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, ‘Trends and Current

Status in Childhood Mortality: United States, 1900-85,” Vita/and Hea/fh Statistics, Series 3, No. 26, DHHS Pub. No. (PHS) 89-1410 (Washington,

DC: U.S. Government Printing Office, 1989). 1987 data: U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, unpublished mortality data, Washington, DC, 1990.

Passengers of adolescent drivers are also at

increased risk of being involved in a motor vehicle

crash. The majority of adolescents killed as passengers are in vehicles driven by other adolescents

(124). In addition, adolescents have been found to be

disproportionately involved in the vehicle-related

deaths of other nonadolescent drivers, passengers,

and pedestrians (122,124).

Drowning

National data indicate that drowning is the second

leading cause of accidental injury death among U.S.

adolescents ages 10 to 19 (88,90). A review of

national drowning rates indicates that the risk of

drowning increases substantially during adolescence, before peaking during the early- to midtwenties (84). Similar patterns have been reported in

local studies in North Carolina (54) and in Maryland

(25).

Death rates from drownin g are higher for adolescent males than for adolescent females. Furthermore, according to data from the National Center for

Health Statistics in DHHS, black adolescents (particularly males) are at greater risk of drowning than

their white counterparts (see figure 5-4).

The site of adolescent drowning is usually a lake,

river, stream, pond, or canal rather than an ocean or

swimming pool (54,126). This finding may reflect

greater exposure time near these bodies of water or
11-124. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

lower levels of supervision. Interestingly, however,

the 10 to 19 age group accounted for half of all

drownings in public or motel pools in a North

Carolina study (54).

Alcohol is involved in close to 40 percent of

adolescent drownings (39,53,54,126). Alcohol may

impair judgment of the adolescent in a dangerous

situation. It also may decrease the likelihood of

struggling to get out of the water, thus increasing the

chances of drowning (71).

Accidental Firearm Injuries

Accidental firearm injuries follow drownings as a

cause of accidental injury death among adolescents

ages 10 to 19 (see table 5-1 and figure 5-3). It is

encouraging to note that death rates for accidental

firearm-related injuries among adolescents ages 15

to 19 have recently been decreasing.21 Accidental

firearm-related death rates for adolescents ages 15 to

19 peaked in 1972 at a rate of 2.5 deaths per 100,000

population but declined to a low of 1,2 deaths per

100,000 in 1987 (29).

Accidental firearm deaths occur primarily among

adolescent males. Accidental firearm-related death

rates for adolescent males exceed rates for adolescent females by almost 8 to 1. Males ages 15 to 19

have the highest accidental firearm death rate (1.33

deaths per 100,000) of all other age groups. Adolescent males ages 10 to 14 have the third highest

accidental firearm death rate (0.99 deaths per

100,000) (99,100,101). Racial differences among

adolescent males vary somewhat by age. For males

ages 10 to 14, the accidental firearm death rate is

nearly twice as high for whites as for blacks (1.93

deaths per 100,000 v. 0.97 deaths per 100,000).

Among 15- to 19-year-old males, rates are slightly

higher among blacks than whites (2.56 deaths per

100,000 v. 2.31 deaths per 100,000) (29,99,100,101).

National data on nonfatal accidental firearm

injuries among U.S. adolescents are unavailable

(5).22 A Massachusetts study found that accidental

firearm injuries were a less common type of

accidental injury among adolescents ages 13 to 19

presenting to hospital emergency rooms, with a rank

order of 15 among all injuries (32).

Little is known about risk factors associated with

accidental firearm injuries among U.S. adolescents,

but adolescents’ exposure to firearms appears to be

quite high. Over 40 percent of the 8th and 10th

graders surveyed in the National Adolescent Student

Health Survey in 1987 reported that they had used a

gun during the past year; of these, over 40 percent

had used a gun more than 10 times (6). In general, the

source of these firearms is unknown. However, the

National School Safety Center reports that the

overwhelming majority of weapons that have been

confiscated in schools were obtained legitimately

(e.g., from parents) (50a). About half the American

households reported having a gun in 1989 (76).

Information on when and where accidental firearmrelated deaths occur among U.S. adolescents is quite

limited. In 1984, more than 30 percent of the

fatalities of adolescents ages 10 to 14 that occurred

in the home resulted from firearm injuries; this was

a significantly higher percentage than for children in

younger age groups (85). A study of a limited sample

of 88 accidental firearm deaths among children

through age 14 in California indicated that most of

these deaths occurred while children were playing

with a gun (127).

In rural areas, accidental firearm injuries may be

associated with hunting. A study of accidental

firearm fatalities in North Carolina indicated that 28

percent of accidental firearms deaths to adolescents

ages 15 to 19 occurred while hunting (45). Another

study of hunting-related accidental firearm injuries

revealed that younger victims (ages 8 to 19) of

hunting injuries were more likely than older hunters

to engage in unsafe hunting practices, including

carrying the gun incorrectly (21).

Sports and Recreational lnjuries23

As noted above, sports and recreational activities

appear to be a leading source of nonfatal adolescent

injury. The U.S. Consumer Product Safety Commission has reported that, in fiscal year 1987, sports and

recreational activities and equipment were responsible for nearly $2 billion in costs of hospital

emergency room treatment for injuries to persons

21u~omtely, however, ~ole~cent d~~~t= for ho~cide and s~cide involving tie use of fwearms have continued to increase. See ch. 11,

“Mental Health Problems: Prevention and Treatment” (suicides), and ch. 13, “Delinquency: Prevention and Treatment” (homicides), in this volume.

‘Because firearms are not under the jurisdiction of the U.S. Consumer Product Safety Cornmissioq data on fuearm-related injuries are not included

in the Commission’s National Electronic Injury Surveillance System (78).

~For a ~ena~ discussion of adolescent fitness, s~ ch. 7) ‘‘Nutrition and Fitness Problems: Prevention and Services, ” in this volume.
Chapter 5—Accidental injuries: Prevention and Services .11-125

ages 5 to 24, more than any other class of consumer

products 24 (79).

Data from limited samples suggest that injury

rates vary considerably by type of sport or recreational activity. A l-year study of 1,283 student

athletes in grades 9 through 12 found that 22 percent

sustained injuries during the year (43). Students

playing football were most likely to experience an

injury (61 percent of those participating), followed

by females participating in gymnastics (46 percent),

males participating in gymnastics (40 percent),

wrestling (40 percent), and males’ basketball (37

percent), Males, who made up 58 percent of the

sample of student athletes, experienced nearly threequarters of the injuries.

A study of sports injuries treated at the University

of Rochester Section of Sports Medicine over a

7-year period found that these injuries peaked during

ages 16 to 19; this age group was responsible for 45

percent of the cases seen (24). Overall, football was

responsible for the greatest number of injuries. Knee

injuries were most common for all sports.

Although the relationship between physical fitness and risk of injury has not been well studied, a

limited study of 124 young men and 186 young

women undergoing basic military training indicated

that higher physical fitness may reduce the risk of

certain types of less serious sports injuries. The

authors conclude, however, that fitness probably has

no effect on reducing severe or catastrophic injury

(22).

Football-Related Injuries--Football is one of

the most hazardous interscholastic athletic activities, accounting for 28 injuries per 100 participants

per year in national samples (46,74).25 In 1988,

football-related injuries were responsible for nearly

236,000 visits to emergency rooms by adolescents

ages 10 to 1926 (see table 5-2) (80). About a third of

high school football players experience an injury

that keeps them out of practice or a game (20).

Between 1973 and 1980, 260 high school and

college players died from football-related injuries.

Improvements in helmet design reduced the frequency of head trauma during the late 1960s and

early 1970s but resulted in greater use of the head for

blocking. As a result, in the early 1970s there was an

increased incidence of neck injuries, including

injuries resulting in quadriplegic. In 1976, the

National College Athletic Association and the National Federation of State High School Athletic

Associations ruled to prohibit ‘ ‘spearing’ (using the

head to strike an opponent while tackling), which

poses particular risks for cranial and spinal cord

injuries. Subsequently, the incidence of permanent

quadriplegic resulting from football injuries declined from an average of 35 cases per year in 1971

to fewer than 10 per year as of 1986 (46,74).

A study examining the injury experience of 5,128

males ages 8 to 15 participating in 208 youth football

teams found that 5 percent of the males sustained

injuries during the football season (33). Of these,

61.4 percent were classified as moderate injuries,

and 38.9 percent were classified as major injuries.

Males on the oldest and heaviest teams in this age

group (Junior Bantam teams) had the highest rates of

injury (9.6 percent of males), and males on the

smallest and youngest teams (Junior Pee Wee teams)

had the lowest rate of injury (1.9 percent of males).

About a third of the males experienced a fracture, the

most common type of injury; another quarter sustained sprains. Most injuries (88.3 percent) resulted

from contact with another player; 41 percent of

injuries occurred during tackling. Over two-thirds of

the injuries occurred during games or scrimmages as

opposed to practices, and more injuries occurred at

away games than home games. A higher prevalence

of injury during practice as opposed to games has

been reported by other researchers. For example, a

study of 1,283 high school athletes, 179 of whom

played football, indicated that about two-thirds of

the football-related injuries occurred during practice. However, given the much greater amount of

exposure experienced in practice rather than game

episodes, it was calculated that game situations were

actually more likely to produce an injury per unit of

exposure (43).

It has been suggested that the elimination of

kickoffs and punt returns could reduce the footballrelated injury rate because of the high incidence of

Z4~e U.S. Comuer ~~uct s~e~ co~~~ion k~~~ @ack of ~juries ~sociated wi~ ~tivities tit involve tie use of consumer produ c

the injuries may not be caused directly by the consumer product.

2S~gher ratfi ~ve ~nrewfled ~ ~~die~ u~@ more limited s~p]es, For ex~p]e, G] percent of s~denw playing football were reported tO hive

sustained an injury in one study (43).

u~~ fiWe ~cludes orgmiz~ ~ well as ifioml football; organized football accounted for 110,253 visits to emergencY rooms.
11-126. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

major injuries sustained during these plays (33). In

addition, improvements could be made in the

teaching methods for blocking and tackling to

reduce the numbers of injuries caused by direct

impact by helmets; this was a cause of 18 percent of

football-related injuries in a study of injuries experienced by males ages 8 to 15 participating in youth

football (33).

Bicycle-Related Injuries-Adolescents ages 10

to 17 accounted for 30 percent of all fatal bicycle

accidents in the United States in 1988 (1 10). The

majority of fatal bicycle accidents in 1988 (91

percent) occurred on roadways rather than at intersections or other locations (1 10). Among adolescents, the older the bicycle rider, the more likely

it is that an injury will be the result of a collision with

a motor vehicle; as many as 90 percent of all

bicycling fatalities involve motor vehicles, and they

are largely the result of head injuries sustained in the

accident (41). For bicycle-related injuries requiring

hospital admission, the injury is five times more

likely to be the result of collision with a motor

vehicle than the result of some other type of event

(e.g., collision with another bicycle or falling off of

a bike) (31).

Figures indicating alcohol involvement among

adolescent bicyclists, specifically, do not exist.

Alcohol testing is not done uniformly in the case of

bicycle accidents, and little information exists about

exposure to alcohol among noninjured bicyclists.

All-Terrain-Vehicle (ATV)-Related Injuries--

ATVs have become a source of considerable controversy since their introduction in the United States in

the 1980s. Originally designed as tractors for use in

the flat, wet rice paddies of the Orient, these 3- or

4-wheel vehicles have been adopted for off-road

recreational use in rough terrain (66). Instability of

ATVs, some of which are capable of speeds as high

as 70 miles per hour, is a major problem (66). In

1985, there were 238 documented deaths attributed

to ATVs among persons of all ages (2,51). In 1988,

ATVs were associated with 27,000 visits to emergency rooms by adolescents ages 10 to 18 (80).

Injuries from ATVs are primarily a consequence

of hitting an obstacle or tipping over. Among all age

groups, head injuries are responsible for 70 percent

of the deaths involving ATVs and are the major

cause of hospitalization (19,70). Helmets are used by

less than 20 percent of the victims, despite clear

evidence of their potential to reduce the incidence

and severity of head injury (27,63,73,120).

Adolescents ages 12 to 15 account for 27 percent

of accidents involving 3-wheel ATVs and 42 percent

of those involving 4-wheel ATVs; adolescents and

young adults ages 16 to 24 account for 35 percent of

accidents involving 3-wheel ATVs and 19 percent of

those involving 4-wheel ATVs (1,51). Males are

involved in close to 80 percent of the cases, most

likely a function of their greater exposure time

relative to females.

As of March 1988, the U.S. Consumer Product

Safety Commission had instituted a ban on the sale

of 3-wheel ATVs and ruled that the sale of 4-wheel

vehicles to minors be more closely controlled27 (75).

Nonetheless, because many previously purchased

3-wheel ATVs are still being used, nearly half of the

emergency room visits by adolescents ages 10 to 18

in 1988 that were associated with ATVs occurred

with 3-wheel ATVs (80).

Factors Associated With Accidental Injuries

Among Adolescents

Factors associated with accidental injuries can be

categorized as demographic factors, risk-taking

behaviors, and stressful life events.

Demographic Characteristics

Demographic characteristics of adolescents that

appear to be associated with differing rates of

accidental injuries among adolescents include age,

gender, and race/ethnicity. While these characteristics are not amenable to change and thus cannot be

the targets of intervention or prevention efforts, this

information is useful to identify groups at highest

risk.

Age~Children at different developmental stages

experience different types of injuries (59). Thus,

adolescents can be expected to have different

patterns of experience with injury than younger

children or adults, and older adolescents experience

different patterns of injury than younger adolescents. For example, adolescents experience much

higher rates of motor vehicle occupant injuries,

bicycle injuries, and sports injuries than younger

ZIU.SA. v. Polaris Industries, LP. 87-3525 GAG (108).
Chapter 5—Accidental injuries: Prevention and Services . II-127

children, but young children are more likely to

experience pedestrian accidents (32,59).

In addition, dramatic increases in the rates of

accidental injury deaths occur during adolescence

and early adulthood. For example, although the rate

of death due to accidents in a recent year was 15.7

deaths per 100,000 population for adolescents ages

12 to 14, it was 55.8 deaths per 100,000 for those

ages 15 to 17, and 93.3 deaths per 100,000 for those

ages 18 to 19 (40). An evaluation of Massachusetts

data also revealed differences between injury patterns for younger adolescents ages 13 to 15 and older

adolescents ages 16 to 19 (9).28 The older adolescents experienced higher rates of injury and more

severe injuries than the younger ones; the older

adolescents’ rates of admission to hospitals due to

injuries were 1.26 times higher than the younger

adolescents’ rates, and their death rates due to

injuries were 1.50 times higher, Although the

younger adolescents experienced more bicyclerelated injuries, older adolescents experienced more

injuries of other types, including motor vehicle

occupant injuries, motorcycle injuries, burns, and

deaths due to overexertion. Because 19-year-olds are

likely to disproportionately contribute to the totals

of injuries or deaths due to some types of accidents

(e.g., motor vehicle crashes or accidents involving

alcohol), figures presented in this chapter that

include 19-year-olds may actually be higher than if

19-year-olds were excluded.

Gender—Adolescent males are at considerably

higher risk of death from injury than adolescent

females. Although there is some variation by cause

of injury, total rates of injury death for males ages 10

to 19 exceed those for females by as much as 9 to 1

(see table 5-3). The magnitude of this difference is

greater for older adolescents ages 15 to 19 than for

those ages 10 to 14 (65). For example, the male-tofemale ratio of deaths due to motor vehicle occupant

injury for the years 1984 to 1986 was 1.3:1 for ages

10 to 14, compared with 2.1:1 for those ages 15 to

19; similarly, the male-to-female ratio for drowning

deaths increases from 4.4: 1 forages 10 to 14, to 9.9:1

for ages 15 to 19.

It is impossible, because appropriate data are not

systematically collected, to determine the extent to

Table 5-3-Male-to-Female Ratios of Injury Deaths

Among U.S. Adolescents Ages 10 to 14 and Ages

15 to 19, by Selected Causes, 1984-86

Age group

Cause 10 to 14 15 to 19

Motor vehicle occupant . . . . . . . . . . . . . . . . . . . 1.3:1 2.1 :1

Motorcycles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4:1 8.2:1

Pedestrians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7:1 2.4:1

Fires and burns . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5:1 2.7:1

Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.8:1 5.9:1

Drowning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4:1 9.9:1

Firearms-accidental . . . . . . . . . . . . . . . . . . . . . . 8.9:1 8.9:1

Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2:1 4.4:1

Firearms.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6:1 5.8:1

Homicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5:1 3.2:1

Firearms.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6:1 5.0:1

SOURCE: U.S. Department of Health and Human Services, Public Health

Serviee, National Center for Health Statistics, Vhd ~atisfks of

the United States, Vo/urne /1-Morta/ity, %rf A (Washington,

DC: U.S. Government Printing Office, various years).

which differences between adolescent males and

females in accidental injury rates are a function of

differing exposure to situations where injuries may

occur, or to differing susceptibility based on some

other factor. There is some evidence that males tend

to engage more in behaviors that put them at higher

risk of injury. For example, the 1987 National

Adolescent Student Health Survey of 8th and 10th

graders found that 71 percent of males v. 48 percent

of females rode a motorcycle or minibike during the

past year; 32 percent of males v. 20 percent of

females swam alone; 71 percent of males v. 46

percent of females drove or rode a go-cart, snowmobile, or ATV; and 64 percent of males v. 19 percent

of females used a gun during the past year (6). These

data suggest that adolescent males, and the high risk

activities that males engage in, should be prime

targets of preventive interventions.

Race and Ethnicity—Race and ethnicity are

sometimes, but not always, differentially associated

with accidental injury deaths among U.S. adolescents.29 For example, the 1986 rate of accidental

injury death for black adolescents ages 10 to 14 was

14.7 deaths per 100,000, as compared with 13.0

deaths per 100,000 for white adolescents ages 10 to

14 (40). The 1986 rate of accidental injury death for

black adolescents ages 15 to 19 was 27.9 deaths per

100,000, as compared with 52.6 deaths per 100,000

for whites (40). These overall rates consist largely of

~Dam rewtid by Bass and colleagues (9) were collected from Sept. 1, 1979 through Aug. 31, 1982.

%e extent to which racial and ethnic differences reflect factors associated with socioeconomic status is not known. See ch. 18, “Issues in the

Delivery of Sewices to Selectcxi Groups of Adolescents,” in Vol. III for discussion.
11-128. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 5-5-Motor Vehicle Accident Deaths Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19,

by Race and Gender, 1968-87

100

F

10-14 years

80

60

—

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-> /--

-- - \

\,—1

-~. . ~ \

/ ‘. . .

.- ———. ./ , \ —

/’ —./ --- / ‘, / ‘.

.- -- ,’,

. . . . . -

‘ . /’ / - . . =., ‘- . . ‘. Z

‘,./’ \

--- - - --

,~

1968 1970 1975 1980 1985 1987

Year

100 –

80 –

60 –

40 –

20 –

10 –

8 –

6 –

4 –

2 –

15-19 years

\

\

— — \ /---

--- .—— -

\

\— ‘-; /

\~\ _b ,/, > .= ----

,~’\

/’ \

\

\ .“ ‘\ ,/ \ . ’ \

\/ \

\

\ ,-~ \

. - -. / \ ~. ,-- - ~

‘ .~-,

\ -.. -- - --

‘. , ../

J I I I 1 I J

1968 1970 1975 1980 1985 1987

Year

White male — — — Black male

———. White female ---------- Black female

SOURCES: 1966-85data: U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, ‘Trends and Current

Status in Childhood Mortality: United States, 1900-85,” 14ta/and HeaMr Statistics, Series 3, No. 26, DHHS Pub. No. (PHS) 89-1410 (Washington,

DC: U.S. Government Printing Office, 1989). 1987 data: U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, unpublished mortality data, Washington, DC, 1990.

motor vehicle accident-related deaths. As noted

above, black adolescents are somewhat more likely

than white adolescents to die as a result of drowning.

As shown in figure 5-5, motor vehicle accident

deaths declined somewhat for black male and female

adolescents between 1968 and 1987, although recently, death rates have leveled off.

Native American adolescents ages 10 to 19 are at

particularly high risk for injury, experiencing death

from accidental injury at over twice the rate of blacks

or whites. In 1986, Native American adolescents

ages 10 to 14 experienced injury deaths at a rate of

33.2 per 100,000; Native Americans ages 15 to 19

experienced injury deaths at a rate of 108.4 per

100,000 (12). There are several explanations for the

higher rates of injury among Native Americans (77).

Because a high proportion of Native Americans live

in rural areas, they are less likely to be discovered

quickly if they crash, and, once injured, they may not

have speedy access to trauma centers for treating

emergencies. Also, because alcohol cannot be legally purchased on reservations, many Native Americans travel some distance in order to drink, thus

increasing the number of miles that they drive under

the influence of alcohol if they drive home after

consuming alcohol.

There are few data on injuries among other racial

and ethnic groups of adolescents. According to The

Injury Fact Book, when all ages are considered

together, Asians have the lowest rates of injury (8a).

A recent analysis of childhood injury deaths found

that Asians ages O to 14 had an overall injury death
Chapter 5—Accidental injuries: Prevention and Services . 1/-129

rate equivalent to that of white children ages O to

1430 (117a). However, Asian children ages 0 to 14

were found to have higher death rates than average

for pedestrian traffic deaths, drownings, and deaths

resulting from falls (117a).

Other Demographic Factors--In the aggregate,

both social class and rural v. urban locale have been

shown to be associated with many types of injuries,

but many of the specific relationships between these

factors and injury among adolescents have not been

well-investigated. Adolescents in rural areas have

been found to be at higher risk of accidental injuries,

in part because of work with farm equipment (43a).

People who live in poverty, whether in rural or urban

environments, are at greater risk for drowning,

residential fires, and motor-vehicle-related deaths

(8a). As noted elsewhere in this Report, existing data

on the health status of poor adolescents and research

on the health effects of poverty have severe limitations.31

Risk-Taking Behavior

Some adolescents engage in behaviors that potentially increase their risk of accidental injury. These

include unsafe driving or bicycling practices (e.g.,

driving after consuming alcohol, not wearing safety

belts, not wearing a helmet), participating in football

or other contact sports, and not following water

safety rules (e.g., swimmin g alone) .32

Three types of risk-taking behaviors known to

increase the risk of accidental death or injury are

discussed below: alcohol or drug use, failure to use

safety belts, and failure to use bicycle or motorcycle

helmets.

Alcohol or Drug Abuse-Alcohol use is a major

risk factor for all types of injury .33 Alcohol affects

the injury process in at least three ways. First, it

impairs judgment, increasing the chances that the

user wilI become involved in a potentially injuryproducing situation (e.g., driving too fast, diving

into shallow water); second, alcohol impairs the

ability of the user to perform tasks necessary to

avoid injury (e.g., negotiating a slippery curve while

driving, Swimming to shore); and third, alcohol

exacerbates the severity of injuries by inhibiting the

ability of the body to withstand trauma (1 19).

In 1988, 3,158 adolescents ages 15 to 19 died in

alcohol-related motor vehicle crashes (1 13). Data

from the U.S. Department of Transportation’s Fatal

Accident Reporting System indicate that there have

been significant decreases in driver alcohol involvement in fatal motor vehicle crashes since the early

1980s (116). In 1988, 12.1 percent of drivers under

age 18 involved in fatal motor vehicle crashes had a

blood alcohol content of 0.10 percent or greater,

compared with 18.6 percent of drivers of that age in

1982 (1 10). Another 9.5 percent of the fatally injured

drivers under age 18 in 1988 (and 11.4 percent in

1982) had a blood alcohol content between 0.01 and

0.09, suggesting that alcohol use below the usual

legal limit is also associated with fatal accidents.

Alcohol is also frequently involved in fatal

pedestrian and bicycle accidents; in 1988, 23.6

percent of victims of fatal pedestrian or bicycle

accidents had a blood alcohol content of 0.10 percent

or greater (1 10).

A review of blood alcohol levels measured in 41

adolescents ages 16 to 18 admitted to a trauma center

following motor vehicle, bicycle, or pedestrian

accidents in North Carolina revealed that 29 percent

had measurable (although not legally prohibited)

levels of blood alcohol (55).35 Males were much

more likely to test positive for alcohol than females;

32 percent of males had measurable levels of blood

alcohol, compared with only 18 percent of females.

30N0 further age breakdowns were provided.

SIS= ch. 18, “Issues in tie Delive~ of Health and Related Services to Selected Groups of Adolescents, ” in VO1. ~.

32~ 1987, for e-pie, over ~ ~rd of 8~ and 1~ graders pficipating ~ tie Natio~ Smdent Heal~ Swey reported that they SWam alone dutig

the previous year, 26.4 percent that they swam in a restricted or unsupewised area and 28.4 percent that they dove into water of unknown depth (6).

33 For a general discussion of the use of alcohol and other drugs by adolescents, Sm Ch. 12, “Alcohol, Tobacco, and Drug Abuse: Prevention and

Services, ‘‘ in this volume.

34~sA wi~fie us Dep~en[ of Tr~portation defines a motor ve~cle crash as king relat~ to alcohol if the driver or nOnOCCUpaIlt (e.g,

pedestrian) has a blood alcohol concentration of 0.10 percent or greater. Persons with a blood alcohol content of 0.10 percent or greater are considered

to be intoxicated (1 16).

qs~e s~dy also includ~ 34 individuals ages 19 and 20. Blood alcohol content @AC) determina tions were made for only 50 of the total 86 patients

admitted to the hospital during the survey period. Unfortunately, the authors do not indicate the ages of the patients for whom BAC readings were not

obtained; rather they report the numbers of patients of each age with positive BAC relative to the total number of patients of each age who were admitted

to the hospital.
11-130. Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Less information is available on the possible link

between alcohol consumption and other types of

accidental injuries (47). Also, other drugs, such as

marijuana or cocaine, may elevate risk of injury,

though no systematic epidemiologic studies have

been conducted to identify the role these other drugs

may play in accidental injuries.

Failure To Use Safety Belts-There is substantial evidence that the use of safety belts in cars

reduces the chances of experiencing serious injury in

the event of a crash. For example, although about the

same proportion of restrained and unrestrained

passenger car occupants involved in fatal crashes in

1988 sustained nonfatal injuries (42 percent of

restrained occupants v. 40 percent of unrestrained

occupants), nearly twice as many unrestrained

occupants as restrained occupants were killed as a

result of injuries (49 v. 26 percent) (112).36

Surveys of U.S. adolescents indicate that most

adolescents do not wear safety belts (35). In the 1987

National Adolescent Student Health Survey of 8th

and 10th graders, only 41.2 percent reported that

they had worn a safety belt the last time they were in

a car (6).

U.S. adolescents do report, however, that protection in a crash is one of the most important factors in

their deciding to wear a safety belt; 81.2 percent of

adolescents surveyed in the National Adolescent

Student Health Survey reported that this was a very

important factor; in comparison, only 12.1 percent

said that friends’ use was a very important factor,

and over half reported that friends’ use was not

important at all (6). Riccio-Howe found that safety

belt use by family and friends was an important

factor in adolescents’ safety belt use (57a). Laws

were also found to be an important factor. RiccioHowe found that adolescents reported higher safety

belt use when a law mandating such use was in effect

than when it was repealed, and that adolescents who

had learned to drive during the period the law was in

effect continued to report higher safety belt use

(57a). The law was more predictive of adolescents’

safety belt use than were the adolescents’ health

beliefs and perceived locus of contro137 (57a).

Failure To Use Bicycle or Motorcycle HelmetsEvidence suggests that very few adolescents wear

bicycle helmets and that adolescents are less likely

than bicycle riders in older age groups to wear

helmets (120). Only 3.7 percent of over 200 bicyclists ages 11 to 19 interviewed in one study were

found to be wearing helmets; this compared with

16.2 percent of those age 30 or older (120). In the

1987 National Adolescent Student Health Survey of

8th and 10th graders, fewer than 10 percent said that

they ever wore a bicycle helmet, and less than 1

percent reported that they always wore a helmet (6).

A review of bicycle-riding-related accidents to

children ages 1 to 18 (80 percent of whom were

between ages 5 and 14) found that less than 1 percent

(ages not specified) had been wearing protective

equipment at the time of their injury (68).

Peer influence appears to play a role in whether

U.S. adolescents wear bicycle helmets. Over 60

percent of the 8th and 10th graders surveyed in the

National Adolescent Student Health Survey reported that they thought that their friends would

think that wearing a bicycle helmet was a “silly

thing to do” (6). Anecdotal evidence suggests that

some young adolescents distinguish between casual

neighborhood riding of bicycles and longer bicycle

trips and are more likely to wear helmets during the

latter activity.

Use of helmets among adolescents riding minibikes or motorcycles is also low. As of April 1990,

only 23 States required use of motorcycle helmets

for riders of all ages (44). Another 23 States required

use under a specified age, usually 18 (although in

some States the maximum age is as low as 15 years

old). Data on crashes in States where only minors are

required to wear motorcycle helmets indicate that

fewer than 40 percent of fatally injured minors were

wearing helmets, even though the law required them

to do so (1 14). Enforcement of helmet wearing

among minors is difficult, as it can be difficult to

distinguish them from older riders. Nearly 60

percent of 8th and 10th graders participating in the

1987 National Adolescent Student Health Survey

reported that they sometimes rode a motorcycle or

~~ese data are for all ages combined.

37A ~r.son~~ ~r=lv~ IW~ of ~on~ol is ~ or her gene~ sense tithe or she ei~er con~ls or is contioll~ by events (63a). Riccio-Howe USd

a locus of control scale speeifkally related to the occurrence of accidents (57a).

38 Smd~ts were not ~k~ &wfly whe~er, or how frquently, ~q rode a motorcycle ortib~, Rather, thq were tlskd how fr~UeIldy ~ey WOIE

a helmet when they did ride a motorcycle or minibike. Thus, it is not possible to determin e frequency of riding from the survey responses.
Chapter 5—Accidental injuries: Prevention and Services . II-131

minibike; however, only a third of those reported

that they always wore a helmet when riding (6).38

Stressful Life Events

In a study that compared ill and injured hospitalized adolescents on a variety of measures including

demographics, impulse control, emotional tone, and

alcohol and other drug use, Slap and her colleagues

found that the occurrence of stressful life events was,

along with gender and previous hospitalization for

an injury, a reliable characteristic distinguishing the

injured from the ill adolescents (68a). The stressful

life events most associated with hospitalization for

an injury included suspension from school, failing a

grade level, difficulty getting a summer job, breaking up with a boyfriend or girlfriend, and the death

of a grandparent (68a). However, Slap and her

colleagues note that their study sample was small

and otherwise somewhat limited methodologically

and that a prospective study to confirm the results is

needed (68a). It is also important to note that 28

percent of the injured patients in the Slap et al.

sample had been victims of assault; thus, the study’s

findings may be applicable to violent as well as

accidental injuries. Nonetheless, Slap and her colleagues’ results suggested that stresses that may be

minimized by adults are important risk factors for

injury during the adolescent years (68a). In an article

directed at school nurses, Lee and colleagues also

noted that high school is a stressful time for

adolescents, and that there is a potential relationship

between high levels of stress and accidental injury

(41a).

Consequences of Accidental Injuries

Among Adolescents

In general, the total dollar costs associated with

injuries, both accidental and intentional, in the

United States are enormous. An estimated $158

billion in aggregate lifetime direct and indirect

costs 39 is imposed annually by injuries in this

country (58).40 About a quarter of those costs

(around $39.4 billion) can be attributed to injuries

incurred by persons ages 15 to 24 (58). It is

important to note, however, that costs have not been

estimated separately for 10- to 18-year-olds. Thus, it

is difficult to infer the actual proportion of costs

attributable to accidental injuries among 10- to

18-year-olds.

For the 15- to 24-year-old age group, motor-vehiclerelated injuries are responsible for the greatest

lifetime costs, followed by falls, firearms, burns and

frees, drownings and near drownings, and poisonings

(58). Overall, males, who experience greater mortality and morbidity due to accidental injuries, also

account for more mortality and morbidity costs.

According to a study based on data gathered in the

1980 National Medical Care Utilization and Expenditure Survey, injuries and poisonings are responsible for the third greatest proportion of direct medical

costs to persons under age 17,41 accounting for $1.9

billion in 1980 dollars42 (36).

Anecdotal evidence from case studies indicates

that injuries have a tremendous impact on injured

adolescents, their families, and society (58). Along

with lost productivity, school absenteeism, and

health care expenses, injuries can have long-term or

permanent effects including disfigurement and loss

of ability to perform social roles.43 However, data on

injury-related disabilities are surprisingly sparse. No

national data are available to examine injury-related

disability in a systematic manner. Little information

is available on the long-term consequences of

injuries, particularly those that are less severe (47).

As a result, it is very difficult to document the impact

of injury survival beyond the acute phases of

treatment for injuries.

Data on the health consequences of accidents for

adolescents in terms of restricted-activity days, as

mentioned earlier, are available through NHIS

(93). In 1988, injuries (accidental and intentional

3QDirect cosrs we “~OWItS ptid for personal hedti c= . . . (and) for home mocliflcationj vocational rehabilitation and overhead and administrative

costs for automobile and health insurance’ for those tijured (58). Indirect costs can be divided into morbidity and mortality costs; morbidity costs include

the value of goods and services not produced because of injury-related illness and disability, while mortality costs constitute the value of lifetime earnings

lost by all who die prematurely as a result of injury.

Wstirnates are based on the lifetime costs for the 57 million persons injured in 1985 (58).

41~clud= children underage 10.

42However, inj~= ~d poiso~g5 ~co~ted for a lower proportion Of direct rnedi~ cm cOStS for ~jury for tie ~der IT age grOUp bit did f O

17- to #-year-oIds.

43sW ch. (j, “C~onic physical Illnesses: Prevention and SerVICeS, “ in this volume for additional discussion of disabilities among adolescents.
11-132 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

combined) were responsible for 18 percent of

restricted-activity days and 8.5 percent of school10SS days for acute conditions (93).44 Injuries were

responsible for 133.5 restricted-activity days and

38.9 bed-disability days per 100 males, and 104.9

restricted-activity days and 26.1 bed-disability days

for females (92). Injuries accounted for 32.3 school10SS days for every 100 students ages 10 to 17. For

adolescents ages 15 to 17, injuries accounted for 55

school-loss days per 100 students.

Prevention of Accidental Injuries

Among Adolescents

Accidental injury prevention efforts can focus

either on reducing or eliminating the occurrence of

accidents or on minimizing the effects of accidents—

i.e., reducing the severity of the injuries that might

result from the accident.

Three basic approaches have been used for the

prevention of accidental injuries: 1) persuasion or

education, 2) legislation and regulation, and 3)

automatic protection (47,58). The provision of direct

incentives or other tangible support, sometimes

combined with education, is another prevention

strategy (18,26).

Although results of evaluation efforts are not

definitive, there appears to be some consensus that,

in general, automatic protection is the most effective

strategy for injury protection, followed by laws and

regulation, and that education and persuasion is the

least effective strategy for injury prevention (9,47,

58,128). The use of direct incentives, sometimes

combined with education, has not been evaluated as

an overall strategy, but results of some programs

suggest that it too is promising (18,26). As with

other adolescent health problems, it is likely that no

single approach to prevention is sufficient (see also

12a).

Rivara has estimated that 29 percent of deaths

from trauma to U.S. children ages 1 to 14 could be

prevented if only 12 currently available prevention

strategies were implemented (60). Some of these

strategies (e.g., use of infant restraint seats) are not

applicable to adolescents ages 10 to 18. Nonetheless,

Rivara’s approach could be used to develop estimates of the numbers of preventable adolescent

injury deaths.

Injury prevention approaches targeted to individuals (education and incentives), regulation and legislation, and automatic protection are discussed below,

along with specific examples of injury prevention

efforts.

Educational and Incentive Approaches

Educational strategies are some of the mos t

widely used approaches to preventing injury; they

tend to be relatively inexpensive and have a high

level of community acceptance (78). The success of

educational efforts, however, has been mixed, and

there appears to be some consensus in the injury

field that, as mentioned above, education and

persuasion alone has been the least effective means

of accident prevention (9,47,58,128). OTA agrees

with this finding.

There are a number of reasons why educational

efforts may be unsuccessful. First, the change in

behavior advocated by the educational effort maybe

too complex (e.g., executing safe turns on a 3-wheel

ATV may be quite difficult ‘for a 13-year-old).

Second, complete compliance may be required for

the behavior to be effective (e.g., safety belts must be

worn every time the adolescent rides in a car). Third,

the required behavior may be unpleasant (e.g.,

adolescents may feel that wearing a bicycle helmet

is hot and uncomfortable or socially unacceptable).

And last, there may be other external barriers to

compliance (e.g., bicycle helmets may be unaffordable or unavailable; there maybe cultural, literacy, or

language barriers to receiving or responding to the

educational message). Thus, some interventions

have offered positive incentives to adolescents to

help increase health-enhancing behaviors such as

the use of safety belts and bicycle helmets.

Some education may help adolescents avoid

accidents. Educational efforts can be directed at

many different audiences including adolesents ,

parents, teachers, manufacturers, and policymakers.

For example, educational efforts can be directed

toward convincing adolescents to use safety belts,

parents can be taught how to discuss safety belt use

with their children, manufacturers can be educated

about public views regarding safety belt design, and

policymakers can be educated about the effectiveness of a law requiring safety belt use.

~R~trict~.activi~ days ~c~c~tti for 10 to 18-year-olds. School-loss &tys are calculated for 10- to 17-yw-olds (w)
Chapter 5—Accidental injuries: Prevention and Services . II-133

Examples of education and incentive efforts

targeted at changing the behavior of adolescents are

discussed below.

Driver Education

The lack of evaluation information on injuryprevention interventions has resulted in the implementation of programs that are ineffective, or that

even have adverse effects. A good example of this is

high school driver education programs (47,128).

Driver education had long been endorsed as an

intervention to reduce adolescent morbidity and

mortality due to motor vehicle crashes, Subsequent

research, however, has not supported the use of

driver education as it is currently delivered as a

strategy to reduce motor vehicle crashes (47,78).

A driver education study, involving random

assignment of students to an extensive driver education course, a shortened version of the course, or no

course at all, found that although students in the

shortened class experienced slightly fewer crashes

than those who had not taken a class, no reduction in

crashes was found for those who completed the

longer version of the class (69). Other research

indicates that driver education programs may actually result in higher rates of accidents among

adolescent drivers, in part because they make it

possible for adolescent drivers to obtain a license at

a younger age, when they may be more likely to be

in motor vehicle crashes (47,78). This occurs in

States where taking driver education is a prerequisite

for license at an earlier age (e.g., at age 16 instead of

17) (78). Another explanation of the low impact of

high school driver education courses is that such

courses provide novice drivers with inadequate

behind-the-wheel experience (72,105). In response,

some States have developed resource materials to

assist parents in providing behind-the-wheel practice (72). An additional response, of course, would

be for schools themselves to increase the amount of

behind-the-wheel experience provided to students

learning to drive.

Incentives

Safety restraints in automobiles have gained

increasing acceptance over the past decade as a

means of preventing or limiting the severity of

injuries associated with motor vehicle crashes. 4 5

However, because adolescents have lower rates of

use of safety belts than other age groups, special

approaches to encourage adolescents to use safety

belts seem to be necessary (6,47,109).

One such program, which used cash incentives to

increase voluntary safety belt use, was implemented

in Chapel Hill, North Carolina (18). Students’ cars,

identified by bumper stickers, were stopped randomly by study personnel as they entered the school

parking lot and, if the occupants were wearing their

safety belts, they were rewarded with $5 in cash. For

students not driving to school, family cars were

identified by bumper stickers. When the occupants

were observed anywhere in the community to be

wearing safety belts, the adolescent was rewarded

with $5 the next day in school. The program

involved soliciting donations from parents and

private businesses, paired with extensive publicity at

the high school (18). The program succeeded in

increasing observed use of safety belts among

adolescent males from just under 20 percent to close

to 39 percent, and among adolescent females from

21 percent to 44 percent. The long-term effects of

this program have not been assessed, so it is

unknown whether increases in safety belt use by

adolescents were maintained over time.

Combining Education and Incentives

The use of bicycle helmets has the potential to

reduce head injury among cyclists. Helmets are

relatively ineffective in most crashes that result in

fatalities but have considerable potential for reducing the severity of injury in nonfatal crashes. Several

studies have indicated that hardshell bicycle helmets

are associated with as much as a tenfold reduction in

the incidence of significant injuries to cyclists

(27,64,120). Despite its demonstrated effectiveness

in reducing the severity of injury, helmet use among

adolescent bicyclists is low (6,73,120).

In Seattle, a communitywide education campaign

was implemented in an effort to increase the use of

bicycle helmets (26). The campaign included efforts

to increase parental awareness of the need for

helmets, to promote the use of helmets by children,

and to reduce financial barriers to the purchase of

helmets. To increase parental awareness of the need

for helmets, the campaign included the use of a

variety of media to promote the use of bicycle

helmets, such as public service announcements on

television and radio, press conferences, informa4sAfibags ~e dis~ssed in tie sm[ion on ‘‘Automatic ROteCtiOn’ ~low.
//-134 ● Adolescent Health—Volume II: Background and the Effectiveness Of Selected prevention and Treatment Services

tional pamphlets distributed through physicians and

health departments, and presentations to community

groups. Efforts to promote use of helmets included

the implementation of a bicycle safety program in

public elementary schools, distribution of stickers

promoting helmets to school and youth groups and

at bicycling events, and the provision of incentives,

such as baseball tickets, to children who wore

helmets at bicycling events. Finally, in order to

reduce financial barriers to the purchase of bicycle

helmets, more than 100,000 discount coupons that

lowered the cost of helmets to about $25 were

distributed through physicians’ offices, schools,

youth groups, and community events; 1,300 helmets

were sold at cost through the Parent-Teacher Association; and 1,300 helmets were donated to youth

groups serving low-income children.

The effectiveness of the campaign was evaluated

by comparing observed use of bicycle helmets

before the campaign with observed use at various

intervals after the start of the campaign. Observations were made at a variety of sites, including

schools, bike trails, parks or playgrounds, and

streets. To control for intervening events not related

to the helmet campaign, observations of helmet use

were also made in a demographically similar city

(Portland, Oregon), where no organized effort to

increase helmet use occurred during the study

period. A total of 9,871 observations were made in

the two cities of children estimated to be ages 5 to 15.

Results of the evaluation indicated significantly

greater increases in the use of bicycle helmets in

Seattle as compared with Portland (26). Use of

helmets in Seattle increased from 4.6 to 14.0 percent

16 months after the campaign commenced, compared with an increase from 1.0 to 3.6 percent in

Portland. % Both before and after the campaign, use

was associated with race (whites were most likely to

wear helmets), bicycle type (riders of geared bikes

were more likely to use helmets), and site type

(riders on bicycle paths were more likely to use

helmets). In addition, children riding with companions (either other children or adults) who wore

helmets were much more likely to wear helmets

themselves, suggesting that peer and parental pressure may have an effect on use of helmets. Like other

multifaceted prevention efforts described throughout this Report, it is difficult to disaggregate the

effects of different elements of the Seattle prevention program. An evaluation that could disaggregate

the effects of education from helmet distribution and

other incentives, as well as assess the effectiveness

of both strategies used together, would be useful,

particularly if compared with a multifaceted intervention such as Seattle’s.

Legislation

Another strategy for preventing or controlling

accidental injuries is through legislation. Legislative

measures are usually directed at changing either the

environment or mandating specific behaviors. Examples include the motorcycle helmet and safety

belt laws currently in effect in most States, or

through local ordinances. In the first such effort in

the country, for example, bicycle helmets were

recently made mandatory for all bicycle riders in

Howard County, Maryland, riding on county paths

and streets (13,14). After pressure, however, the

Howard County Council subsequently voted to

amend the law to exempt riders over age 15 (14).

Laws and regulations can also be limited in their

effectiveness and may be least effective for those

who are at highest risk. For example, although 35

States plus the District of Columbia now have safety

belt-use laws47 (44,112), adolescents still have lower

use of safety belts than adults or younger children

(47,112). In 19 cities surveyed by the U.S. Department of Transportation’s NHTSA, safety belt use by

passengers ages 5 to 12 averaged 37 percent, with a

range from 24 to 60 percent, while usage fo r

passengers ages 13 to 19 averaged only 24 percent

(112). As noted previously, in States where only

minors are required to wear motorcycle helmets,

many adolescents do not wear them.

Special Driver Licensing Restrictions

for Adolescents

Nighttime driving curfews for adolescents, and

changes in the minimum driving age have been

shown to be effective in reducing adolescent vehicle

crashes. States with nighttime curfews for 16-yearti~e~e fiwe~ ~ae ~ju~t~ for a “~e~ of co~omfig v~~les, ~clu~g ~ce, type of bicycle, where bicyclist wu observed riding, ~ld with

whom (if anyone) bicyclist rode. The unadjusted rates for Seattle were 5.5 percent use of helmets before the campaign, and 15.7 percent use after the

campai~ unadjusted rates for Portland were 1.0 and 2.9 percent during the same period (26).

47A11 States ~ve laws rw~g fiat yo~ger c~dren be restra~ed by a c~dsafety seat or (for older children) safety belt, but most of these 1aWS

affect only children under the age of 6 (1 12).
Chapter 5—Accidental injuries: Prevention and Services .11-135

old drivers have reduced the fatalities in this age

group by as much as 69 percent (122). Since half of

fatal crashes involving 16- to 19-year-olds occur

between 9 p.m. and 6 a.m., this measure has

considerable potential for reducing injury.

It has also been suggested that the age for

obtaining a driver license be raised so that adolescents would be more mature before taking on the

complex task of driving. This approach is a response

to data demonstrating a disproportionate involvement of young drivers in severe and fatal crashes.

However, the approach does not account for the fact

that it takes time and practice to become a proficient

driver, even at older ages. Another strategy that has

been proposed is to develop a “graduated driver

licensing system” whereby adolescents could actually start driving as early as age 14 under close

parental supervision (11 1). The privileges of driving

at night, and without parents present, would be

phased in over the course of several years. This

would allow a period of time for adolescents to

gradually master the task of driving. Because this

approach has yet to be tested, no conclusions can be

drawn about the potential effectiveness of the

approach in reducing adolescent involvement in

motor vehicle crashes.

Requirements for School Bus Safety Belts

A number of school districts have moved to

require safety belts in school buses, although the

ratio of effectiveness to costs has been of concern48

(1 1), As part of a cost-benefit analysis of safety belts

in Texas school buses, estimates of the numbers of

preventable school bus injuries and fatalities were

calculated. It was calculated that 13 percent of

serious injuries49 to children ages 5 to 14 were

preventable with the use of safety belts, as were 52

percent of injuries to adolescents ages 15 to 18.50

Based on their analyses, the authors concluded that

installation of safety belts in Texas was not costbeneficial because the anticipated savings in direct

medical care and legal costs and indirect costs (e.g.,

foregone earnings) did not offset the significant

costs involved in retrofitting old buses and equipping new buses with safety belts.

A more recent and comprehensive study on school

bus safety was conducted by the Transportation

Research Board of the National Research Council

(48). The analysis examined the effectiveness of

safety belts in buses in preventing injury, assuming

that only one-half of all students would actually

wear the safety belts. It was estimated that, if all

large school buses in the United States were

equipped with safety belts, up to 1 life, 48 incapacitating injuries, 238 nonincapacitating injuries, and

665 injuries could be saved each year for a total

annual cost of $43 million to equip the buses and

maintain the safety belts. Based on these findings,

the Committee concluded that a Federal standard

mandating safety belts was unwarranted. Data from

the U.S. Department of Transportation’s NHTSA

show that far more children are injured or killed in

the process of boarding or leaving school buses than

in school buses themselves. The Transportation

Research Board recommended that, rather than

equipping large school buses with safety belts, the

safety of children riding school buses could be more

effectively improved through driver training, pupil

education, school bus monitors, safer school bus

routing, improved mirrors, and improved signaling

devices.

Automatic Protection

In contrast to voluntary efforts that rely on

education to promote compliance, automatic protection measures typically are directed at changing

consumer products or the environment. These efforts

are frequently intended to provide protection by

making changes that do not require individual

action. Efforts may be voluntary, or required as the

result of legislation or regulation. For example,

Federal regulations now require a wide array of

safety features on cars designed to reduce risks of

injury. These include shatterproof windshields, energyabsorbing steering columns, and automatic safety

belts or airbags. Environmental improvements, such

as better street design, improved lighting, and

installation of energy-absorbing materials at roadside sites where crashes are likely to occur, are also

#s~, “m.tw Schml buS~ we ~Wenfly ~u~~ t. ~ve safe~ ~1~ due to heir simi]ari~ to Cm md he lack of ohm protective features

are found in the larger buses (44).

bgsen’ous injun”e$ wmedefim~ as those receiving a score of 3 or grat~ on tie~‘ um Abbreviated Injury Scale (lMAIS), a commonly used trauma

severity scale (11). A MAIS score of 3 would reflect injuries such as major nerve laceration multiple rib fracture; abdominal organ contusion; or hand,

foot, or arm crush or amputation. A MAIS score of 6 would indicate that the injwy was potentially fatal.

~~er~l, however, chll&en ages 5 to 14 received 84 ~rcent of au injuries, and 83 permnt C)f SeriOUS hJUrieS.
11-136. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Photo credit: Bethesda-Chevy Chase Rescue Squad

In general, automatic safety features such as airbags have

been found to be more effective than education-based

preventive measures in preventing injuries. Airbags are

not yet required standard equipment in cars sold in the

United States and are unlikely to be found in the older

cars that adolescents apparently tend to use.

examples of efforts to provide automatic protection

(2a,78).

In automobiles, passive restraint devices such as

airbags or automatic safety belts are becoming

increasingly available as a result of Federal regulation. These devices are each limited in ways

different from standard shoulder-lap safety belts.

Airbags, as they are currently constructed, are most

effective in frontal collisions, which make up about

35 percent of all fatal car crashes (106). However,

airbags are designed to supplement the use of safety

belts. In order to enhance protection in frontal

crashes, and to provide protection in other types of

crashes, manually operated safety belts must be

worn in conjunction with airbags. While the effectiveness of automatic safety belts is believed to be

slightly less than traditional lap and shoulder belts,

the use of automatic safety belts could have a

substantial impact on injury reduction because, like

airbags, they do not rely upon active compliance. In

addition, the effectiveness of some automatic safety

belts can be enhanced by the simultaneous use of a

manually operated lap belt.

Federal Motor Vehicle Rule 208 required that all

new cars sold in the United States after September

1989 must have an automatic crash protection

system as standard equipment (28,1 13). However,

this system could be either airbags or automatic

safety belts. Some observers have noted that more

expensive model cars have been the first to use

airbags (121). (Honda, for example, will not make

airbags standard until late 1993, and even then ‘‘a

few low-priced, stripped cars may not have standard

airbags” (121)). Anecdotal evidence suggests that

adolescent drivers tend to use older, less expensive

cars.

Treatment of Accidental Injuries

Among Adolescents

Health service needs for acute and short-term

treatment of accidental injuries differ by the type and

severity of the injury sustained and, to a lesser

degree, the developmental characteristics of the

injured person.

Adolescents may present some special concerns

for treatment. For example, medical personnel may

have difficulty dealing with adolescents (22).51 In

addition, adolescents may have a need for additional

types of services beyond the immediate medical

treatment of the injury.

National data are not available, but there is some

evidence reported in smaller studies that the treatment needs of adolescents differ from those of

younger children. A study of persons under age 18

residing in upper Manhattan who sustained severe

injuries that resulted in hospitalization, for’ example,

found differences in the need for nonmedical services identified at the time of treatment. Adolescents

ages 10 to 16 were more likely than younger children

to have a need for psychological services,52 and less

likely to need child welfare services, according to

information recorded on hospital charts (52).

There is also evidence that the pattern of injury

differs by age. Data from emergency departments in

Massachusetts indicated that adolescents ages 16 to

19 sustain more severe injuries than adolescents

ages 13 to 15 (9). Adolescents ages 16 to 19 had

51AIS0 see ch. 15, “~jor ~~es Pe_ to the Delive~ of Primary and Comprehensive Services to Adolescents, ” in Vol. III for a diSCU55i0n Of

issues in the delivery of health services to adolescents.

szAdolescents were more Mely to have received gun shot wounds or to be referred for ingestions Of tOXiC substances.
Chapter 5—Accidental injuries: Prevention and Services .11-137

more injuries requiring treatment in emergency

rooms and higher rates of hospital admission. Data

from 88 Los Angeles County emergency departments indicate that 28 percent of all trauma cases

involved children and adolescents ages 1 to 19;

adolescents ages 13 to 19 had twice the number of

injuries requiring emergency services as children

under the age of 13 (67). In addition, head injuries

and abdominal injuries were found to be more

common among children and adolescents ages 1 to

19 than among adults.

The immediate treatment goal for all victims of

moderate to severe injury is timely and appropriate

prehospital and hospital care, regardless of age.

Guidelines specific to the treatment of adolescents

sustaining an injury do not exist; neither the

American College of Emergency Medicine nor the

American College of Surgery has a special protocol

for adolescents who sustain injury. Because extremes of age are a factor in the initial management

of a severely injured person, however, guidelines for

the very young (under 8 years of age) and the elderly

have been developed (4).

The issue of pediatric trauma care has received

increased attention over the past decade (37,38). The

American Pediatric Surgical Association and the

American College of Surgeons, for example, have

endorsed standards of care for critically injured

pediatric patients (3,57). These standards of care

recognize that children may have different treatment

needs from adults. Children tend to sustain different

types of injuries (e.g., head injuries), some types of

injuries need to be managed differently (e.g., growth

plate fractures must be properly managed to prevent

limb shortening or deformity), children have smaller

nutritional reserves and have different metabolic

requirements, and there is a need for providing

psychological support. There are no special guidelines for adolescent patients, however.

Following a 1987 conference on unintentional

injury among adolescents, the American Medical

Association’s (AMA) Council on Scientific Affairs

reviewed issues surrounding the use of emergency

room services by adolescents (15). The review was

prompted by the concern that the unique health

needs of adolescents might be neglected when it

comes to procedures and training of personnel

involved with emergency services. Unfortunately,

the AMA review was limited by a lack of current

.

Photo credit: Bethesda-Chevy Chase Rescue Squad

After a committee of the American Medical Association’s

Council of Scientific Affairs found that there was an

insufficient body of scientific knowledge relating to the

specific needs of adolescents in emergency rooms to

warrant a full report, the committee planned

to monitor the issue.

data on adolescent use of emergency room services.

Their analysis of clinical and developmental issues

suggested that adolescents in emergency rooms had

several requirements that might not be recognized

by emergency room personnel: the need for confidential services; the need for physicians to identify

hidden agendas (e.g., suicidal ideation in an 18-yearold male who has had a motorcycle accident); and

the need for followup services. These needs were

believed to apply to adolescents in all clinical

settings, not just in emergency facilities, and the

report suggested that “as more family practice,

pediatric, and internal medicine programs include

training in adolescent medicine, the care of adolescents in emergency rooms should improve’ (15). It

is not clear why specialists in emergency care were

not included in this group. The most important

conclusion seemed to be that the body of scientific

knowledge relating to the specific needs of adolescents in emergency rooms ‘‘is not large enough

currently to support a full [Council of Scientific

Affairs] report. The Committee pledged to monitor

the issue.
11-138. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Major Federal Policies and Programs

Pertaining to Accidental Injuries

Among Adolescents

Wide-ranging injury prevention and control activities, related to both accidental and intentional

injury, are conducted by the Federal Government.

These activities involve a number of different

agencies, each focusing on different aspects of the

injury problem. The involvement of many agencies

and activities has meant that attention has been given

to many injury-related issues, but the overall Federal

response has been fragmented (16).53

Some efforts have been made by DHHS and other

agencies to coordinate Federal injury prevention and

control efforts. Within the Centers for Disease

Control’s (CDC) Center for Environmental Health

and Injury Epidemiology and Control, a Division of

Injury Epidemiology and Control has been established to carry out a program of injury prevention

research in conjunction with the U.S. Department of

Transportation’s NHTSA, with half of the funding to

be directed to prevention and control of motor-vehiclerelated injury (16,30,108). In fiscal year 1989, a

Federal advisory committee for Injury Prevention

and Control was established through the Bureau of

Maternal and Child Health and CDC within DHHS,

and NHTSA within the U.S. Department of Transportation (50). The charge of the Advisory Committee is to report on the state of injury prevention and

set priorities for injury-related research; the first

meeting of the advisory committee took place in

September 1989 (50,87).

Various injury prevention and control activities of

the Federal Government that include a focus on

adolescents are described below.

U.S. Department of Health and Human Services

Centers for Disease Control

The Division of Injury Epidemiology and Control

(DIEC) in CDC was created in 1986 through funding

from NHTSA in an effort to better coordinate

Federal efforts in the area of injury control. Prior to

this, no central agency had Federal responsibility for

reducing the incidence of injuries (47).

Funding for injury research activities at CDC has

increased substantially over the past several years,

although it is still quite low in comparison with the

funding appropriated for heart disease or cancer.

Appropriations for fiscal year 1989 were over $23

million, more than twice the budget for 1988 (103).

Some programs that are funded through DIEC

specifically target accidental and intentional injury

among adolescents (e.g., motor-vehicle-related injuries, adolescent suicide or homicide); however, most

do not. Although there is no budget line item specific

to adolescents at DIEC, an estimated 15 percent of

their funding, $3.3 million, is directed at adolescent

issues (87).

The priorities of DIEC are to support intramural

and extramural injury research and to support State

and local injury prevention and control programs

(87). Funded activities include the development of

injury surveillance systems; collection and analysis

of data; professional education and training; and

research in acute care, biomechanics, epidemiology,

and prevention (87,103). In addition, several multidisciplinary, injury prevention academic research

centers are funded; these centers provide injuryrelated research, training, and technical assistance

(87).

Health Resources and Services Administration

The Bureau of Maternal and Child Health in the

Health Resources and Services Administration of

DHHS has provided grants for injury prevention

projects through the special projects of regional and

national significance (SPRANS) program authorized under Title V of the Social Security Act. In

fiscal year 1988, 23 SPRANS projects dealt with

injury prevention among adolescents.54 Children

and adolescents are targeted through these programs. Projects have been funded to implement

injury prevention programs in States, provide injury

prevention services to Native American adolescents,

and reduce drinkin. g and driving among adolescents

(49,94). Also funded through the Bureau of Maternal

and Child Health are 12 demonstration projects

designed to improve emergency medical services for

children, including adolescents, although adolescents are not specifically targeted (95).

ss~e gene~ problem of fragmen~tion in the Federal approach to adolescent health is discussed at length iLI ch. 19, “T’he Role of Federal Agencies

in Adolescent Healt&” in Vol. III.

~For tier diseussio~ see ch. 19, “The Role of Federal Agencies in Adolescent HedtlL” in Vol. III.
Chapter 5—Accidental Injuries: Prevention and Services . II-139

National Institute for Child Health and

Human Development

The National Institute of Child Health and Human

Development (NICHD) within the National Institutes of Health identifies the prevention of childhood

injury as one of its priorities. In 1987, NICHD

developed a plan for the development of research on

the prevention of childhood injury (102). Initially

funded projects focus on the prevention of injury

among younger children rather than adolescents.

U.S. Department of Transportation’s National

Highway Traffic Safety Administration

NHTSA was established within the U.S. Department of Transportation in 1970 by the Highway

Safety Act of 1970 (108). The mandate of NHTSA

is to reduce deaths, injuries, and economic costs

resulting from motor vehicle crashes. NHTSA’s

activities and research include efforts to stimulate

activities to improve occupant protection, improve

traffic law enforcement, improve the quality of

emergency medical services, and establish and

maintain a computerized traffic recordkeeping system (109).

Adolescents and young adults ages 15 to 24 are a

major focus of the efforts of NHTSA to increase

safety belt use and to reduce drunk and drugged

driving-related traffic fatalities (109). NHTSA annually awards four to five research and demonstration

grants targeted at 15- to 24-year-olds. Most of the

past research conducted through NHTSA has focused on programs to educate young people about

the risks of drinking and driving, and about safety

belt usage.

Although most efforts of NHTSA are not agespecific, some efforts are directed at adolescents and

young adults under the age of21. In fiscal year 1988,

NHTSA focused over $1 million on research and

program activities designed to address highway

safety problems of individuals ages 15 to 24 (109).

The majority of programs have targeted high-school

age adolescents. These include media campaigns

addressing the issue of drunk driving, the development of high school assembly programs, and training programs for teachers to enhance their abilities

to discuss alcohol and drug abuse issues with their

students. In January 1990, NHTSA issued a report

on a “Young Adult Highway Safety Plan,” which

focuses on the involvement of 15- to 24-year-olds in

motor vehicle crashes (1 15). Areas of emphasis in

the plan include adjudication, supervision, enforcement, legislation, licensing, school-based and extracurricular programs, and community- and workbased programs.

NHSTA also funds activities aimed at younger

children which affect adolescents in the 10- to

14-year-old age group. These activities include

Pedestrian Safety Programs that teach children ages

9 to 12 to deal with a complex traffic environment

(44,56). In 1990, a Bicycle Education Program

directed at children in grades 5 and 6 was in the

planning stages; and a new instructional kit providing information on occupant protection to junior and

middle school students, ‘‘The Car Club,” was under

development (44).

NHTSA also administers the Fatal Accident

Reporting System, which gathers data on fatal

vehicle accidents, and the National Accident Sampling System, which reports on fatal and nonfatal

traffic crashes based on a sample of cases.

U.S. Consumer Product Safety Commission

The U.S. Consumer Product Safety Commission,

in operation since 1973, is responsible for overseeing a wide range of consumer products to ensure that

they are not hazardous to consumers (79). The

commission uses several strategies for correcting

consumer hazards, including issuing and enforcing

mandatory standards, working with industry to

develop voluntary standards, banning products,

recalling products, conducting research on potential

hazards of products, encouraging the development

of new or improved voluntary standards, and conducting consumer information programs. For example, the commission was responsible for banning the

sale of 3-wheel ATVs, and the request that industry

develop a voluntary standard for 4-wheel ATV

safety.

The commission also oversees the National Electronic Injury Surveillance System, which maintains

information on emergency room visits for injuries

that are related to consumer products (excluding

motor vehicle, firearms, and several other classes of

consumer products that are not under the jurisdiction

of the commission).

Conclusions and Policy Implications

Accidental injuries are responsible for more

deaths among U.S. adolescents than any other

problem. In 1987, 10,658 U.S. adolescents ages 10
11-140. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

to 19 died as a result of accidental injury. Nearly

two-thirds of these deaths resulted from motor

vehicle crashes. U.S. adolescents are particularly

susceptible to being involved in a motor vehicle

crash when driving at night, or when driving after

consuming alcohol.

Accidental injury deaths, however, represent just

the “tip of the iceberg” of problems resulting from

accidental injuries (58). Such injuries also cause

temporary or permanent disabilities,55 utilization of

health care, school loss, and other problems. Sports

and recreational activities, such as basketball and

football, are a leading cause of nonfatal injuries

among adolescents.

Three basic approaches have been used for the

prevention of accidental injuries. These are persuasion or education, legislation and regulation, and

automatic protection. Positive incentives to encourage the use of protective equipment have also been

tried and evaluated. Although results are not definitive, there appears to be some consensus that

automatic protection (e.g., airbags in cars) is the

most effective strategy for injury prevention, followed by laws and regulation, and that education and

persuasion is the least effective strategy for injury

prevention. In a few evaluations, however, programs

that provide incentives to use protective devices

(e.g., safety belts, bicycle helmets) have shown

promise.

Over the past few years, there has been a

significant increase in the amount of attention paid

to injury research (62). Nonetheless, few reliable

data exist on the causes of accidental injuries among

adolescents, or on the effectiveness of interventions

to prevent accidental injuries or limit their severity.

Studies have primarily been descriptive in nature;

rigorous effectiveness evaluations of prevention

programs are particularly needed, as well as studies

that seek to identify causal relationships so interventions may be developed (62).

There is little information on the long-term

economic and other costs of injury (58). Neither the

long-term monetary costs of injuries nor the sometimes devastating effects on families of seriously

injured adolescents (e.g., financial and emotional

stress) have been extensively assessed.56

The lack of comprehensive national data on

accidental injuries among adolescents ages 10 to 18

makes it difficult to reach conclusions about which

groups of adolescents are most at risk, and about the

environmental characteristics that increase risk for

accidental injury (17). This lack of data inhibits the

development of a national strategy to address the

problem of accidental injury. At the same time, it is

critical that local jurisdictions have adequate injury

surveillance systems so they can effectively identify

problem areas, develop community responses that

address their unique injury problems, and evaluate

the effectiveness of their efforts (86).57

Evidence about the cause of injury is essential for

determining appropriate interventions. While diagnostic information helps to distinguish skull fractures from concussions or lacerations from contusions, it does not identify factors pertinent to the

prevention of the injury. Data about injury causation

are essential to differentiate, for example, whether

the skull fracture resulted from a fall, a motorcycle

crash, or from playing football. Each of these causal

factors implies the need for different preventive

strategies (e.g., installation of a secure railing on a

bridge, passage of motorcycle helmet laws, or

changes in the design of football helmets). Inclusion

in medical records of information on the causes of

injuries would greatly enhance the utility of injuryrelated diagnostic information.

Data on the full spectrum of injuries, including

those that do not result in hospitalization or death,

are necessary to monitor the injury problem adequately, and to define appropriate countermeasures.

Focusing only on injuries with the most severe

outcomes results in a biased view of the injury

problem. For example, although motor vehicle

crashes are clearly the most important cause of

severe injuries and death among adolescents, sports

and recreational injuries actually account for many

more injuries and are experienced by many more

adolescents. A review of mortality data alone would

not reveal the important role that sports and recreational activities play in adolescent injuries.

55s= Ch. 6, “@onic physic~ Illnesses: Prevention and SerViCeS, “ in this volume for a discussion of the effects of chronic physical illnesses and

disabilities on adolescents.

fisome of tie effec~ of Molewent ~s~ility on families are discussed in ch. 6, ‘ ‘Chronic Physical Illnesses: Prevention and Services, ’ in thiS vOIUme.

STFor Cxmple, a @@ n~~r of ~des~~ injuries along a particular stretch of road might indicate a need for better lightkg, the need for a pedestrian

walkway, or a need for warning signs, depending on the circumstances.
Chapter 5—Accidental injuries: Prevention and Services .11-141

Another type of information that is lacking is the

measurement of exposure. This is a difficult task that

typically requires collection of data outside the

health care delivery system. For example, in drawing

appropriate conclusions about the risk of motor

vehicle crashes involving adolescent drivers, it is

important to document both the numbers of adolescent drivers and the extent to which they drive. This

kind of exposure information serves as the denominator in calculating rates. It allows comparisons that

take into account whether adolescents contribute

disproportionately to motor vehicle crashes, or

become involved in crashes at rates (per mile driven

or time spent driving) that are no different from their

parents or other adults. Some estimates of miles

driven by adolescents can be obtained by transportation or insurance authorities; however, this kind of

exposure information is not available for other types

of injuries. Thus, for example, information on how

many miles adolescents log on bicycles or ATVs or

on how many adolescents know how to swim or

swim well is not available.

Few good evaluation studies have been conducted

on the effectiveness of specific injury prevention

programs or intervention approaches. Although

there appear to be many good ideas among injury

prevention efforts, few have been well evaluated

(50). It is critical that adolescent attitudes and beliefs

about injury problems and various modes of injury

prevention be considered when developing injury

prevention interventions (65).

Although there is some evidence that adolescents

with injuries may require some specialized treatment (e.g., psychological services, education on

injury prevention) after injury, there is little information available on these needs, or on whether there is

a need to train medical personnel in the special care

of adolescents with injuries. Information is also

lacking on long-term outcomes of accidental injury

and the costs associated with injury. This requires a

recordkeeping system with the ability to track injury

victims over time and through various systems of

health care, rehabilitation, and education services.

Funding for injury prevention research is scarce

and has not been sufficient to permit well-designed

intervention trials or solid evaluation studies. The

new initiatives within CDC to fund research and

intervention programs are directed, in part, at

meeting this need. In proportion to the magnitude of

the problem and funding of programs for other

health problems, however, funding for these injury

prevention programs is minimal. For example,

despite the significant costs of injuries, both monetary and personal, overall finding for injury prevention and control is significantly less than that for

cancer and cardiovascular diseases (58).

There is a critical need for a focus by Federal and

local governments on the problem of accidental

injury, including support for prevention research and

programming g, and for data systems to provide the

information necessary to develop informed policies.

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Chapter 6

CHRONIC PHYSICAL ILLNESSES:

PREVENTION AND SERVICES

Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Background on Physical Health Problems of Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

Physical Causes of Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

Reasons for Hospitalizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Reasons for Visits to Office-Based Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

Findings From National Population-Based Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

National Health Interview Survey (NHIS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

National Health Examination Survey (NHES) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

Physical Health Problems From the Perspective of Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

Physical Health Problems From the Perspective of Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Background on chronic Physical Illnesses and Disabilities of Adolescents . . . . . . . . . . . . . . . . . . . 163

Trends in the Incidence and Prevalence of Chronic Physical Illnesses and Disabilities

Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Consequences of Serious Chronic Conditions for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

Activity Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Psychosocial Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Prevention of Chronic Physical Illnesses and Disabilities Among Adolescents . . . . . . . . . . . . . . . . 168

Services and Interventions for Adolescents With Chronic Physical Illnesses and Disabilities . . . 169

Use of Health Services by Adolescents With Chronic Conditions . . . . . . . . . . . . . . . . . . . . . . . . . 169

Costs of Treatment for Adolescents With Chronic Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Interventions To Treat Psychosocial Problems of Adolescents With Chronic Conditions . . . . . 171

State and Local Services for Adolescents With Chronic Conditions . . . . . . . . . . . . . . . . . . . . . . . 173

Examples of Chronic Physical Illnesses Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

Cancer Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

Trends in the Incidence and Prevalence of Cancer Among Adolescents . . . . . . . . . . . . . . . . . . 174

Consequences of Cancer Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

Prevention of cancer Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Services and Interventions for the Treatment of Adolescent Cancer . . . . . . . . . . . . . . . . . . . . . 177

Major Federal Policies and Programs Pertaining to Cancer Among Adolescents . . . . . . . . . . 179

Acne Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Dysmenorrhea Among Adolescent Females . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

Major Federal Policies and Programs Pertaining to Adolescents With Chronic Conditions . . . . . 183

Education for All Handicapped Children Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Developmental Disabilities Assistance and Bill of Rights Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Other Federal Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

Chapter 6 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186

Boxes

Box Page

6-A. Examples of Definitions of Chronic Illness and Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

6-B. Federal Sources of Data on the Physical Health of U.S. Adolescents . . . . . . . . . . . . . . . . . . . . 152

6-C. Trends in the Prevalence of Chronic Physical Conditions Among U.S. Adolescents . . . . . . . 164

Figures

Figure Page

6-1. Parents’ Ratings of Child and Adolescent Health Compared to Physicians’ Findings

on Examination, U.S. Children Ages 6 to 17, 1963-65 and 1966-70 . . . . . . . . . . . . . . . . . . . . . 162

6-2. Incidence of Cancer Among U.S. Adolescents Ages 10 to 19, 1975 -87 . . . . . . . . . . . . . . . . . . 175

6-3. Cancer Mortality for U.S. Adolescents Ages 10 to 19, 1973-87 . . . . . . . . . . . . . . . . . . . . . . . . . 175

Tables

Table Page

6-1. Rates of Different First-Listed Diagnoses for U.S. Adolescents Ages 10 to 18 Discharged

From Short-Stay Non-Federal Hospitals, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

6-2. Number of Different First-Listed Diagnoses for U.S. Adolescents Ages 10 to 18

Discharged From Short-Stay Non-Federal Hospitals, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

6-3. Visits to Office-Based Physicians by U.S. Adolescents Ages 10 to 18: Number and

Distribution by Diagnosis, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

6-4. Visits to Office-Based Physicians by U.S. Adolescents Ages 10 to 18: Number and

Distribution by the 15 Most Common Principal Diagnoses, 1985 . . . . . . . . . . . . . . . . . . . . . . 156

6-5. Number of Restricted-Activity Days Associated With Acute Conditions per 100

U.S. Adolescents for Noninstitutionalized Adolescents Ages 10 to 18, by Sex, Age,

and Type of Condition, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

6-6. Number of School-Loss Days Associated With Acute Conditions per 100 U.S. Adolescents

for Noninstitutionalized Adolescents Ages 10 to 17, by Sex, Race, Family Income,

and Type of Condition, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

6-7. Prevalence Rate for 20 Leading Chronic Conditions Among Noninstitutionalized

U.S. Adolescents Ages 10 to 18, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

6-8. Distribution of U.S. Adolescents Ages 10 to 18 by Degree of Activity Limitation Due to a

Chronic Physical or Menta1 Condition and Socioeconomic Characteristics, 1988 . . . . . . . . . 160

6-9. Estimated Prevalence of Chronic Conditions in U.S. Children Ages O to 20, 1980 . . . . . . . 165

6-10. Number of Restricted-Activity Days Due to Acute/Chronic Conditions Among

Noninstitutionalized U.S. Adolescents Ages 10 to 18, by Type of Restricted-Activity Day

and Sociodemographic Characteristics, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Chapter 6

CHRONIC PHYSICAL ILLNESSES:

PREVENTION AND SERVICES

Introduction

Despite the common perception that U.S. adolescents are among the healthiest of Americans, evidence from a variety of sources discussed below

indicates that many adolescents experience acute or

chronic conditions that adversely affect their lives

(see definitions in box 6-A). Acute conditions

experienced by adolescents include injuries (e.g.,

sprains, lacerations, and fractures)l and illnesses

ranging from colds and influenza to appendicitis.

Chronic conditions include a wide spectrum of

physical and mental health problems (e.g., hay fever,

acne, cancer, diabetes, cardiovascular disease, epilepsy, orthopedic impairments due to injury, hearing

impairments, visual impairments, emotional problems, and mental retardation). Nevertheless, in the

1988 National Health Interview Survey (NHIS)

conducted by the U.S. Department of Health and

Human Services (DHHS), 97.1 percent of 10- to

18-year-olds were reported to be in good to excellent

health (105). NHIS data generally reflect parents’

perceptions of adolescents health status, 2 but other

evidence suggests that, for the most part, adolescents

also regard themselves as healthy. 3

This chapter raises some important issues related

to the prevention and treatment of chronic physical

health problems among U.S. adolescents. 4 First, it

provides background on physical health problems of

adolescents using a variety of data. Next it provides

an overview of chronic physical illnesses and

disabilities among adolescents and discusses the

prevention and treatment of such problems. The

chapter includes an in-depth discussion of cancer

and of two physical health problems whose importance to adolescents is sometimes overlooked by

parents, health care providers, and policymakers:

acne and dysmenorrhea (painful menstruation). Finally, the chapter reviews major Federal programs

pertaining to chronic physical illness and disability.

It is important to emphasize that this chapter is not

designed to be a comprehensive assessment of all

chronic physical health problems affecting adolescents. Rather, this chapter is intended to stimulate

further discussion of issues such as how to assess the

physical health status of adolescents; how to prevent

and treat adolescents’ chronic physical health problems; and what role the Federal Government can

play in addressing the needs of adolescents with

physical health problems. Other chapters in this

volume cover a variety of specific adolescent

physical health topics.s Chronic physical illnesses

that affect adolescents and merit policy analysis but

are not covered in depth in this chapter include

asthma, diabetes, hypertension, chronic renal disease, seizures, and visual and hearing impairments

(14,22,78).

It is also important to note that this chapter does

not cover generic issues related to the delivery of

health care services to adolescents. The delivery of

primary and comprehensive care to adolescents,

adolescents’ health insurance status and financial

l~njurie~ me -or hu~s ~mted t. the body by an external force (16a). Information on injuries among U.S. adolescents is pre~nted fi ch. 5!

“Accidental Injuries: Prevention and Services, ” in this volume.

WS has a number of limitations. As a household survey of a sample of the civilian noninstitutionalized population, it does not include individuals

who are homeless or in institutions such as nursing homes or hospitaIs. For individuals under age 17, information is collected from a proxy, usually a

parent or guardian. Older adolescents, 17- and 18-year-olds, may respond for themselves (105).

3A Smey of M~e50ta youth found, for exmple, that 91.4 percent of males and 85.9 percent of fdes believed that the~ he~~ status was good

to excellent (88).

dFollowing current mainstream usage, although not without occasional difficulty and ambiguity, this chapter defines physical health problem as

problems ‘‘of or related to the body, and having material existence’ and defines mental health problems as problems ‘‘pertaining to the mind.”

Information on mental health problems in adolescents is presented in ch. 11, ‘‘Mental Health Problems: Prevention and Services, ’ in this volume. Some

mental health problems have a physical basis, so the distinction between physical and mental health problems is somewhat arbitrary.

sFor exaple, tie prev~ence, Con.squences, prevention, and short-term treatment of accidental injties ~ covered in this ‘ol~eh Ch. 5!

“Accidental Injuries: Prevention and Services’ nutrition and fitness problems, in ch. 7, ‘ ‘Nutrition and Fitness Problems: Prevention and Services”;

dental problems, inch. 8, ‘‘Dental and Oral Health Problems: Prevention and Services’ AIDS and other sexually transmitted diseases, inch. 9, “AIDS

and Other Sexually Transmitted Diseases: Prevention and Services.

-II-149-
11-150. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 6-A—Examples of Definitions of Chronic Illness and Disability

The literature on chronic illness and disability-for adolescents and for individuals of all ages--contains a

wide array of definitions. Although some of the differences cannot be resolved in this chapter, several definitions

are provided below as a guide to OTA’s approach to assessing the prevalence and consequences of chronic illness

and disability among adolescents.

For the purpose of the National Health Interview Survey (NHIS) conducted by the National Center for Health

Statistics in the U.S. Department of Health and Human Services (DHHS), a health condition is a departure from

a state of physical or mental well-being (104). A condition maybe either an illness, an injury, or an impairment (see

below). A condition is considered acute if it has lasted 3 months and is of sufficient consequence to have involved

either a physician visit or at least 1 day of restricted activity; a condition is considered chronic if it has lasted 3

months or more or is a type of condition that normally lasts for at least 3 months (e.g., asthma, diabetes, heart

conditions) (105).

NHIS defines a disability as any temporary or long-term reduction of a person’s activity as a result of an acute

or chronic condition (104). Disabilities are sometimes caused by illnesses (e.g., spina bifida, cerebral palsy, severe

asthma) and sometimes caused by injuries or impairments. In NHIS, an impairment is a chronic or permanent defect,

usually static in nature, that results from disease, injury, or congenital malformation (107a).

NHIS measures disability in several ways. One way is in terms of the number of “disability days,” or days

that a person’s activity has been reduced. NHIS identifies several types of disability days. “Restricted-activity

days” (the most inclusive and least descriptive measure) are any days on which a person restricts his or her usual

activities for more than half the day because of illness or injury. NHIS measures four types of restricted-activity

days: bed-disability days, work-loss days, school-loss days, and cutdown days. “School-loss days” area type of

restricted-activity day determined only for children ages 5 through 17; basically these days are any days on which

a child did not attend school for at least half the day because of illness or injury. ,

NHIS also measures disability in terms of “limitation of activity due to chronic conditions” (107a). A

limitation of activity refers to a long-term reduction in a person’s capacity to perform the average kind or amount

of activities associated with his or her age group. Individuals identified as having a chronic condition by NHIS are

classified into categories that reflect the extent to which their activities are limited because of the conditions as

follows: 1) unable to carry on the major activity for their age group (for children 5 to 17, major activity refers to

school attendance; for individuals age 18 and over, it usually refers to a job, housework, or school attendance);

access to health services, consent and confidentiality offices and for hospitalizations; data from household

issues affecting adolescents, and issues specific to

the delivery of services to selected groups of

adolescents (e.g., black, Hispanic, Asian-American,

American Indian and Alaska Native, Native Hawaiian, rural, and poor adolescents) are topics

addressed in Volume III of this Report.

Background on Physical Health

Problems of Adolescents

There is no single comprehensive source of

information about the physical health status of U.S.

adolescents. Hence, a variety of sources must be

used to identify the most important physical health

problems facing adolescents. As noted in box 6-B,

data available from the National Center for Health

Statistics in DHHS include vital statistics data that

provide information on causes of death for adolescents; data on reasons for visits to physicians’

interview surveys-hat gather information on health

problems, including those that result in limitations in

activity; and data from epidemiologic surveys that

include clinical examinations. Physical health concerns of particular importance to adolescents maybe

identified through surveys of young people that ask

directly about their most pressing health concerns.

Data from all of these sources are presented below

to identify important health problems for U.S.

adolescents.

Physical Causes of Death

As noted in box 6-B, national mortality data are

compiled from State death certificates by the National Center for Health Statistics in DHHS on an

ongoing basis. National mortality statistics include

information on the cause of death and demographic
Chapter 6-Chronic Physical Illnesses: Prevention and Services ● II-151

2) able to perform the basic activity but limited in the amount or kind of major activity performed; 3) not limited

in major activity but limited in the kind or amount of other activities; and 4) not limited in activity.

OTA has sometimes broadly defined a chronic condition as a problem or disease that is lingering and lasting,

as opposed to acute. In its 1982 report Technology and Handicapped People, OTA defined disability as a functional

limitation, noting that a person with a disability has a “limited ability or an inability to perform one or more basic

[daily] life functions (e.g., walking) at a level considered ‘typical’ “ (92). Disabilities are often caused by

impairments (92). According to OTA, an impairment is a physiological, anatomical, or mental loss or

“abnormality” caused by accident, disease, or congenital condition (92). Visual impairments, for example, may

limit the ability to see. A handicap, according to OTA, has to be defined within its environmental and personal

contexts (92). Individuals are handicapped by their disability if it prevents them from performing one or more life

functions at a “typical” level (92). “Handicaps are caused not by the disabilities themselves, but by the interaction

between an individual’s disability and the social environments in which the individual is functioning or expected

to function” (92). Thus, an adolescent with poor vision has an impairment which reduces her ability to see (a

disability). However, if corrective lenses can adequately correct her vision or if she can communicate effectively

through the use of oral interpreters and braille, the visual impairment may not prevent the adolescent from

performing in school, at home, or socially (i.e., it may not become a handicap).

In this chapter, chronic ilnesses are defined as diseases that persist over a long period of time. According to

a current medical dictionary, a disease is “any deviation from or interruption of the normal structure or function

of any part, organ, or system, or combination thereof, of the body that is manifested by a characteristic set of

symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown” (16a). 1 Disabilities

refer to limitations, usually long-term, in an individual’s ability to perform basic activities of daily living.

Mainstream distinctions between physical and mental conditions are adhered to in this Report, so that physical is

generally defined as being “of or related to the body, and having material existence,” whereas mental is defined

as “pertaining to the mind.” Some mental health problems have at least some biological component so the

distinction between physical and mental health problems is rather arbitrary.2

IDis~s are SOmetimeS distinguished horn injuries, which have been defii as “harms or hurts i.tlfliCted to the body by ~ext~

force” (16a). Information on injuries among U.S. adolescents is presented inch. 5, “Accidental Injuries: Prevention and Services,” in this

volume,

2~o-tiononsel=t~ men~ ~~problems tit ~ectu,s. adolescents is presen~ inch. 11, “WM H~thProt)lems: prevention

and Services, “ in this volume.

characteristics of the decedent. Recent mortality hospitals in the United States (see box 6-B).

statistics indicate that the most frequent natural

cause of death among U.S. adolescents ages 10 to

196 is cancer.7

Reasons for Hospitalizations

The National Hospital Discharge Survey (NHDS),

a survey sponsored by the National Center for Health

Statistics, provides information on hospital discharges from a sample of short-stay non-Federal

According to the 1987 NHDS, injury and poisoning

are the problems that most frequently lead to

hospitalization for U.S. males and females ages 10

to 18. Childbirth is the most frequent reason for

hospitalization for U.S. females ages 15 to 18.8 The

types of physical illnesses that most frequently lead

to hospitalization for U.S. males and females ages 10

to 18 are diseases of the respiratory system and

diseases of the digestive system (see table 6-l).

6T0 the extent possible, this OTA Report focuses on adolescents ages 10 through 18. It also attempts, whenever possible, to present evidence for

smatler age groupings of adolescents (e.g., 10 to 14- and 15- to 18-year-olds). Sometimes, however, data were not readily available for these age

groupings, and OTA used other age breaks. As a prominent example, the National Center for Health Statistics typically makes mortality data available

at 5-year age breaks; thus, this section reports on information for 10- to 14-year-olds and 15- to 19-year+ Ms.

l’Natural ~au~e~ of d~~ refer t. ~us~ such as illness, disease, or chronic conditions as opposed to external causes of death such m acciden~

injuries, homicide, or suicide. As shown intigure 5-1 inch. 5, ‘‘Accidental Injuries: Prevention and Services, ’ more adolescents die from external causes

than from natural causes. These other problems are covered in other chapters of the Report. Age differences in causes of death in the U.S. population

are covered in Vol. I of this Repoti.

gsee ch. 10, ‘‘~e~cy and Parenting: Prevention and SerVICeS, ‘‘ in this volume for a discussion of the physical and other consequences of

childbearing among U.S. adolescents.
//-152 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 6-B—Federal Sources of Data on the Physical Health of U.S. Adolescents

National Center for Health Statistics

The National Center for Health Statistics (NCHS) of the U.S. Department of Health and Human Services

(DHHS) is the primary Federal source of data on the physical health of U.S. adolescents. Through the National Vital

Statistics System, NCHS collects and publishes data on births, deaths, marriages, and divorces in the United States

(104). In addition, NCHS collects and publishes data from ongoing and special surveys such as the National Hospital

Discharge Survey, the National Ambulatory Medical Care Survey, the National Health Interview Survey, the

National Health Examination Survey, the National Health and Nutrition Examination Survey, and the National

Survey of Family Growth. Some of these surveys are described below.

National Hospital Discharge Survey (NHDS)

NHDS is a continuing nationwide sample survey that gathers information each year on patients (excluding

newborn infants) discharged from a sample of non-Federal short-stay and specialty hospitals located in the 50 States

and the District of Columbia (108). The information collected includes data on personal information about the

patient (e.g., birth date, race, sex, marital status), administrative information (e.g., dates of admission and discharge),

and medical information (e.g., diagnosis and medical procedures performed). To be included in the sample,

hospitals must have a minimum of six beds for patient use and average patient stays of less than 30 days.

Limitations-Relatively few adolescents are hospitalized each year. Because NHDS does not oversimple for

adolescents, the number of adolescents sampled in the survey is small. Consequently, NHDS does not provide

reliable information on the incidence of hospitalization among adolescents for any but the most frequent reasons

for hospitalization and does not allow for finer breakdowns such as by race, gender, or socioeconomic status. In

addition, data are not reported using appropriate age breaks for adolescents.

National Ambulatory Medical Care Survey (NAMCS)

NAMCS is a continuing national probability sample survey of ambulatory medical encounters. It collects data

on physician-patient encounters in the offices of a sample of non-federally employed physicians classified as

‘‘office-based, patient care physicians. Sample physicians are asked to complete a patient record information form

for a systematic random sample of office visits occurring during a randomly assigned l-week reporting period.

Approximately 3,500 physicians provided data in 1985 (the last year for which data are available), submitting

71,594 patient record forms for patients of all ages. These data are used to develop estimates of the use of

office-based visits by the U.S. population. Data are collected on patient characteristics (e.g., birth date, sex, race,

ethnicity) and medical information (e.g., diagnostic services performed, diagnosis, reason for visit, medication

provided or prescribed, and disposition of visit). Additional data are collected on the expected source of payment,

referral status of the patient, and characteristics of the provider (e.g., specialty).

Limitations-NAMCS does not collect data on visits to hospital-based physicians. In addition, because there

is no stratification of the sample on race or ethnicity and the sample sizes are quite small for racial and ethnic

minorities, NAMCS does not present reliable information on office visits made by minority adolescents. The survey

also includes information only on those individuals who seek care. Thus, adolescents who do not seek care for

medical problems, or who use alternative sources of care, are not included in the survey. These adolescents may

disproportionately include poor adolescents or those of nonwhite racial or ethnic backgrounds.

National Health Interview Survey (NHIS)

NHIS is a continuing nationwide survey of households (105,106), Data are collected from a probability sample

of the civilian noninstitutionalized population residing in the United States on personal and demographic

characteristics, restricted-activity days due to acute and chronic conditions, injuries, activity limitations due to

chronic health conditions, and use of medical services. In 1988,47,485 households, representing 122,310 persons,

were sampled; 94.9 percent of these households were surveyed. The 1988 NHIS included a special focus

1~-and limitations of Fedexai data O?.I U.S. adokacents’ accidental injuries nutrition and fitness problems; dental and oral

W@ cases of ArDs d sex* transmitted diseases pregnancy; mental health problems; alcohol, tobacco, and drug abuse problems;

delinquq, and hopelessness are discussed in the relevant chaptem of this volume. Also see ch. 18, “hues in the Dclivcxy of Health and

Related %xvices to Sekxted @UpS of Adol cscents,” in Vol. III of this Report and app. C, “Issues Related to the Luck of Information About

Molesccnt Health and Health and Related Semices,” in Vol. I of this Report.
Chapter 6---Chronic Physical Illnesses: Prevention and Services .11-153

on the health status of children and adolescents. Since 1985, the survey has oversampled black persons in order to

increase the precision of estimates for this population. Data have been collected continuously since 1957.

Limitations-The NHIS sample does not include homeless persons, persons residing in institutions, or

members of the armed services. Proxy interviews are generally used for all persons underage 17. Because the adults

interviewed may be unaware of, or be reluctant to report, certain health problems or use of health services of

adolescents, this information may not reflect the true health status of and utilization of services by adolescents in

the household. The NHIS adolescent sample is too small to provide adequate measures of low prevalence physical

conditions. Data are generally not reported using age groupings appropriate to describe adolescents.

National Health Examination Survey (NHES) and the National Health and

Nutrition Examination Survey (NHANES)

National clinical epidemiological information on the health status of today’s U.S. adolescents is not available.

There are no recent national population surveys that provide clinical data about the health status of adolescents. One

of the most comprehensive sources of national clinical epidemiological data on adolescents was NHES (94). The

third cycle of this survey, which was conducted from 1966 to 1970, gathered information through interviews and

physical examinations on the health status of a representative national sample of 6,768 adolescents ages 12 to 17.

However, because this information is now over 20 years old, it is difficult to generalize to today’s adolescents. There

are likely to be many similarities in the health status of adolescents today and those of 20 years ago, but there may

be significant differences as well.

NHANES was initiated as a successor to NHES in 1971 but has not yet collected comparable information on

the health of U.S. adolescents. To measure the health status and characteristics of a sample of the civilian

noninstitutionalized population of the United States, ages 1 to 74, NHANES uses interviews and, for a subsample,

clinical examinations. NHANES I took place from 1971 to 1974, with a subsample of persons ages 25 to 74 selected

for in-depth examinations. NHANES II began in 1976 and ended in 1980; this study oversampled persons 6 months

to 5 years of age and those ages 60 to 74 (96,104). NHANES III is underway and has child health as a special focus

(99). However, the adolescent sample in NHANES III will be small in comparison to the 1966-1970 NHES sample,

and although blacks and Mexican Americans are being oversampled generally, the numbers of such adolescents

included in NHANES III will be small. A total of 3,200 adolescents ages 12 to 19 will be included in the survey,

including 1,120 black adolescents, 1,120 Mexican-American adolescents, and 980 white and other adolescents (17).

Data collection for NHANES III is not expected to be completed until 1994. Thus, at this time, there is no good

source of national clinical epidemiological information on the health status of today’s adolescents.

Other Federal Agencies

Although NCHS is the primary source of national data on the physical health of U.S. adolescents, other DHHS

agencies also collect and publish such data (104). The National Cancer Institute within the National Institutes of

Health, for example, collects data from 11 population-based registries on people diagnosed with cancer through its

Surveillance, Epidemiology, and End Results Program. That program is described below.

Surveillance, Epidemiology, and End Results (SEER) Program of Data Collection on Cancer

The SEER program provides information about the incidence of and the mortality due to malignant neoplasms

in the United States (all ages included). Incidence data are based on information collected from a sample of 12 sites

in the United States, plus one in Puerto Rico, representing approximately 13 percent of the total U.S. population.

Participants in the program provide data annually to the SEER program. Mortality data are derived from mortality

tapes obtained from NCHS, and include data on cancer mortality for the entire United States. The program began

in 1972.

Limitations-SEER data are only limited if information is required on very specific cancers for smaller

populations. In addition, although certain ethnic groups are oversampled (e.g., Japanese, Filipinos), small sample

sizes make data on these groups somewhat unreliable.

Because relatively few U.S. adolescents are hos- sions about the specific diseases for which adoles

pitalized each year for physical illnesses and thus cents are hospitalized. Nonetheless, a more detailed

few are represented in the NHDS sample, sample review of the leading causes of hospitalization for

sizes for number of hospitalizations for most spe- 10- to 18-year-olds indicates that asthma, chronic

cific illnesses are too small to draw reliable conclu- diseases of the tonsils and adenoids, and acute

!!17 (1 11; t)] (, Q1, ,{
11-154 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 6-l—Rates of Different First-Listed Diagnosesa for U.S. Adolescents

Ages 10 to 18 Discharged From Short-Stay Non-Federal Hospitals, 1987

Number of first-listed diagnoses/1 ,000 inpatients

Males Females

Diagnosis by ICD-9-CM categoryb

10 to 14 15 to 18 10 to 14 15 to 18

Injury and poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.8 33.1 16.3 8.2

Diseases of the digestive system . . . . . . . . . . . . . . . . . . . 13.9 11.7 12.1 5.8

Diseases of the respiratory system . . . . . . . . . . . . . . . . . . 13.4 10.7 19.5 6.1

Mental disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.9 14.3 8.8 7.1

Diseases of the nervous system and sense organs . . . 5.9 —“ —● —●

Diseases of the musculoskeletal system and

connective tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 5.8 —“ 2.8

Diseases of the genitourinary system . . . . . . . . . . . . . . . 5,2 —* 4.3 7.5

Endocrine, nutritional and metabolic diseases, and

immunity disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.7 3.4 —“ 1.9

Infectious and parasitic diseases . . . . . . . . . . . . . . . . . . . . 4.0 —* ●

1.8

Complications of pregnancy, childbirth . . . . . . . . . . . . . . . —“ —*

—●

12.1

Supplementary classification.. . . . . . . . . . . . . . . . . . . . . . —* —*

—

5.0 39.7

ain the National Hospital Discharge Survey, a ~irst-listed diagnosis is the diagnosis listed first on the face sheet of a

patient’s medical record.

b[CD-9-CM refers t. the International Classification of Disea~e~, 9th Revision, Clinical M~ification, ~hi~h is u~~ to

code morbidity data.

cEntries mark~ with an asterisk (*) did not meet the requisite standard of reliability.

dFemales with deliveries are inducted under “Supplementary classifications.”

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control,

National Center for Health Statistics, unpublished 1987datafrom the National HosDital Discharae Survev.

Hyattsville, MD, 1989.

appendicitis are among the physical illnesses most

frequently leading to the hospitalization of U.S.

adolescents (see table 6-2).

Reasons for Visits to Office-Based Physicians

As noted in box 6-B, the National Ambulatory

Medical Care Survey (NAMCS) gathers information

periodically on visits made by patients to a sample

of non-Federal physicians in office-based practice

(106). Inferences from NAMCS data are limited

because the number of physicians sampled in the

survey is small; furthermore, adolescents are one of

the groups least likely to visit physicians.9

The most recent available NAMCS data are from

1985. According to these data, diseases of the

. . .

respiratory system are the most frequent diagnosis

for visits by adolescents to office-based physicians

(17.0 percent of visits), followed by injury and

poisoning (16.3 percent of visits), followed by

diseases of the skin and subcutaneous tissue (9.9

percent of visits) (see table 6-3).

If one groups NAMCS data by more specific

conditions, acne emerges as the most frequent

diagnosis for an office visit for a physical problem

(4.8 percent of visits) (see table 6-4).10 Acne is

particularly prevalent among older adolescents, who

received a diagnosis of diseases of the sebaceous

glands (e.g., acne) for 7.4 percent of visits; acne was

the 12th most common diagnosis for younger

adolescents (1.9 percent of visits) .11

%or a discussion of barriers to adolescents’ use of physician services, see ch. 15, “Major Issues Pertaining to the Delivery of Primary and

Comprehensive Health Services to Adolescents,” in Vol. III.

l~e ne~ for a general medic~ examimtion is actually the most frequent specific principal diagnosis (5.8 percent of visits). The need for a gene~

exam does not, however, reflect any specific health problem and is more likely to be part of general preventive health care.

11A prel~~ ~ysis by OTA suuest~ some interesting discontinuities in the NAMCS data using year-by-year age breti, but ~ause of tie

lower reliability and interpretability of information based on fewer numbers of adolescents, it was not possible to look at information using these fme

breakdowns. Age breaks of 10 to 14 years and 15 to 18 years were used based on the recommendations of the National Center for Health Statistics (60),

and analysis of the patterns of visits to office-based physicians using the NAMCS data. Analysis of visit rates for adolescents of different ages indicated

that the rate of visits for adolescent females increases at about age 15, most likely reflecting the increase in pregnancy-related visits. Pregnancies generally

involve more than one visit per pregnant female during the course of a year (including postnatal visits). Thus, 10- to 14-year-old females have fairly

similar visit patterns, as do 15- to 18-year-olds. No clear pattern emerged for males. The age break between 10- to 14-, and 15- to 18-year-olds. the~

is driven by the utilization of physicians by females, which is in turn driven by pregnancy-related visits.
Chapter 6-Chronic Physical Illnesses: Prevention and Services .11-155

Table 6-2—Number of Different First-Listed Diagnoses for U.S. Adolescents Ages 10 to 18

Discharged From Short-Stay Non-Federal Hospitals, 1987

Estimated number of discharges b

NHDS

diagnostic Males Females

Diagnosis code 10 to 14 15 to 18 10 to 14 15 to 18

Other fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 18,969 27,184 —* —*

Appendicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 16,843 16,727 —* —“

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 13,845 ● —* —*

Other mental disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 —* 21,174 13,485 24,190

Other injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 —* 15,307 —●

11,000

Lacerations/wounds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 —* 14,847 ● —*

Other psychoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 —*

—

11,570 ● . 10,747

Chronic disease of tonsils and adenoids . . . . . . . . . . . . . . . . . . . . . . . . . . 75 —* —* 20,681 16,387

Females with deliveries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 — — —* 309,689

Other implications of pregnancy, childbirth, and the puerperium. . 137 — — —* 47,459

Other inflammatory diseases of the female pelvic organs . . . . . . . . . . 120 — — —* 20,532

Other disorders of the genital tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 — — —* 19,720

Other pregnancy with abortive outcome . . . . . . . . . . . . . . . . . . . . . . . . . . 128 — — —* 16,500

Poisoning by drugs, medicinal agents, and biological substances.. 178 —* —* —* 15,443

Other neurosis and personality disorders . . . . . . . . . . . . . . . . . . . . . . . . . 35 —* —* —* 11,569

aEqimate~with fewerthan 60=mpled@ seshavebeen omhtedfrom thistaNe.Many ofthespe~ficd iagnosticc ategories formales andfemalesages 10

to 14and15to 18hadfewerthan 60sampledcases.Thus, many ofthediagnostic categories Iistedherecansistofaggregations of’’other:’ ratherthanmore

specific categories.

bEntfies marked with an asterisk (*) did not meet the requisite standard of reliability.

SOURCES: Discharges: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health

Statistics, unpublished 1987 data from the National Hospital Discharge Survey, Hyattsville, MD, 1989. NHDS diagnostic codes: U.S. Department

of Health and Human Services, Public Health Service, National Center for Health Statistics, “NHDS Diagnostic Recodes for ICD-9-CM,”

Hyattsville, MD, June 1987.

Table 6-3—Visits to Office-Based Physicians by U.S. Adolescents Ages 10 to 18:

Number and Distribution by Diagnosis, 1985

Number of

visits in Percent

Diagnosis by ICD-9-CM CategoryaICD-9-CM Codeathousands distribution

All diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50,218 100.0

Diseases of the respiratory system . . . . . . . . . . . . . . . . . . . . . . . 460-519 8,535 17.0

Injury and poisoning . . . . . . . . . . . . . . . . . . . . . . . . . ... ........800-999 8,177 16.3

Diseases of the skin and subcutaneous tissue . ...........680-709 4,957 9.9

Diseases of the nervous system and sense organs . ......320-389 4,833 9.6

Infections and parasitic diseases . . . . . . . . . . . . . . . . .. .......001-139 3,593 7.2

Diseases of the musculoskeletal system and connective

tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 O-739 2,280 4.5

Diseases of the genitourinary system . . . ... ..............580-629 1,969 3.9

Diseases of the digestive system . . . . . . . . . . . . . . . . . . . . . . . . 520-579 1,607 3.2

Mental disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...290-31 9 1,226 2.4

Endocrine, nutritional and metabolic diseases, and

immunity disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240-279 587 1.2

Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140-239 470 0.9

Diseases of the circulatory system. . . . . . . . . . . . . . . . . . . . . . . 390-459 454 0.9

Supplementary classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . VO1-V82 8,467 16.9

Symptoms, signs, and ill-defined conditions . . . . . . . . . . . . . . . 780-799 1,424 2.8

Unknown diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 965 1.9

All other diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673 1.3

alCD-g-CM refers t. the International Classifimtion of Diseases, 9th Revision, clinical Modification, which is used to

code morbidity data.

b~is includes blank diagnosis, noncodable diagnosis, and illegible diagnosis.

~his includes diseases of the blood and blood-forming organs (280-289); complications of pregnancy, childbirth, and

the puerperium (630-676); congenital anomalies (740-759); and certain conditions originating in the perinatal period

(760-779).

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control,

National Center for Health Statistics, unpublished 1985 data from the National Ambulatory Medical Care

Survey, Hyattsville, MD, 1989.
11-156. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 6-4-Visits to Office-Based Physicians by U.S. Adolescents Ages 10 to 18:

Number and Distribution by the 15 Most Common Principal Diagnoses, 1985

Number of Percent of

Most common principal diagnosis visits in all adolescent

Rank by ICD-9-CM Categoryathousands visits

1 General medical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,914 5.8

2 Diseases of sebaceous glandsb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,394 4.8

3 Acute pharyngitis.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,822 3.6

4 Acute upper respiratory infections of multiple or unspecified sites . . . . . . . 1,627 3.2

5 Normal pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,548 3.1

6 Earache or ear infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,368 2.7

7 Suppurative and unspecified otitis media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,236 2.5

8 Disorders of refraction and accommodation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,197 2.4

9 Other diseases due to viruses and chlamydiae . . . . . . . . . . . . . . . . . . . . . . . . . 1,139 2.3

10 Certain adverse effects not elsewhere cfassifiedc . . . . . . . . . . . . . . . . . . . . . . . 1,086 2.2

11 Contact dermatitis and other eczema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,063 2.1

12 Health supervision of infant or child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,000 2.0

13 Acute tonsillitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 799 1.6

14 Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 704 1.4

15 Open wound of other and unspecified site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659 1.4

alCD.9.CM refers t. the International cla~~ifi=tion of Di~ea~e~, 9th Re~~ion, Clin&l Modif~ation, which is us~ to

code morbidity data.

bchiefly ~ne other than varioliformis.

cpflmarily allergy, unspecified.

SOURCES: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control,

National Center for Health Statistics, unpublished 1985data from the National Ambulatory Medical Care

Survey, Hyattsville, MD, 1989.

Findings From National

Population-Based Surveys

Judgments about the importance of particular

health problems derived from health care utilization

data are limited in that they do not reflect the health

concerns of individuals who do not use the health

care system.

12 Such concerns are more likely to be

reflected in population-based surveys. As noted in

box 6-B, the National Center for Health Statistics

has used two types of population-based surveys. The

National Health Interview Survey (NHIS) collects

data from a sample of the civilian noninstitutionalized U.S. population through personal household

interviews (108). The National Health and Nutrition

Examination Survey (NHANES)--formerly the

National Health Examination Survey (NHES)-

collects health-related data by means of direct

physical examinations, clinical and laboratory tests,

and related measurement procedures (108). The

latter two surveys have been conducted more rarely

than NHIS, and no adequate sample of adolescents

was included in NHANES I or II. (NHANES) III is

collecting some adolescent-specific data, but the

results are not expected until 1994.)

National Health Interview Survey (NHIS)

NHIS collects information on both acute conditions and chronic conditions. A physical or mental

condition is considered ‘‘acute’ for purposes of

NHIS if: 1) it was first noticed 3 months before the

reference date of the interview; and 2) it is not one

of the conditions considered chronic regardless of

the time of onset. To be counted in NHIS data, an

acute condition must also have been of sufficient

consequence to have been associated with at least

1 restricted-activity day or at least one visit to a

doctor. A physical or mental condition is considered

“chronic” for purposes of the NHIS if: 1) the

respondent indicates it was first noticed more than 3

months before the reference date of the interview

and it exists at the time of the interview, or 2) it is a

type of condition that ordinarily has a duration of

more than 3 months. Examples of physical conditions that are considered chronic regardless of their

time of onset are diabetes, heart conditions, emphysema, and arthritis.

Acute Conditions-The impact of acute conditions on adolescent health is measured in terms of

restricted-activity days (overall and due to specific

problems) and school-loss days (overall and due to
Chapter 6-Chronic Physical Illnesses: Prevention and Services . II-157

Table 6-5-Number of Restricted-Activity Daysa Associated With Acute Conditionsb per 100 U.S. Adolescents

for Noninstitutionalized Adolescents Ages 10 to 18, by Sex, Age, and Type of Condition, 1988

Both Number of restricted-activity days/100 adolescents in age groupc

sexes,

ages Males Females

Type of acute condition 10 to 18 10 to 18 10 to 14 15 to 18 10 to 18 10 to 14 15 to 18

All acute conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Infective and parasitic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Common childhood diseases . . . . . . . . . . . . . . . . . . . . . . . . . . .

Intestinal virus, unspecified . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Viral infections, unspecified . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Respiratory conditioned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Common cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other acute upper respiratory infections . . . . . . . . . . . . . . . . .

Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Digestive system conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Injuriesf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fractures and dislocations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sprains and strains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other current injuries.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Selected other acute conditionsg 

. . . . . . . . . . . . . . . . . . . . . . . . . . .

Delivery and other conditions of pregnancy and

peurperium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

659.6

121.7

25.7 —.

28.0

57.5

307.0

72.5

35.4

175.0

23.3

119.5

40.8

29.4

19.2

74.8

606.7

117.9 —●

—.

—●

55.6

287.2

71.3

35.6

152.2 —●

133.5

51.7 —●

—●

39.4

629.2 580.6

104.3

714.4

125.6

—.

—.

—.

59.4

327.6

73.7

35.3

198.7

—●

104.9

—●

—●

—●

111.5

664.7 770.7

129.6 156.0 91.1

●

✎

✎

✎

● ●

●

✎

●

— —.

●

● —.

—● —

—. —.

325.7 242.3

57.4

.

319.6 336.7

64.8

●

83.2 81.6 —. — —. —

169.0 132.5 179.5 220.6 —. —. ● —●

118.7

.

94.9 178.4 92.7

●

●

●

●

● ●

●

●

●

— —

—● —.

—. —.

●

174.9

24.7 50.3 —. — — 107.4

aForthepurpo~G~ ~fthe Nati~nal Health lnterviewSurvey (N~S), ~es~’~~.a~i~’~~ayisany dayonwh~haperson restricts tdsortterusual acthities fOr

morethanhalfaday because ofanillnessoran injury (i.e., aschool-loss, work-loss, orcutdownday orabeddisability day). Restricted-activity days are

measures used for both acute and chronic conditions. This table shows only the restricted-activity days associated with acute conditions.

bAmndition isconsider~ ,,ac~e~~ for the Pu~ses of N~S if it has lasted under 3 months, is not a @ndition ~nstiered chronic regardless Of time Of OnSet,

and is of sufficient consequences to have been associated with either at least one doctor visit or at least 1 day of restricted activity.

cEntries marked with an asterisk (*) did not meet the requisite standard Of rdiablity.

dcategories not shown ~use of low reliability of estimates i~l~e acute bronchitis, pneumonia, and “othet’ respiratory conditions.

~his includes dental conditions; indigestion, nausea, and vomiting; and other digestive conditions. No specific category had enough sampled cases to be

considered reliable.

fcatwories not shown ~Quse of Iow reliability of estimates i~lude “open wounds and lacerations” ad “contusions and superfi~al injuries.”

9Categories not shown because of low reliability of estimates include eye conditions, acute ear infections, other ear conditions, acute urinary cxmditions,

disorders of menstruation, other disoders of the female genital tract, skin conditions, acute musculoskeletal conditions, headache (excluding migraine), and

unspecified fever.

SOURCE: U.S. Department of Health and Human Services, Public Health Serviee, Centers for Disease Control, National Center for Health Statistics,

unpublished 1988 data from the National Health Interview Survey, Hyattsville, MD, 1990.

specific problems). As noted in box 6-A, a restrictedactivity day is any day on which a person restricts his

or her usual activities for more than one-half day

because of an illness or injury (106).13 A school-loss

day, a type of restricted-activity day calculated for

5-to 17-year-olds, is any day on which a child did

not attend school for half a day because of illness or

days associated with acute conditions (see table 6-6).

Other acute conditions that cause relatively high

numbers of restricted-activity and school-loss days

among U.S. adolescents are infective and parasitic

diseases and injuries.

Although the reported average rate of restrictedactivity days due to acute conditions for younger

(10- to 14-year-old) adolescents is similar to that for

older (15- to 18-year-old) adolescents, there are

some interesting age differences by condition and

general differences by sex and race. As shown in

table 6-5, younger adolescents are more likely to

have restricted-activity days due to acute physical

illness (respiratory conditions, infective and parasitic diseases), and older adolescents are more likely

injury.

The 1988 NHIS found the acute conditions

causing the highest numbers of restricted-activity

days among noninstitutionalized adolescents ages

10 to 18 were acute respiratory conditions (particularly influenza), followed by infective and parasitic

diseases (see table 6-5). Acute respiratory conditions

are also responsible for over half of the school-loss

136 *~eSr~cfe~-dc~vig &YS’ f me ~duplimted ~oun~ of tie fouowing: 1) bed-~sability days, d~g which a yrson spent more thm hdf a

bed because of illness or injury: 2) work-loss days, during which a currently employed person 18 years of age and over missed more than half a day from

a job or business; 3) school-loss days, during which a student 5 to 17 years of age missed more than half a &y from the school in which he or she was

currently emolled; and 4) cut-down days, during which a pemon cuts down for more than half a day on the things he or she usualIy does. Note that a

“day of restricted activity” due to an acute condition is not the same as a “limitation in activity’ caused by a chronic condition (105).
11-158. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 6-6—Number of School-Loss Daysa Associated With Acute Conditionsb per 100 U.S. Adolescents

for Noninstitutionalized Adolescents Ages 10 to 17, by Sex, Race, Family Income, and Types of Condition, 1988

Number of school-loss days/100 adolescents ages 10 to 17C

Sex Race Family income

All

ages Less than $10,000-$20,000- $35,000

Type of acute condition 10 to 17 Male Female White Black $10,000 $19,999 $34,999 or more

All acute conditions . . . . . . . . . . . . . . . . . . .

Infective and parasitic diseasesd . . . . . . .

Common childhood diseases . . . . . . . .

Viral infections, unspecified . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Respiratory Conditionse 

. . . . . . . . . . . . . . . .

Common cold . . . . . . . . . . . . . . . . . . . . . .

Other acute upper respiratory

infections . . . . . . . . . . . . . . . . . . . . . . . .

Influenza . . . . . . . . . . . . . . . . . . . . . . . . . .

Digestive system Conditionsf 

. . . . . . . . . . .

Injuriesg 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Selected other acute conditions . . . . . . .

All other acute conditions. . . . . . . . . . . . . .

379.6

79.9

22.0

17.3

33.0

210.0

48.4

23.7

122.3

15.4

32.3

34.3

—*

362.8

82.6

—*

—●

36.7

199.8

47.8

—*

110.0

—*

42.4

22.2

—*

397.1

76.9

—*

—*

—*

220.7

49.1

●

135.3

—*

—*

46.9

—*

399.9

84.8

—*

20.5

39.3

226.2

48.9

26.7

132.2

—*

35.5

29.8

—*

302.8

—*

—*

—*

—●

137.8

—*

—*

—*

—*

—*

—*

—*

483.1

—●

—*

—*

—*

235.1

—*

—*

151.5

—*

—●

—*

—*

403.2

—*

—*

—*

—*

196.2

—*

●

119.0

— *

—*

—*

— *

419.3

84.3

—*

—●

—*

236.5

61.7

—*

133.3

—*

—*

—●

—*

349.1

83.8

—*

—*

42.8

200.2

—*

●

123.1

—*

—●

—*

—*

aFor the purposes of the National Health Interview Survey (NHIS), a schoo/-/oss day is a day on which a student 5 to 17 years of age missed more than half

a day from the school in which he or she was currentty enrolled. A school-loss day is one type of restricted-activity day.

bA ~.ndition is ~nsider~ ilW~e” for the Pu~ses of NHS if it has lasted under 3 months, is not a andition mnsidered chronic regardless Of time of onset,

and is of sufficient consequences to have been associated with either at least one doctor visit or at least 1 day of restricted activity.

cEntfles marked with an asterisk (*) did not meet the requisite standard of relia~lity.

~ategories not shown because of insufficient reliability include: intestinal virus, unspecified.

ecategorie.s not shown ~=use of insuff~ient reliability in~ude: acute bmn~itis, pneumonia, “other” respiratory conditions.

fcategones not shown -use of insuff~ient reliability include: &ntal conditions; indigestion, nausea, and vomiting; and other digestive conditions.

9Categories not shown because of insufficient reliability include : fractures and dislocations; sprains and strains; open wounds and lacerations; contusions and

superficial injuries; other current injuries.

hsu~ategories are not shown because of insufficient reliability.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics,

unpublished 1988 data from the National Health Interview Survey, Hyattsville, MD, 1990.

to have restricted-activity days due to injuries and

pregnancy-related causes. Female adolescents in

general (but particularly older female adolescents)

are more likely than males to have days of restricted

activity due to acute conditions; perhaps not surprisingly, this phenomenon is largely due to pregnanct. 14 Black adolescents are less likely (506.6

days per 10010- to 18-year-olds per year) than white

adolescents (704.4 days per 10010- to 18-year-olds

per year) to have restricted-activity days reported for

acute conditions.1s

School-loss days and restricted-activity days generally show similar age, sex, and race patterns,

except that 10- to 14-year-old females have fewer

school-loss days than their male counterparts (107).

As shown in table 6-6, adolescents in families with

annual incomes less than $10,000 have higher rates

of school-loss days (483.1 days per 100 adolescents

per year) than adolescents in families with annual

incomes of $35,000 or more (349.1 days per 100

adolescents per year). Differences in school-loss

days by family income level are more marked for

adolescents ages 10 to 14 than for those ages 15 to

17, although they follow the same general pattern.l6

Chronic Conditions--The 1988 NHIS found the

most frequently reported chronic physical conditions for noninstitutionalized U.S. adolescents ages

10 to 18 were hay fever or allergic rhinitis without

asthma, chronic sinusitis, acne, asthma, deformity or

orthopedic impairment, chronic bronchitis, chronic

disease of the tonsils or adenoids, dermatitis, and

Ids= ch. 10, ‘‘pre~cy and Parenting: Prevention and S_iCeS, “ in this volume for a discussion of adolescent pregnancy.

ls~teres~gly, the nm~r of restricted-activity &ys per 1~ ~mo~ per y~ bcr~s with age for black adolescents ~d decreases for white

adolescents. Because of small sample sizes, it is not possible to be speci.tlc about mce differences for specific conditions.

16~e average nm~r of school.loss &ys ~r 10010- to l~ye~+l~ per yea reported by families with ~ud incomes less thaII $10,000 W~ 491.9

days; by families with annual incomes from $10,000 to $19,999 was 379.8 days; by families with annual incomes from $20,000 to $34,999 was 402.0

days; and by families with incomes of $35,000 or more was 340.7 days. See ch. 18, “Issues in the Delivery of Services to Selected Groups of

Adolescents, ‘‘ in Vol. III for a discussion of the health problems of adolescents in poor and near-poor families.
Chapter 6---Chronic Physical illnesses: Prevention and Services . II-159

Table 6-7—Prevalence Rate for 20 Leading Chronic

Physical Conditionsa Among Noninstitutionalized

U.S. Adolescents Ages 10 to 18,1988

Number of chronic conditions/

1,000 Personsb

Ages

10 to 18 10 to 14 15 to 18

Hay fever or allergic rhinitis

without asthma . . . . . . . . . . . . . . 91.2 92.4 89.8

Chronic sinusitis . . . . . . . . . . . . . . . . 89.6 82.9 97.4

Acne . . . . . . . . . . . . . . . . . . . . . . . . . . 61.7 34.6 92.9

Asthma . . . . . . . . . . . . . . . . . . . . . . . . 58.1 62.1 53.5

Deformity or orthopedic

impairment. . . . . . . . . . . . . . . . . . . 54.2 39.3 71.3

Back . . . . . . . . . . . . . . . . . . . . . . . . 26.6 16,6 38.1

Lower extremities . . . . . . . . . . . . 26.5 23,0 30.5

Chronic bronchitis . . . . . . . . . . . . . . 38.8 33.8 44.5

Chronic disease of tonsils or

adenoids . . . . . . . . . . . . . . . . . . . . 31.1 29.6 32.9

Dermatitis . . . . . . . . . . . . . . . . . . . . . . 31.1 32.3 29.8

Migraine headaches . . . . . . . . . . . . 28.6 27,4 29.9

Heart disease . . . . . . . . . . . . . . . . . . 22.4 20.4 16.1

Heart murmurs . . . . . . . . . . . . . . . 16.7 19.8 13.1

Hearing impairment.. . . . . . . . . . . . 20.7 19.7 22.0

Visual impairment . . . . . . . . . . . . . . 18.9 16.5 21.6

Trouble with ingrown nails . . . . . . . 17.6 10.1 26.4

Color blindness . . . . . . . . . . . . . . . . 12.3 10.4 14.6

Trouble with dry, itching skin . . . . 10.1 —* 12.8

Speech impairment . . . . . . . . . . . . . 9.0 11.3 —’

Diseases of female genital

organs . . . . . . . . . . . . . . . . . . . . . . 7.1 —* 13.0

Anemias . . . . . . . . . . . . . . . . . . . . . . . 6.2 —* —*

Arthritis. . . . . . . . . . . . . . . . . . . . . . . . 4.7 —* —*

High blood pressure . . . . . . . . . . . . 4.5 —* —*

aA physkal or mental co~ition is considered “chronic” for purposes of the

National Health Interview Survey if it has lasted more than 3 months or is

a type ofcxmdition that ordinarily lasts more than 3 months (e.g., diabetes,

heart conditions, emphysema, or arthritis).

bEntnes mark~ with an asterisk (*) did not meet the requisite standard of

reliability.

SOURCE: U.S. Department of Health and Human Services, Public Healt h

Service, Centers for Disease Control, National Center for Health

Statistics, unpublished 1988 data from the National Health

Interview Survey, Hyattsville, MD, 1990.

migraine headaches (see table 6-7). Other physical

chronic conditions with a rather high reported

prevalence among adolescents were heart disease,

hearing impairments, and visual impairments (see

table 6-7).

Each person identified by NHIS as having a

chronic physical or mental condition is classified

according to the extent to which his or her activities

are reported as limited.17 As shown in table 6-8, the

1988 NHIS found that 93.2 percent of U.S. adolescents were reported to have no activity limitation

due to a chronic physical or mental condition; 6.8

percent were reported to have some activity limitation. The 6.8 percent with activity limitation due to

a chronic condition included 0.6 percent of U.S.

adolescents who were unable to perform a major

activity (e.g., attending school); 4.3 percent who

were limited in the amount or kind of major activity;

and 1.9 percent who were limited but not in major

activity (see table 6-8). Among adolescents with

chronic conditions, there was very little difference in

reported degree of activity limitation by age, sex,

race, or place of residence. However, there were

some differences by income, with a larger proportion

of adolescents (94.9 percent) in higher income

families than in the lower income families (e.g., 90.2

percent in families with annual incomes under

$10,000) free of an activity limitation (107).

Newacheck conducted an in-depth analysis of

1984 NHIS data by type of serious chronic disorder

(62). This analysis revealed that 75 percent of U.S.

adolescents ages 10 to 18 with a reported limitation

of activity due to a chronic disorder or disorders had

a disorder in one of the five following categories:

●

●

●

●

●

mental disorders (including mental retardation,

psychoses, and substance dependence syndromes), 32 percent;

respiratory conditions (e.g., asthma), 21 percent;

diseases of the musculoskeletal system or

connective tissue (e.g., arthritis or acquired

limb deformities), 15 percent;

diseases of the nervous system (e.g., multiple

sclerosis, cerebral palsy, or epilepsy), 6 percent; and

diseases of the ear and mastoid process (e.g.,

hearing impairments), 4 percent.

National Health Examination Survey (NHES)

A compelling source of information on the health

status of any group is a population-based survey that

includes clinical examinations by health care providers. Unfortunately, the last such survey to include

sufficient numbers of adolescents for meaningful

analysis was the NHES completed in 1970 by the

U.S. Department of Health, Education, and Welfare

(now the U.S. Department of Education and DHHS)

I_/Note tit l~l~tiom of ~ctlvl~ a~s~iated ~i~ ~~onic con~tiom differ from restricted-activity &ys discussed above. NHIS meWW2d

restricted-activity days for both acute and cbronic conditions, but limitations of activity only for chronic conditions.
II-160 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 6-8--Distribution of Noninstitutionalized U.S. Adolescents Ages 10 to 18 by Degree of Activity Limitation

Due to a Chronic Physical or Mental Condition and Socioeconomic Characteristics, 1988

Percent

Percent Percent limited Percent

Percent Percent with unable in amount limited,

with no with limitation to carry or kind but not

activity activity in major on major of major in major

Characteristic Total a

limitation Iimitation a

activity b c activity cactivity c

activity b c

All 10- to 18-year-olds . . . . . . . . . . . . . . . . .

Age:

10- to 14-year-ods . . . . . . . . . . . . . . . . . . . .

15- to 18-year-olds . . . . . . . . . . . . . . . . . . . .

Sex and age:

Male

All ages (10 to 18) . . . . . . . . . . . . . . . . . .

10- to 14-year-olds . . . . . . . . . . . . . . . . . .

15- to 18-year-olds . . . . . . . . . . . . . . . . . .

Female

All ages (10 to 18) . . . . . . . . . . . . . . . . . .

10- to 14-year-olds . . . . . . . . . . . . . . . . . .

15- to 18-year-olds . . . . . . . . . . . . . . . . . .

Race and age:

White

All ages (10 to 18) . . . . . . . . . . . . . . . . . .

10- to 14-year-olds . . . . . . . . . . . . . . . . . .

15- to 18-year-olds . . . . . . . . . . . . . . . . . .

Black

All ages (10 to 18) . . . . . . . . . . . . . . . . . .

10- to 14-year-oids . . . . . . . . . . . . . . . . . .

15- to 18-year-olds . . . . . . . . . . . . . . . . . .

Family Income and age:

Under $10,000

All ages (10 to 18) . . . . . . . . . . . . . . . . . .

10- to 14-year-olds . . . . . . . . . . . . . . . . . .

15- to 18-year-olds . . . . . . . . . . . . . . . . . .

$10,000 to $19,999

All ages (10 to 18) . . . . . . . . . . . . . . . . . .

10- to 14-year-olds . . . . . . . . . . . . . . . . . .

15- to 15-year-olds . . . . . . . . . . . . . . . . . .

$20,000 to $34,999

All ages (10 to 18) . . . . . . . . . . . . . . . . . .

10- to 14-year-olds . . . . . . . . . . . . . . . . . .

15- to 18-year-olds . . . . . . . . . . . . . . . . . .

$35,000 or more

All ages (10 to 18) . . . . . . . . . . . . . . . . . .

10- to 14-year-olds . . . . . . . . . . . . . . . . . .

15- to 18-year-olds . . . . . . . . . . . . . . . . . .

Geographic region:

Northeast . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Midwest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Place of residence:

Metropolitan statistical area . . . . . . . . . . . .

Central city . . . . . . . . . . . . . . . . . . . . . . . . . . .

Not central city . . . . . . . . . . . . . . . . . . . . . . . .

Not metropolitan statistical area . . . . . . . .

100.00

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

93.2

93.2

93.3

92.7

92.3

93.0

93.8

94.1

93.5

93.0

92.9

93.2

93.2

93.3

93.2

90.2

88.8

91.5

91.1

91.5

90.5

92.9

93.5

92.0

94.9

94.4

95.5

94.1

92.6

93.0

93.5

93.5

93.7

93.3

92.5

6.8

6.5

6.7

7.3

7.7

6.9

6.2

5.9

6.5

7.0

7.1

6.8

6.8

6.7

6.8

9.8

11.2

8.5

8.9

8.5

9.5

7.1

6.5

8.0

5.1

5.6

4.5

5.9

7.3

7.0

6.5

6.5

6.3

6.7

7.5

4.8

5.3

4.4

5.4

6.1

4.6

4.3

4.4

4.1

4.9

5.4

4.4

5.1

5.3

—*

7.8

9.5

—*

6.6

6.6

6.5

5.0

4.8

5.2

3.5

4.1

2.7

4.3

5.5

5.0

4.2

4.7

4.7

4.7

5.3

0.6

—*

0.9

—●

—*

—*

—*

—●

—●

0.6

—●

—*

—*

—*

—●

—*

—*

—*

—*

—*

—*

—*

—*

—*

—*

—*

—*

—●

—*

—*

—*

0.6

—*

—*

—*

4.3

4.9

3.5

4.9

5.8

3.9

3.6

4.0

3.2

4.4

5.1

3.6

4.4

4.3 —●

6.9

9.2 —*

6.0

6.2

5.7

4.3

4.4

4.1

3.1

4.0 —*

3.9

5.0

4.4

3.6

4.1

4.0

4.2

4.8

1.9

1.6

2.3

1.9

1.6

2.3

1.9

1.5

2.3

2.0

1.7

2.4

—-●

—.*

—.*

—*

—*

—*

—.*

—*

—*

2.1

—●

—●

1.6

—*

—*

—●

1.8

2.0

2.2

1.8

1.6

2.0

2.2

aNote that the numbers in horizontal rows do not ati Up to 100 percmt. The reason is that the last four columns show breakdowns of the overall Percentage

with activity limitations shown In the third column. In addition, numbers in some rows may not add up because of rounding.

b~~mx~~(or usual ~ti~ty) refers to the Primipal actitity of a person or of a person of his or her age-sex group (e.g., Mool attendan-, wo~n9 at a job).

cEntries ma~~ ~th an asterisk (*) did not meet the requisite standard Of re[ia~lity.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics,

unpublished 1988 data from the National Health Interview Survey, Hyattsville, MD, 1990.
Chapter 6-Chronic Physical Illnesses: Prevention and Services . //-161

(94,95). 18 Because they are so old, estimates of

adolescents’ physical health problems based on

NHES may not pertain to the health status of

contemporary adolescents. Still, the data from NHES

suggest that the physical health of American adolescents may not be as positive as is often assumed.

Most troubling is the NHES’ finding that more than

one adolescent out of jive (about 22 percent) had

‘‘some illness, deformity, or handicap . . . affecting

normal growth, development, or function—

cardiovascular, neurological, musculoskeletal, or

other” (94). NHES found that the proportion of

adolescents ages 12 to 17 with physical health

problems was greater than the proportion of younger

children (ages 6 to 1119) with physical health

problems.

NHES also recorded information by race, region,

and family income. This survey found no differences

in physical health status by race. Adolescents living

in the South had more health problems than adolescents from other regions, and adolescents of lower

income had more health problems than adolescents

from families with higher incomes (94).

Physical Health Problems From the

Perspective of Adolescents

Adolescents themselves are rarely asked to identify the physical (or other) health problems that they

believe are most important. Even in adolescent

health surveys, adolescents are infrequently asked to

rate the importance of various health issues. The

National Adolescent Student Health Survey conducted by a consortium of groups funded partially by

the Federal Government in 1987, for example,

questioned more than 11,000 8th and 10th graders

nationwide but failed to ask respondents to identify

the most important physical health issues for adolescents (4). Adolescents were asked to identify physical health issues in the Minnesota Adolescent Health

Survey of over 36,000 Minnesotan students in

grades 7 through 12, but reports of the Minnesota

survey results emphasized nonphysical concerns

(88). 20 Thus, data are very limited on the specific

physical health concerns identified as most important by adolescents.

Some evidence suggests, however, that adolescents do not always agree with adults on what

adolescents’ most important health needs are. A

Canadian study that asked a random sample of 1,000

adolescents ages 12 through 20 and 100 schoolbased public health nurses and school psychologists

or counselors to rate the seriousness and prevalence

of a variety of health problems among adolescents

found differences in the perceptions of adolescents

and the professionals (32). The health providers

identified menstrual problems, acne, and headaches

as common, but not serious, problems; pregnancy,

venereal diseases (i.e., sexually transmitted diseases), and chronic health problems as serious but

not common; and nervousness or emotional, schoolrelated, and birth control problems as serious and

common problems. Adolescents concurred with the

health providers that menstrual problems and acne

were common complaints, but few of the adolescents identified birth control problems, venereal

diseases, or chronic health problems as significant.

The professionals cited substance abuse (alcohol

and drugs) and sexual problems as the most serious,

but relatively uncommon, psychosocial problems.

Adolescents reported fairly high rates of alcohol use

(49.0 percent), drug use (15.1 percent), and sexual

intercourse (22. 1 percent) but did not perceive these

to be problems.

Another study conducted in Canada asked adolescents ages 13 to 18 what issues they would like to

discuss or have covered when they visit primary care

physicians and how often the issues were actually

discussed during a visit (50). This study was

somewhat flawed in that it asked adolescents both

questions simultaneously; the results would have

been more valid if the responses had been independent.

Nonetheless, the results of this Canadian study are

consistent with the results of previous studies that

‘pediatricians examined 12- to 17-year-olds using a standardized physical examination for problems with eyes, ears, nose, and throat; goiteq

musculoskeletal and limited neurological evaluatio% cardiovascular examination; grading of facial acne; assessment of sexual maturation through a

genital examination and an appraisal of nutrition. The examination did not include an evaluation of mental health problems, except for an assessment

of mental retardation by appearance.

190TA ~Cluded lo ~d 1 l-ye~-olds in me adolescent age ~oup, but ~S ag~egated many of its findings by hvO age ~OUpS: 6- tO 1 I-year-olds

and 12- to 17-year-olds. Fewer 6- to 11 -year-olds than 12- to 17-year-olds were found to have ‘‘signifkxmt abnormal findings” on ex arnination by the

physician (one in eight 6- to 1 l-year-olds v. one in five 12- to 17-year-olds). Much of the difference between the rate of problems for children and

adolescents was attributed to “the conditions associated with the onset of puberty or other aspects of maturation” (94).

~physlc~ heal~ ~oncem were not, however, listed as a possible response in he Minnesoti survey item concerning lhiIlgS students ‘ ‘ WOITy d)ollt. ’
11-162. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

found diverging interests of health care providers

and adolescents (see 50, for a review) and suggest

that, at least from the adolescents’ perspective,

adolescents’ real concerns are not being attended to

by health care providers. In almost all cases, the

adolescents who were questioned in this study

reported that discussion of issues of interest to them

took place considerably less frequently than the

adolescents desired (50).21 For example, while over

80 percent of responding adolescents were interested

in discussing physical fitness, nutrition, and growth,

discussion of these topics reportedly took place in

only 40 to 50 percent of visits. From 60 to 70 percent

of adolescents were interested in discussing sexually

transmitted diseases, contraception, acne, fear of

cancer, and obesity, but these topics were reported to

be discussed only 12 to 30 percent of the time.

Almost 60 percent of adolescents were interested in

discussing feelings of depression and lack of confidence, but such discussion took place only 16 and 11

percent of the time, respectively. Interestingly, the

only topic with a close match between adolescents’

desire for discussion and how often it actually took

place was the topic of menses (of interest to

adolescents 55 percent of the time and discussed 49

percent of the time); no specific details of the content

of discussions about menses were provided.22 Dysmenorrhea (painful menstruation) has been identified through surveys of small samples of adolescent

girls as a leading cause of pain and absence from

school due to physical problems (44,120).

Physical Health Problems From the

Perspective of Parents

As discussed above, some surveys (e.g., NHIS

and part of NHES) use adolescents’ parents as a

source of information about the health of their

adolescent children. It is important to note that

parents may not be a valid source of information on

the health of their adolescent children.

No current data are available on this issue, but the

1963-65 and 1966-70 NHES, conducted by the U.S.

Department of Health, Education, and Welfare, was

able to compare parents’ ratings of their children’s

25

20

15

10

5

0

Figure 6-l-Parents’ Ratings of Child and Adolescent

Health Compared to Physicians’ Findings on

Examination, U.S. Children Ages 6 to 17,

1963-65 and 1966-70a

Percent

Significantly

abnormal findings

on examination /\l

,.~ by physicians

/ - . ~~

--- /1 -.

/’ ,//Health a worry ,’

------ / ~t / to parents -----. , \

k ~ 1’ . -\ --- \

, /1 .

\ /’ \ /

, \

\ /

/’ , .- ,{

\ ,.” \/.,/ ‘.-

Health rated

fair or poor

- ——

/’———

/

~ by parents —

\

I

/’\

/

\/— \/”

I I I I I

6 8 10 12 14 16

Child/adolescent’s age in years

%hildren ages 6 to 11 were examined from 1963 to 1965 and adolescents

12 to 17 were examined from 1966 to 1970.

SOURCE: U.S. Department of Health, Education, and Welfare, “Examination and Health History Findings Among Children and Youths,

6-17 Years: United States,” Vita/ and Health Statistks: Data

From the Nationa/ Health Survey, Series 11, No. 129, DHEW

Pub. No. (HRA) 74-1611 (Roekville, MD: November 1973).

(including adolescents’) health with findings from

physicians’ physical examinations 23 of the adolescents (94). As shown in figure 6-1, parents’ worries

about their children’s health dropped considerably at

about age 13, but there was a large increase in

significantly abnormal findings on examination

beginning at age 11 through age 17 (the last year of

age included in the survey). Parents of 12- to

17-year-olds tended to rate their children’s health

significantly better than did parents of children ages

zl~e ~encm he~~ ~me ~y~tem’s compet~~ to treat the he~th needs of adolescents is discussed more fully in ch. 15, “Major Issues Pe*g

to the Delivery of Primary and Comprehensive Health Services to Adolescents, ” in Vol. III.

22For e~ple, the ‘‘discussion” could have consisted merely of a question about whether menses had begun.

~As noted above, the physical examination was generally limited to the identification of primarily physicxd abnommlities, although apparent mental

retardation would have been noted.
Chapter 6-Chronic Physical illnesses: Prevention and Services .11-163

6 to 11,24 both when giving a categorical statement

of their child’s health status and when indicating

whether or not aspects of their child’s health were a

concern or worry.

25 In contrast, survey pediatricians,

who actually examined the children and adolescents,

rated substantially more adolescents than children as

having some significant abnormality. The National

Center for Health Statistics could not come to

definitive conclusions about the reasons for the

reduction in parents’ concern but suggested that the

reduction probably reflected ‘‘a change in attitude or

concern. ’ The National Center for Health Statistics

was not able to tell if this change occurred because

of increased maturity of the child, because more of

the abnormal conditions were under care, or because

of some other factor.

Unfortunately, children and adolescents themselves were not asked to report on their overall

health status or specific health concerns in a survey

comparable with that given to parents.

Background on Chronic Physical

Illnesses and Disabilities

of Adolescents

Trends in the incidence and prevalence of chronic

illness and disability among adolescents are reviewed below. Also discussed are consequences

common to many chronic illnesses, with a focus on

psychosocial consequences. Two other chronic physical health problems of importance to adolescents

themselves—acne and dysmenorrhea-are also reviewed in this section.

Trends in the Incidence and Prevalence

of Chronic Physical Illnesses and Disabilities

Among Adolescents

A small but significant number of U.S. adolescents are believed to experience very serious chronic

physical conditions such as severe asthma, juvenileonset diabetes, congenital heart disease, leukemia,

cystic fibrosis, and chronic kidney diseases (70).

Unfortunately, however, it is difficult to determine

the incidence and prevalence of such illnesses

among adolescents. Most studies of chronic illness

among children do not report information separately

for adolescents. Furthermore, many serious chronic

illnesses are not of sufficient prevalence in adolescents to reliably measure in national epidemiological and health services utilization surveys that

sample only a small number of adolescents (e.g.,

NHIS, NAMCS, NHDS, and NHANES). Estimates

of the prevalence of serious chronic disorders among

all children under age 20 range from 10 to 20 percent

(27,72,80) (see box 6-C).

In 1984, using published prevalence estimates for

21 types of chronic conditions, Gortmaker and

Sappenfield estimated the prevalence of chronic

conditions in U.S. children under the age of 20 (see

table 6-9). In aggregate (assuming that each child

had no more than one of the specified problems),

Gortmaker and Sappenfield estimated that 13.3

percent of U.S. children ages O to 20 had a chronic

physical or mental condition. If one excludes some

chronic mental disorders (i.e., mental retardation,

Down’s syndrome, and autism),

26 the figure for the

remaining chronic conditions drops to 10.6 percent

of U.S. children ages O to 20. If one assumes that 90

percent of children experiencing these 18 chronic

conditions survive to age 20 (as Gortmaker and

Sappenfield estimate) and thus experience a chronic

condition during adolescence, the prevalence of

these 18 remaining chronic conditions among adolescents would be 9.5 percent. Not all of these 18

conditions result in major activity limitations. If one

excludes the chronic physical conditions that do not

result in a major activity limitation (i.e., mild

asthma, nonsevere congenital heart disease, mild

and moderate hearing impairments, and mild visual

impairments), one could estimate that 4 to 5 percent

of U.S. adolescents have chronic physical conditions

that make them either unable to carry on a major

activity (e.g., attending school) or limited in the

amount or kind of major activity. It is important to

note that this prevalence estimate by OTA does not

include chronic mental disorders.

240TA ~efer~ t. 10. and 1 l-ye~+]d~ ~ adolescents, but the National Center for Health Statistics ~ports on NHES referred to 6- tO 1 l-year-olds m

children and 12- to 17-year-olds as ‘‘youths” or, less frequently, “adolescents.’ When compwisons by age were made in the narrative, the National

Center for Health Statistics typically aggregated data for these two age groups. However, detailed tables also provided results by each year of age from

6 through 17 (94).

~Differences ~Neen reports of abnormalities in the medical history (taken from parents) and findings on examina tion were also reported. Large

differences were found for hearing trouble, walking trouble, arm or leg limitations, with more findings on examination than reports of abnormality. (Tt

is important to note, however, that reports of any abnormality in the medical history were compared with specifi’c abnormalities on examination (94).)

ZbAs noted at tie &ginning of this chapter, some chronic mental disorders have a physical basis.
II-164 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 6-C—Trends in the Prevalence of Chronic Physical Conditions Among U.S. Adolescents

During the 1960s, an estimated 4 percent of U.S. children’s visits to primary care practices were for chronic

health problems (27). By 1980, some 13 percent of visits to pediatric practices by children under the age of 15 and

18 percent of their visits to all physicians were for chronic problems, both routine and flareup. The increase in

proportion of primary care visits by children for chronic conditions reflects a decrease in the incidence of acute

illnesses (e.g., infectious diseases1

) and in the proportion of children with chronic conditions who survive through

adolescence (27).

Over the last several decades, technological and medical advances have greatly increased the survivability into

adolescence of children with certain chronic illnesses. For example, chances of survival to age 21 for children with

cystic fibrosis increased from an estimated 5 percent between 1945 and 1959 to an estimated 70 percent during the

1970s (25). Less dramatic, but significant, improvements in the survivability of children with acute lymphocytic

leukemia, sickle-cell anemia, congenital heart disease, and chronic kidney diseases have also been noted (25).

According to data from the National Health Interview Survey (NHIS), the prevalence of chronic conditions

that limit activity more than doubled between 1960 and 1981 among U.S. children under 17 years of age (63). There

is some disagreement about whether these prevalence changes are real or due to changes in questionnaire design,

parent and physician perceptions, and other factors (63). Thus, the degree to which the prevalence of chronic

conditions has actually increased among children is somewhat unclear (64).

Gortmaker suggests that dramatic increases in the absolute numbers of children and adolescents with chronic

illnesses should not be expected during the coming decades for several reasons (25,26). First, there is little room

for improvement in levels of survivability, given current rates of greater than 90 percent survival to age 20. Second,

even if higher levels of survivability are achieved, smaller birth cohorts since the post World War II ‘baby boom”

have resulted in lower absolute numbers of children with chronic illnesses, thus tending to offset any increases. The

only substantial evidence for increases in the incidence of chronic physical conditions in children is the evidence

of an increasing number of infants infected with human immunodeficiency virus (HIV).2

‘I%ere is also increasing

concern about the disabling long-term effects of crack cocaine use during pregnancy on children.

lu~ ~ ~iden~ of some infectious diseases, tk intid- of -yWmiWdti=~~. For further discussio~

see ch. 9, “AIDS and Other Sexually TransmI“tted Diseases: I%evention and Services, “ in this volume.

%urrent problems associated with HIV infection among adolescents am discussed inch. 9.

As noted earlier, data from the 1988 NHIS suggest are institutionalized are probably more likely to have

that 6.8 percent of noninstitutionalized U.S. adolescents ages 10 to 18 are limited in a major or other

activity by a chronic physical or mental condition:

4.8 percent are limited in or are unable to perform a

major activity (e.g., attending school), and 1.9

percent are limited in an activity other than major

activity as the result of a chronic condition (see table

6-8). Although OTA’s estimate (based on Gortmaker and Sappenfield’s work) that between 4 and

5 percent of U.S. adolescents have a chronic physical

condition that limits major activity is similar to the

NHIS estimate (4.8 percent), it is important to

emphasize that the NHIS estimate includes mental

disorders, while the OTA estimate does not. If

mental disorders were included in the OTA estimate,

it would be higher. Another difference between the

OTA and NHIS estimates is that the OTA estimate

(based on Gortmaker and Sappenfield’s work)

includes at least some institutionalized populations,

while the NHIS estimate does not. Individuals who

seriously disabling chronic conditions than individuals who are not institutionalized.

Differences in estimates of the prevalence among

adolescents of chronic conditions that significantly

limit their ability to perform a major activity of daily

living) are difficult to resolve. As Gortmaker and

Sappenfield noted in their review, “Widely varying

estimates concerning the population prevalence of

chronic childhood disorders exist, depending upon

the definitions used, the methods of study, and the

population under investigation” (27).

Consequences of Serious Chronic Conditions

for Adolescents

There are significant differences in the physical

(and thus the emotional and social) consequences of

specific types of chronic physical conditions. Still,

the experiences of adolescents with various types of
Chapter 6-Chronic Physical illnesses: Prevention and Services .11-165

Table 6-9-Estimated Prevalence of Serious Chronic Conditions in U.S. Children

Ages O to 20, 1980

Prevalence Range of prevalence

Disorder a

estimates/1,000 estimates/l ,000

Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2 1.0-3.0

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38.0 20.0-53.0

Moderate to severe... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.0 8.0-15.0

Autism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.44 0.40-0.48

Central nervous system injury

Traumatic brain injury.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.05 .

Paralysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 2.0-2.3

Cerebral palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5 1.4-5.1

Chronic renal failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.080 —

Terminal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.010 —

Nonterminal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.070 —

Cleft lip/palate” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5 1.3-2.0

Congenital heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.0 2.0-7.0

Severe congenital heart disease” . . . . . . . . . . . . . . . . . . . . . . . . . . 0.50 —

Cystic fibrosis” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.20 —

Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8 1.2-2.0

Down’s syndrome” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 —

Hearing impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.0 —

Deaf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.1 0.06-1.5

Hemophilia” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5 —

Leukemia

Acute lymphocytic leukemia’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.11 —

Mental retardation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.0 20.0-30.0

Muscular dystrophy” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.06 —

Neural tube defect’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.45 —

Spinabifida” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.40 —

Encephalocele” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.05 —

Phenylketonuria’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.10 —

Sickle-cell disease* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.46 —

Sickle-cell anemia’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.28 —

Seizure disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5 2.6-4.6

Visual impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.0 20.0-35.0

Impaired visual acuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.0 —

Blind . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.6 0.5-1.0

aEntrieS ma~edWitha naStefiSk(*)deSignatO estimatesthatweremade using specificprevalence atbirthandsurtival

data, as well as incidence and duration data, which are described in detail in the original study.

SOURCE: S.L. Gortmaker andW, Sappenfield, “ChronicChildhood Disorders: Prevalence and Impact” Pediatric

Clinics of fVorth America31(l ):3-18, 1984, reprintedby permission.

serious chronic conditions show at least some

similarities (72).

As discussed below, adolescents with such conditions may experience consequences ranging from

lost school days to limitations in major activity.

They also may experience psychosocial consequences. The families of adolescents with such

conditions (and society) may have to bear substantial financial costs (see the section of this chapter on

services and interventions for the treatment of

chronic physical illness).

Activity Limitations

As noted earlier, the 1988 NHIS found that 6.8

percent of noninstitutionalized U.S. adolescents

ages 10 to 18 have limitations of activity due to

chronic physical or mental conditions (see table

6-8). About 0.6 percent of noninstitutionalized U.S.

adolescents (or about 1 in every 200) are unable to

carry on their major activity (i.e., attending school or

working) because of a chronic condition; an additional 4.3 percent are limited in the amount or kind

of major activity; and an additional 1.9 percent are

limited in an activity other than major activity.

The 1988 NHIS also found that noninstitutionalized U.S. adolescents experienced an average of

8.7 restricted-activity days due to acute and chronic

conditions per person (see table 6-10). Newacheck’s

analysis of 1984 NHIS data found that adolescents

with a reported limitation of activity due to chronic

illness experienced more restricted-activity and

bed-disability days than other adolescents (62). In

the Newacheck study, adolescents reporting some

limitation of activity due to a chronic condition
II-166 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 6-10-Number of Restricted-Activity Days Due to Acute/Chronic Conditions Among Noninstitutionalized

U.S. Adolescents Ages 10 to 18, by Type of Restricted-Activity Day and Sociodemographic Characteristics, 1988a

Number of days per person in year Number of days in thousands

All Bed- Work- or Ail Bed- Work- or

restricted- disability school-loss restricted- disability school-loss

Characteristic activity daysa days b daysc

activity daysa daysbdaysc

Ail persons ages 10 to 18 . . . . . . . . . . . . . . . . . . . . . . .

Age

10 to 14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15 to 18 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sex and age

Male

All ages (10 to 18) . . . . . . . . . . . . . . . . . . . . . . . . . . .

10 to 14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15 to 18 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Females

All ages (10 to 18) . . . . . . . . . . . . . . . . . . . . . . . . . . .

10 to 14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15 to 18 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Race and age

White

All ages (10 to 18) . . . . . . . . . . . . . . . . . . . . . . . . . . .

10 to 14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15 to 18 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black

All ages (10 to 18) . . . . . . . . . . . . . . . . . . . . . . . . . . .

10 to 14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15 to 18 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Family income and age

Less than $l0,000

All ages (lOto 18) . . . . . . . . . . . . . . . . . . . . . . . . . . .

IO to 14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15 to 18 years........ . . . . . . . . . . . . . . . . . . . . . .

$10,000-$19,999

All ages (lO to 18) . . . . . . . . . . . . . . . . . . . . . . . . . . .

10 to 14 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15 to 18 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$20,000-$34,999

All ages (lOto 18) . . . . . . . . . . . . . . . . . . . . . . . . . . .

10 to 14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15 to 18 years ...,..... . . . . . . . . . . . . . . . . . . . . . .

$35,000 or more

All ages (lO to 18) . . . . . . . . . . . . . . . . . . . . . . . . . . .

10 to 14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15 to 18 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Geographic region

Northeast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mideast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Place of residence

Metropolitan statistical area. . . . . . . . . . . . . . . . . . . . . .

Central city . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Not central city . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Not metropolitan statistical area . . . . . . . . . . . . . . . . . .

8.7

8.2

9.3

8.0

8.3

7.6

9.5

8.1

11.0

9.3

9.9

9.8

6.6

5.8

7.6

11.8

11.4

12.3

9.1

8.1

10.4

8.4

8.6

8.2

8.0

7.5

8.6

6.7

9.1

7.8

11.4

8.7

8.0

9.1

8.7 .

4.1

3.9

4.4

3.4

3.5

3.1

4,9

4.2

5.6

4.4

4.2

4.6

3.3

2.7

3.9

5.8

5.7

5.8

4.2

3.8

4.7

4.0

3.9

4.2

3.9

3.8

4.0

3.2

4.1

3.7

5.5

4.1

3.9

4.2

4.0

4.7

4.5

5.0

4,5

4.6

4.3

5.0

4.4

5.7

4.9

4.8

5.0

4.0

3.6

4.5

6.7

6.9

6.5

5.0

4.5

5.7

4.8

4.5

5.3

4.1

4.2

4.1

4.1

4.9

3.9

6.3

4.7

4.4

4.9

4.8

269,439

135,717

133,722

125,674

70,051

55,624

143,764

65,666

78,098

233,185

119,105

114,080

31,844

15,036

16,808

43,548

20,591

22,957

44,637

21,364

23,273

62,974

36,231

26,743

84,720

42,540

42,180

37,896

72,918

84,267

74,358

204,409

72,344

132,065

65,030

127,082

64,077

63,005

52,952

30,121

22,831

74,130

33,956

40,174

109,763

56,355

53,408

15,654

7,061

8,592

21,182

10,348

10,835

20,443

9,951

10,491

29,999

16,308

13,681

41,411

21,805

19,603

18,141

32,805

40,180

35,935

96,945

35,332

61,613

30,136

137,604

75,286

62,520

66,710

39,469

27,241

71,096

35,816

35,280

116,810

64,751

52,059

17,657

9,340

8,317

20,890

12,471

8,419

23,170

11,978

11,192

34,933

19,103

15,831

42,116

23,891

18,539

21,891

37,156

39,935

38,825

104,397

36,799

67,597

33,409

aForthe pljrposesoftheNational Health [nterview Survey(NHIS), aresttid~adiwlydayis any dayonwhichaperson restricts hisorher usualactivfties for

morethanonehalfdaybecauseofan ilinessoran injury. Restricted-activity daysareunduplicated countsofbeddisability days,work-lossdays, school-ioss

days, andcutdowndays.

bAb~~j~~flj~~ayisdefined by NHSasany dayon~hicha per~nstaysin~formorethan ha~theda$ight hours (ornormaiwaking hours) because

ofanillness orqninjury.

cAs&oo/-/o~~&Yis~fin~ by NHiSasany ~yonwhi.ch achflddid notattend school forat least ha~ofhis or hernormal school day because OfaSp~ifiC

Illnessorlnjury.school-lossdays aredetermlned onlyforchildren 5t017yearsofage.A work-/ossdayisdefined byNHiSas anydayonwhichan Individual

did not work at his or her job or business for at least half of his or her normal workday because of a specific illness or injury. The number of work-loss days

is determined only for currently employed persons.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics,

unpublished 1988 data from the National Health Interview Survey, Hyattsville, MD, 1990.
Chapter 6---Chronic Physical Illnesses: Prevention and Services .11-167

experienced an average of 27 restricted-activity days

per year, while other adolescents experienced 7.7

restricted-activity days per year. Adolescents reporting some limitation of activity due to a chronic

condition also experienced significantly more beddisability days than other adolescents: 12.2 bed-days

v. 3.7 bed-days (62).

Newacheck found that male adolescents in the

1984 NHIS were more likely to be reported as

having a limitation of activity due to a chronic

condition than females (7.2 percent of males v. 5.2

percent of females). Younger adolescents were more

likely to be reported as having a limitation of activity

due to a chronic condition than older adolescents

(6.6 percent of 10-to 14-year-olds v. 5.7 percent of

15- to 18-year-olds). Newacheck also found that

poor adolescents were 46 percent more likely to be

reported as having limitations of activity due to a

chronic condition than adolescents living in families

with incomes above the poverty line (62).

Not surprisingly, several studies have found that

children with chronic conditions miss more school

days than healthy children (44). One study found

that among children ages 6 to 17, those with chronic

mental or physical conditions (e.g., mental retardation, cerebral palsy, or asthma) missed 8.7 days of

school, while other children missed 5.8 days of

school (1 17). Another study revealed that students

with allergies in nursery school through 12th grade

(15 percent of whom were in grades 8 through 12)

experienced significantly more absences than nonallergic children (data on magnitude of differences

were not presented) (53). Also, one study reported

that asthmatic children ages 4 to 16 (one-third of

whom were age 12 or older) had an absence rate

approximately 24 percent higher than other children

(19).

Psychosocial Consequences

McAnarney suggests that social experiences for

adolescents with physical disabilities may differ

from those of other adolescents in three ways: 1)

their exclusion from school activities because of

their high levels of school absence, 2) their inability

to keep up with their peers physically and their

exclusion from some activities because they feel

different or ill, and 3) their lack of opportunity for

normal peer interactions, both in and out of school

(52).

Only a few studies have examined the associations between chronic illness or disability and

psychosocial outcomes for adolescents. Most of

these studies suffer from various methodological

limitations, including small sample sizes and lack of

appropriate control groups (9). In addition, most

studies are cross-sectional rather than longitudinal,

making it difficult to draw conclusions about causality or about the process of adjustment through the

course of an illness or disability. Despite these

methodological limitations, existing studies do provide some useful information on young people with

disabilities.

In the aggregate, adolescents with physical disabilities appear to be more like than unlike their

able-bodied peers with respect to their social maturation (52), but the evidence is not consistent. For

example, studies of large cohorts comparing adolescents with and without physical disabilities have

generally found that these groups do not differ

significantly in their levels of self-esteem. Other

studies using samples of adolescents with the same

types of disability have frequently found that disabled adolescents have lower levels of self-esteem

than nondisabled adolescents (52). Still other research, such as a study of survivors of childhood

cancer, have found that adolescents with chronic

illness actually score higher on measures of selfconcept than do normative samples (21).

A recent study found higher levels of emotional

and behavioral problems among adolescents ages 12

to 17 with serious chronic physical conditions than

among adolescents without such problems (28).

Adolescents with serious chronic physical conditions in this study were particularly likely to be

reported by their parents to be depressed and socially

withdrawn. Although flawed in some ways,27 this

study is impressive in that it was able to disaggregate

the effects of socioeconomic status from the effects

of having a chronic physical disorder, demonstrating

that both have independent effects.

An interview survey comparing matched samples

of adolescents with diabetes (n = 31, mean age =

14.7 years) or cystic fibrosis (n = 31, mean age =

14.5 years) with healthy adolescents (n = 31, mean

27A ~oSS1ble flaw not Pofited out ~ the s~dy is tit the msessrnent of problems relied entirely on a child be~vior ch~~t fdled out by p~nts;

children and adolescents themselv~ were not surveyed.
//-168 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

age = 14.5 years) found no statistically significant

differences among the three groups on how often

they used various strategies to cope with their social

and emotional problems, their perceived degree of

social support, their feelings of social competency,

their perception of control over their life, or feelings

of depression (9). However, results indicated that the

adolescents with chronic illness were more concerned about their parents’ reaction to their health

than healthy adolescents were; believed that their

parents experienced more stress because of their

illness; and were more concerned about their future

health (9). The survey found some differences

between the adolescents with diabetes and those

with cystic fibrosis; adolescents with cystic fibrosis

rated their health worse than did adolescents with

diabetes or healthy adolescents.

In a study examining depressive symptoms over

time in a sample of 17 adolescents ages 13 to 19 with

cancer, the mean level of depressive symptoms for

adolescent cancer patients did not differ from a

general population sample of adolescents (41). As in

the general population of adolescents, depressive

symptoms for the adolescents with cancer were

associated with psychosocial events, such as arguing

with parents, breaking up with a girlfriend or

boyfriend, or being dissatisfied with one’s appearance. Similarly, another study found that depression

was uncommon among adolescent survivors of

childhood cancer (21). (Other consequences associated with cancer during adolescence are discussed in

the following section.)

Normal tasks of adolescence may be particularly

difficult for adolescents with serious chronic physical conditions (52). Many of the concerns of

adolescents with disabilities are the same concerns

experienced by all adolescents, but the concerns may

be exacerbated by a disability (52). Adolescents with

some disabilities may experience more difficulty in

achieving separation and independence from their

parents than other adolescents, for example, if they

rely heavily on their families for financial and

personal assistance. And, although adolescents with

disabilities have the same concerns about their

sexuality as other adolescents, adolescents with

some disabilities may have limited chances to

develop their sexuality as a result of constraints that

include the lack of knowledge about or denial of

their sexuality by their parents and the adolescents

themselves (52). Lack of socialization with ablebodied peers, either because of limited contact or

because of negative attitudes among peers towards

developing romantic attachments with someone

with a disability, also limits opportunities for some

adolescents with disabilities to explore their sexuality.

Independence for people with disabilities requires

access to the same opportunities afforded to people

without disabilities and sufficient capacity to take

advantage of those opportunities (87). Thus, independence may require access to a full range of

residential alternatives, accessible transportation,

and participation in the political process and may

also require family support and assistance; personalcare assistance in the activities of daily living; social

support from friends, neighbors, and communities;

and the application of technology, such as computers. Some adolescents with disabilities need training

to improve their capacities to make life choices, such

as through life planning, instruction in problem

solving, participation in the development of their

individualized education program,28 and participation in self-advocacy groups (87). The ability of

disabled adolescents to achieve independence depends on the severity of their condition, the ability

of their family to cope financially and psychologically with that condition, and their personal motivation to become independent (52).

Prevention of Chronic Physical Illnesses

and Disabilities Among Adolescents

Many of the chronic physical illnesses and

disabilities that U.S. adolescents experience (except

those due to injuries) are not really preventable

during adolescence. Some of the illnesses (e.g.,

cystic fibrosis, heart disease, spina bifida, sickle-cell

disease) are congenital conditions that cannot be

prevented during adolescence. Other chronic illnesses may develop during adolescence, but for

many of them (e.g., cancer, arthritis, diabetes, renal

failure), not enough is known to establish protocols

for prevention for adolescents. Until effective means

2S~ individ~~ ~du~atio~ pro- for each ‘ ‘~di~ppd” c~d is rqfied under the Education for ~ Handicapped Chikken Ad (fiblic

Law 94-142), which was passed in 1975 (92). The program must include a statement of the child’s present levels of educational performance; annual

goals, including short-term instructional objectives; and other things specified in the regulations implementing Public Law 94-142.
Chapter 6--Chronic Physical Illnesses: Prevention and Services . II-169

of primary prevention29 are developed, the emphasis

for many chronic illnesses that adolescents experience must be on early intervention30 and other forms

of treatment. Clearly, however, efforts can be made

to prevent adolescents’ disabilities from becoming

handicaps (see OTA definition of handicap in box

6-A).

It is important to note that health-compromising

behaviors initiated in adolescence may lead to the

development of chronic illness among adults. For

example, smoking may lead to the development of

lung cancer, engaging in unprotected sexual activity

may lead to the development of acquired immune

deficiency syndrome (AIDS) and other sexually

transmitted diseases, and eating high fat diets may

lead to an increased risk of heart disease. Attention

to the prevention of these and other healthcompromising behaviors during adolescence may be

warranted.31

Services and Interventions for

Adolescents With Chronic Physical

Illnesses and Disabilities

Use of Health Services by Adolescents With

Chronic Conditions

Adolescents with chronic conditions have more

contact with the health care system than do other

adolescents. According to 1984 NHIS data, adolescents with a chronic condition (mental disorders

included) have more physician contacts annually

than other adolescents (8.8 physician contacts v. 2.7

physician contacts) (62). They are also more likely

to experience a hospitalization (O. 181 hospitalizations per year v. 0.038 hospitalizations per year).

Furthermore, when adolescents with a chronic

condition are hospitalized, they spend nearly twice

as long in the hospital as adolescents without such

conditions (9.1 v. 4.8 days on average) (62).

A survey of 456 children ages 3 to 18 (no further

age distribution was provided) with chronic physical

conditions (i.e., cystic fibrosis, cerebral palsy, myelodysplasia, or multiple physical handicaps) found

that these children were far more likely than a

randomly selected comparison group of children

from the same region to be hospitalized during the

year (34 percent were hospitalized v. 6 percent of

controls) and to have more lengthy periods of

hospitalization (11.0 days v. 3.7 days for controls)

(81). A relatively small subset of children in the

study accounted for the majority of health care use;

75 percent of all outpatient use was accounted for by

25 percent of the sample, and all hospital care was

accounted for by 33 percent of the sample.

Similar results were reported from an analysis of

1980 data from the National Medical Care Utilization and Expenditure Survey (NMCUES) by

Newacheck and McManus (65). Children and adolescents with activity limitations due to chronic

conditions (mental disorders included) were twice as

likely to be hospitalized, made twice the number of

visits to physicians, and saw nonphysician health

care professionals (e.g., physical therapists, social

workers) five times more frequently than children

and adolescents without activity limitations due to

chronic conditions.

Costs of Treatment for Adolescents With

Chronic Conditions

Little is known about the total costs of medical

services for chronically ill children in the United

States (66). There is no single source of information

on the full range of costs of care for people with

chronic conditions, including adolescents. Total

expenditures include personal expenses; expenditures

reimbursed by insurance companies; services provided by private organizations; and costs of various

2~e ~ditioml t=onomy of prevention &s@uishes among primary, secondary, and tertiary prevention (see, e.g., 93a). f’n’~ry Preven~~n ‘fa

to activities designed to avoid disease or other conditions that adversely affect health. Immuniza tions are one example of primary prevention but

regulatory activities to protect health (health protection) are also forms of primary prevention. Seconalzry prevention includes efforts to identify existing

conditions that could cause illness and disability before the appearance of clinical symptoms, or to minimize the progression of disease. Screening for

the existence of disease is one form of seconday prevention. Terriary prevention refers to efforts to control irreversible chronic conditions in order to

avoid disability or death. Some have suggested that this typology does not adequately distinguish among preventive services (see 93a). Another way

to characterim preventive services is by the target of an intervention (e.g., the environment, the individual) and the intended beneficiary (usually

individuals).

3oAs de~cn~d a~ve, ~eco~o ~d te~i~~ prevention (but especi~y ~e~tiary prevention) ~ficlude ~ea~ent. k this Repofi lhe term early

.

intervention is also used for treatment services delivered before a problem becomes serious and/or chronic.

31~event10n of smoking is covered in this volume inch. 12 “Tobacco, Alcohol, and Drug Abuse: Prevention and Semices”; prevention of AIDS

is discussed inch. 9, ‘‘AIDS and Other Sexually Transmitted Diseases: Prevention and Services’; and nutrition and fimess problems among adolescents

are covered in ch. 7, “Nutrition and Fitness Problems: Prevention and Semices. ”
11-170. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Federal programs, such as Medicaid, that provide

coverage for health care of people with disabilities.

One study that defined disability as having a

reported long-term limitation in usual activities

(e.g., school) estimated that U.S. children and

adolescents with disabilities accounted for a relatively small proportion-$ 3.9 billion in 1986 dollars

(10.9 percent)--out of a total of $35.7 billion in

charges for health services provided to persons

under the age of 21 (65).32 3334 In this study, the four

leading reported causes of disability for individuals

under age 21 were mental and nervous system

disorders (prevalence of 7.3 cases per 1,000),

followed by respiratory diseases (6.0 cases per

1,000), musculoskeletal and connective tissue diseases (4.3 cases per 1,000), and eye and ear diseases

and disorders (3.7 cases per 1,000).35

Other evidence suggests that children and adolescents with chronic physical conditions have significantly higher health care costs than other children.

For example, one report estimated that a sample of

chronically ill and disabled children ages 3 to 18

with cystic fibrosis, cerebral palsy, myelodysplasia,

or multiple physical impairments averaged 10 times

the yearly expenditures for health care of a general

population comparison group of children (81). Half

of this difference was accounted for by the greater

amount of hospitalization experienced by the children with chronic physical illness and disability.

The costs of care for children and adolescents with

chronic conditions are not evenly distributed across

this population. In a ranking of children and

adolescents under age 21 who were reported to have

activity limitations due to chronic conditions in the

1980 NMCUES according to their total health

charges, the 10 percent who experienced the greatest

health care expenses accounted for 65 percent of all

charges accumulated by the children and adolescents with activity limitations (65). Those who

experienced the highest total health care costs were

most likely to be between ages 16 and 20.

An estimated 14 percent of adolescents with

chronic conditions do not have health insuranceabout the same percentage as for adolescents without chronic conditions (62,93).36 Because adolescents with chronic conditions often have high health

care expenses, it is critical that they have health

insurance. In addition to needing basic coverage

provided by most health insurance policies, many

adolescents with chronic conditions need more

extensive coverage, such as for mental health

services, prescription drug coverage, and long-term

care benefits.37 Even those who do have adequate

health insurance coverage may incur significant

related expenses that are not covered (e.g., travel to

health care centers) (61). Thus, families shoulder a

significant burden of costs of care for chronically ill

children of all ages (7,37), although the extent of the

family role is often not considered by policymakers

(37). Moreover, excessive burdens to the family may

be a factor in a family’s decision to institutionalize

a chronically ill child rather than attempt to care for

the child at home.

Few studies have assessed the actual economic

impact of caregiver costs on families with a seriously chronically ill or disabled child. Available

studies use different methods and categories of costs

and focus on children of different ages with different

types of disabilities (sometimes including mental

illness and mental retardation). Consequently, it is

difficult to generalize the results to all children with

chronic physical illness or disability, particularly

adolescents, or to assess the overall economic

burden to these families. Nonetheless, it is clear that

substantial family costs are associated with the care

of chronically ill or disabled children (37).

Analyses of the health care costs borne by

families of chronically ill or disabled children in

32Da~ were collected ~~ pa of the 1980 ~c~s. Fi~es were adjust~ up to 1986 leve~ using the m~~ care component of the Consumer ~Ce

Index (65).

3S~e ~op~ation considered ~~s s~dy is a subset of thepop~ation with chronic conditions, which * includes peopkwhohw c~onic conditions

but who do not suffer activity limitations.

~k 1980, individu~s under 21 constituted 34 percent of the U.S. resident population (93b).

35~ese fow categories accomted for ju5t over Mof repofled disabilities ~ the s~ey. Note that individu~s with disability as a resdt of’ mental

and nervous system disorders, which include mental retardation and neurotic and personality disorders, are included in these analyses. It is not possible,

however, to determine from the data presented (65) what the impact of these disorders is relative to other causes of disability.

sG~eW ~yses included adolescents with chronic mental, as well as physical, disorders.

37sW ch. 16, “Financial Access to Health StT%’lUs, “ in Vol. III for fiuther information on adolescents’ health insurance status and health insurance

benefits.
Chapter 6-Chronic Physical Illnesses: Prevention and Services .11-171

general (or by society) have been scarce (65).

Newacheck and McManus’ analysis, based on data

from the 1980 NMCUES, suggested that only a

small fraction of families incur ‘‘catastrophic

costs, but that analysis was limited by NMCUES’

small sample size (65). Of the 6,245 persons younger

than age 21 in the sample, only 249 were reported to

be limited in their activities. According to

Newacheck and McManus, the small sample implies

that few children with low prevalence, very serious

and costly, chronic conditions will be represented in

the sample, In addition, the NMCUES sample

excludes the institutional population, and thus excludes a large segment of the most severely ill

children and adolescents. Also, the NMCUES data

were collected in 1980 and 1981, when children

were often hospitalized rather than cared for at home

and when health care costs were lower. Finally,

NMCUES interviewers were instructed to indicate

to survey respondents that limitation of activity

refers to a limitation caused by long-term illness or

disability only when a respondent asked for clarification; in some cases, therefore, a limitation reported

in the NMCUES may have been caused by an acute,

rather than a chronic, condition. Although

Newacheck and McManus suggest that the number

of such cases should be small (and that other features

of the NMCUES questions could compensate for the

ambiguity about chronicity), the small overall number with reported limitations in activity still invites

cause for concern, Thus, a particular finding from

Newacheck and McManus’ analysis should be

viewed very cautiously—namely, the finding that

families of all children with limitations in activity

averaged $135 in 1980 dollars per child in out-ofpocket expenses for health care and that families of

the 10 percent of children consuming the greatest

amount of care averaged $300, while families with

children without activity limitations averaged $76.

A study by Butler et al. examining sources of

payment for physician visits by disabled children38

(about a third of the 1,726 children in the study were

ages 11 to 13) found that in families without health

insurance, parents paid all of the costs of the visit

70.6 percent of the time (8). In families with private

health insurance, parents paid all costs 30.7 percent

of the time and partial costs 44.3 percent of the time;

in families with public health insurance, parents paid

all costs 4.6 percent and partial costs 2.8 percent of

the time. Whether children with disabilities had seen

a physician in the past year was significantly

associated with whether the children were covered

by insurance, even after controlling for survey site,

race and ethnicity, socioeconomic status, age, and

type of disability. Disabled children with health

insurance were 1.8 times more likely to have seen a

physician than those without insurance.

Jacobs and McDermott’s review of three studies

of family caregiver costs for chronically ill and

disabled children concluded that: 1) estimated incremental money costs (i.e., apart from the costs of

therapy) to families of children (ages unspecified)

with cancer ranged from $1,121 to $4,012, and 2)

estimated annual time costs (e.g., family members

giving up time from work and other activities)

ranged from $1,514 to $4,697, for a total range of

estimated incremental money costs from $3,000 to

$9,000 annually (37). Two studies that met minimal

methodological criteria and covered other serious

chronic diseases were also subject to review. One of

the studies, on cystic fibrosis, found an annual

incremental money cost of $334, but the reviewers

were unable to estimate the incremental time or

money costs to families of a child with spina bifida

(37).

In conclusion, current estimates of the financial

costs to families of chronic illness and disability

among adolescents are highly variable, and more

research on this topic is warranted.

/interventions To Treat Psychosocial Problems

of Adolescents With Chronic Conditions

In a 1990 review of the association of chronic

physical health problems and behavioral or emotional problems, Gortmaker and colleagues concluded that, despite general acceptance of the idea

‘‘that children with chronic conditions are at higher

risk for developing behavioral problems,’ the literature contains few accounts of systematic, welldocumented attempts to prevent or ameliorate these

functional problems” (28).

38~~study~l=~fl~d~~l&~n~dl~abl~don theb~ls of emo]lment in speci~ education c~ses. me prim~ disabling condition of about a third

of the children in the sample was a neuromuscular, orthopedic, or sensory impairment or a chronic disease, The remainder of the disabled sample included

children with problems such as 1earning disabilities, attentional deficits, mental retardation% speech impairments, or emotional or behavioral dysfunctions

(8).
II-172 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Photo credit: Katherine Criss, New York, NY

Independence for adolescents with disabilities may require

access to the same opportunities in life afforded to

people without disabilities.

The Gortmaker review found only five accounts

of systematic, well-documented attempts to prevent

or ameliorate chronically ill children’s psychosocial

problems (28). All but one of the studies found

beneficial effects, but only two of the programs

included or focused on adolescents (28). Two

studies with small samples documented the effectiveness of educational programs geared to increase

health knowledge and self-care and to improve the

functioning of children with asthma (18,46). A

randomized controlled trial of a university hospitalbased home care program for children with a broad

range of long-term health needs demonstrated beneficial effects on the pyschologic functioning of the

children (82). Pless and Satterwhite found that a lay

family counselor intervention also improved psychosocial functioning of children with chronic

physical health problems (73). On the other hand, a

randomized controlled trial of a social work intervention conducted by Nolan et al. at Montreal

Children’s Hospital indicated no effects from a

6-month intervention intended to improve psychosocial functioning for children with chronic physical

conditions (68).

The two programs that included or focused on

adolescents were the lay family counselor intervention (73) and the social work intervention in

Montreal (68). Both of the programs focused on

providing assistance to families as a whole (primarily parents), although it was the aim of the programs

to improve the psychosocial status of the adolescents. Differences between these two programs may

be helpful in evaluating why one failed and the other

did not. The program reported by Nolan et al. was a

short-term (6-month) intervention in which social

workers had minimal (an average of three times)

personal contact with some member of the family

(68). Half the families did not find the intervention

helpful. Although the program reported by Pless and

Satterwhite used lay volunteers rather than professionals, these lay volunteers were able to spend

much more time with the families (an average of 4.6

hours per month with each of eight families) over the

course of a year (73). Pless and Satterwhite found

that children’s psychological improvement increased

with the amount of time spent by the lay counselor

(73). In addition, the lay volunteers were chosen on

the basis of their personal characteristics and proven

success in childrearing, which Pless and Satterwhite

asserted might not be possible to do with professional staff (73).

One of the main issues for adolescents with

serious chronic physical illnesses or disabilities is

the development of greater independence (49), and

a number of programs have developed to enhance

the capacities of adolescents with serious chronic

physical illnesses or disabilities to be independent.

Some programs employ interdisciplinary teams to

assess and provide services to adolescents with

chronic illness or disability. One such program is the

Comprehensive Adolescent Medicine program at

the Montefiore Medical Center in New York City.

The program, originally funded by the Robert Wood

Johnson Foundation in 1979, provides chronically

ill young people ages 10 to 20 with comprehensive,

interdisciplinary care designed to help them develop

into independent adults. The program serves between 450 and 500 young people each year (77).

Another program, the Youth in Transition Project

at the University of Washington in Seattle, is a

demonstration project funded by DHHS’ Bureau of

Maternal and Child Health. This program is designed to facilitate transitions from high school and

home to employment and independent living for

individuals ages 17 to 21 with developmental

disabilities, cognitive impairments, or chronic physical illness (10). Each participant in the project

receives an extensive evaluation from an interdisciplinary team including a physician, nutritionist,

psychologist, and a social worker. A transition plan

is then developed that might include, depending on

the needs of the adolescent, vocational planning, life

skills training, sexuality education, and nutrition

education and a diet plan. Followup is then provided

to determine how clients are progressing in their
Chapter 6--Chronic Physical Illnesses: Prevention and Services ● II-173

transition and whether assistance is needed in

implementing the transition plan. Preliminary evaluations of the demonstration project based on the first

27 clients indicate that families found the assessment process useful.

Other types of programs focus on experiential

learning for adolescents with chronic illness or

disability to increase their sense of personal efficacy.

Adventure, Inc. is a program that provided an

Outward Bound experience, consisting of a 9-day

wilderness and a 5-day urban experience, for chronically ill, physically disabled, and able-bodied adolescents (42). After participating in the program,

both able-bodied adolescents and adolescents with

disabilities or chronic illnesses, showed improved

body image, declines in family conflict, and increases in individual recreational activities relative

to family recreational involvement. Although the

study is limited by a small sample size (n= 37, 23 of

whom were chronically ill or disabled), the study

does indicate the potential of an Outward Bound

type of program for developing independence for

adolescents with chronic illness or disability.

Another program, the Adolescent Employment

Readiness Center at Children’s Hospital National

Medical Center in Washington, DC, has provided

vocational services, including vocational aptitude

and aptitude testing and job placement, to over 100

young people ages 12 to 19 with chronic health

problems such as juvenile rheumatoid arthritis, spina

bifida, muscular dystrophy, kidney failure, diabetes,

epilepsy, and cystic fibrosis (12). The program,

which was funded by a grant from the DHHS Bureau

of Maternal and Child Health, is designed to

improve prevocational readiness and enhance independence. Through the program, adolescents are

placed in volunteer or paid jobs ranging from clerical

jobs to lifeguarding. An evaluation of this program

is under way, but no outcome data are available yet

(118).

State and Local Services for Adolescents With

Chronic Conditions

Assistance may be available for adolescents with

physical or mental disabilities from a variety of State

agencies depending on the State (36). These agencies include State departments of education, which

provide special education services; offices of State

coordinators of vocational education for handicapped students, which coordinate vocational education services; and State mental health departments. Other sources include State mental retardation agencies, programs that have received funding

from the DHHS Bureau of Maternal and Child

Health for direct medical and related services to

children with special health care needs, and State

developmental disabilities agencies. State protection and advocacy systems provide services to

persons with developmental disabilities, and State

vocational rehabilitation agencies provide services

needed to prepare persons with disabilities for work.

Finally, a number of universities have universityaffiliated programs, which provide services and

programs for children and adolescents with disabilities and their families. There is considerable variability across States in how these various services are

provided, and in where the various functions are

housed organizationally.

According to Blum, there are major problems in

the care of adolescents with chronic illness and

disabilities (5). These include the lack of coordinated care among subspecialist services; provider

ignorance of the various health, education, and

social services in the community; a lack of attention

on the part of health care providers and policymakers

to providing for adolescents’ transition to the adult

health care system; and failure to address the sexual

and reproductive needs of adolescents with chronic

illnesses and disabilities.

Some observers have noted that services to

children with chronic illness are frequently disease

specific (72). That is, often specialized services

emerge to address the needs of persons with only

certain types of disorders. Voluntary and advocacy

organizations, which represent only one or a few

disorders, rarely coordinate their advocacy efforts .39

The result is that policies are made or programs are

developed that address specific concerns of advocates for specific problems, rather than the generic

needs of people with varying types of disabilities. In

addition, the needs of children with illnesses without

effective advocates may not be addressed in the

policy domain.

3~crc~~~~~bl~~xC~ptiomt.M5 la&of ~oord~atlqforexmp]e, the lkchnology-Related Assistance for htividtis Witi Disabilities Act of

1988 (Public Law 100-407), which was actively backed by a broad coalition of organimations and individuals in the disability community. However,

the coordinated effort was to encourage the passage of legislation not to actually provide services.
II-174 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Examples of Chronic Physical Illnesses

Among Adolescents

OTA has used the available information on the

prevalence and importance of chronic physical

health problems to identify for further discussion in

this chapter one serious problem--cancer--and two

problems with less dire consequences—acne and

dysmenorrhea. Each of these illnesses illustrates

certain important issues about services to treat

physical illness in adolescents.

Cancer was chosen because it is the most frequent

cause of natural death (i.e., death caused by illness,

disease, or chronic conditions as opposed to death

caused by external causes such as accidental injuries, suicide, or homicide) among U.S. adolescents.

Adolescents with serious chronic illness such as

cancer and their families merit public attention for

these major reasons:

●

●

●

significant public funds are consumed by these

children, particularly for health care;

the needs of children with chronic illness are

not likely to be met by the existing health care

system; and,

thanks to the advances in technology and health

care over the past several decades, significantly

greater numbers of children with chronic illness

are now surviving into adolescence and adulthood (72).

Cancer is a low prevalence disease that has very

serious short- and long-term consequences for adolescent victims and their families.

Acne is a leading cause of adolescents’ visits to

office-based physicians, and it is identified by

adolescents as an important concern. Usually

thought of by adults as a minor problem, common

acne (acne vulgaris) is experienced by the vast

majority of U.S. adolescents.

Dysmenorrhea (painful menstruation) is a problem for many young women, and it contributes

significantly to school-loss days among adolescent

females (39,44,120). Although identified by adolescents as an important concern, dysmenorrhea may

not be adequately addressed by health care providers.

Cancer Among Adolescents

Cancer is the leading cause of natural death

among U.S. adolescents. For U.S. adolescents ages

10 to 14, malignant neoplasms (cancer) are the

second leading cause of death, following accidental

injuries; for U.S. adolescents ages 15 to 19, malignant neoplasms are the fourth leading cause of death,

following accidental injuries, suicide, and homicide

(103).

While the number of adolescents dying from

cancer is small, and cancer treatment represents only

a small portion of health care services delivered to

adolescents, a number of issues specific to cancer are

important to address. Adolescents with cancer, and

their families, suffer devastating personal effects as

a result of treatment, and the costs to families of

cancer treatment are high. Cancer and cancer treatment put adolescents at risk for a number of

short-and long-term physical problems, and death.

Trends in the Incidence and Prevalence of

Cancer Among Adolescents

U.S. adolescents generally have lower cancer

rates than Americans in other age groups. However,

adolescents ages 10 to 19 experience the highest rate

of bone cancer except for those ages 60 and above.

And, they experience more acute lymphoblastic

leukemia, the most common form of leukemia

experienced by adolescents, than all Americans

except those ages 9 or younger, or 80 and above

(1 10). In general, the incidence of cancer among

U.S. adolescents has remained relatively stable since

the early 1970s (see figure 6-2), with the exception

of acute lymphoblastic leukemia, which has increased in incidence (110).

Substantial advances in treatment of childhood

cancers have led to declining death rates in recent

years (see figure 6-3). Between 1960 and 1984,

5-year survival rates among children of all ages

increased from 20 to 48 percent for bone cancer,

from 52 to 91 percent for Hodgkin’s disease, from

33 to 82 percent for Wilm’s tumor, from 35 to 55

percent for brain and nervous system cancers, and

from 18 to 60 percent for non-Hodgkin’s lymphoma

(110).

Dramatic increases in survival have also been

realized for leukemia among young people. While as

recently as 40 years ago nearly all children diagnosed with leukemia died of the disease (83), about

half of the white males and females ages O to 14

diagnosed with leukemia in 1979 survived 5 to 6
Chapter 6-Chronic Physical Illnesses: Prevention and Services . //-175

Figure 6-2—incidence of Cancer Among

U.S. Adolescents Ages 10 to 19, 1973-87

Annual incidence rate (new cases per 100,000 population)

18 r-–—— –~

I

() L.–. -–~--777— T

J -———

1973 1975 1977 1979 1981 1983 1985 1987

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Services, Public Health Service,

National Institutes of Health, National Cancer Institute, unpub

Iished Surveillance, Epidemiology, and End Results Program

data, Bethesda, MD, 1989,

years (11O).W Nevertheless, leukemias, followed by

brain and central nervous system cancers, are the

most common cause of cancer deaths among U.S.

adolescents.

Consequences of Cancer Among Adolescents

Increases in survival among cancer patients mean

that more individuals contracting cancer during

early childhood will survive into adolescence and

that persons with cancer during their adolescence

have a high probability of surviving into adulthood.

There are a number of significant short- and

long-term consequences of cancer for adolescents.

Short-Term Consequences for Adolescen--Shortterm consequences of cancer include the side effects

of treatments, interruptions in major academic and

socializing activities, and the psychological distress

that may arise from these more overt consequences.

The side effects of cancer treatments such as

radiation and chemotherapy can be devastating for

adolescents. In a study involving interviews with 40

survivors of childhood and adolescent Hodgkin’s

disease (70 percent of whom were ages 12 to 19 at

the time of diagnosis), half of the respondents

reported that the ‘‘worst’ thing about having

Hodgkin’s disease was experiencing the side effects

of treatment (115). A study by Wasserman et al. of

survivors of childhood/adolescent Hodgkin’s disease found that females, in particular, were likely to

identify side effects of treatment (especially loss of

hair) as the most traumatic part of their illness (1 15).

6

5

4

3

2

1

0

Figure 6-3-Cancer Mortality for U.S. Adolescents

Ages 10 to 19, 1973-87

Mortality rates (deaths per 100,000 population)

p.

— — .

‘.

““’~1

1

i

1973 1975 1977 1979 1981 1983 1985 1987

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Services, Public Health Servioe,

National Institutes of Health, National Cancer Institute, unpub

Iished Surveillance, Epidemiology, and End Results Program

data, Bethesda, MD, 1989.

Immediate side effects of treatment include nausea

and vomiting and pain associated with the administration of the chemotherapy agents. Ulceration of the

mouth or gastrointestinal tract are also common side

effects, appearing several days after a dose of

chemotherapy (57). Radiation and chemotherapy

frequently lead to loss of hair (alopecia), necessitating the use of a wig or appearing bald in public (33).

These side effects of treatment can be particularly

difficult for adolescents because of their heightened

concern about their appearance and relationship to

their peers.

Individuals receiving treatment for cancer also are

particularly susceptible to secondary infections (83).

Even after they receive treatment, some individuals

experience anxiety about their condition. In a 1988

study, a quarter of the 41 survivors of childhood

cancer interviewed were extremely preoccupied

with their physical condition (21).

Young people with cancer may find it difficult to

keep up with school. The need for frequent treatments, often at a distance from home, may result in

high levels of school absence. Many school systems

provide good in-home tutoring services, but the

quality of services is not consistent across schools

(69). Individuals interviewed in Wasserman et al.’s

retrospective study of the effects of childhood and

adolescent cancer missed an average of 6 months of

school while they were undergoing treatment (1 15).

Some may drop out of school after extended

absences (1 15). Even when young people return to

%ata presented are for white children only; data for black chiklren are unreliable because of small sample sizes.
II-176 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

school, they may find that they are ostracized by

their peers. Forty percent of those interviewed in the

study by Wasserman et al. remembered being teased

about their appearance or being treated as outcasts

(115).

Long-Term Consequences for Adolescents--Longterm side effects of cancer can also be quite serious

and include secondary cancers, sterility, and growth

retardation (13,57,83,1 15). Chemotherapy and radiation can also result in gonadal damage, resulting in

smaller testes for males (76). The long-term effects

of gonadal damage resulting from chemotherapy and

irradiation may not become evident until adulthood

(e.g., sexual dysfunction, increased risk of heart

disease) (76). Females treated for leukemia with

chemotherapy and radiation have been found to

experience significantly earlier breast development,

to have a lower mean age of menarche than average,

and to go through puberty in a shorter period of time

than average. This early puberty and limited potential for growth can have a number of psychological

effects on adolescents. Secondary cancers are also

possible sequelae of cancer treatment (57).

Adolescent cancer can also have long-term social

or emotional effects. For example, evidence indicates that survivors of childhood cancer often

confront employment discrimination and discrimination in obtaining life and health insurance policies

(11 1). For people who do not belong to group health

insurance policies (e.g., through an employer),

health insurance may be very expensive or even

unobtainable (115). Discrimination may occur in

other areas as well; Wasserman et al. found that 5 of

their 23 male subjects reported being denied entry

into the armed forces because of their cancer history

(115).

Available evidence suggests that most adolescent

survivors of childhood cancer do not experience

higher levels of depression or lower levels of

self-esteem than other adolescents (29). Survivors

with severe long-term medical effects (e.g., physical

disfigurement, loss of a limb, gonadal failure, or

second malignant neoplasm) tend to experience

greater levels of depression and to have a lower

self-concept than survivors with no long-term cosmetic or organ dysfunction (29).

Many survivors of childhood cancer actually

identify positive effects of their experience with

cancer. One study reported that 61 percent of the

adolescent survivors of childhood cancer interviewed identified positive effects, such as increasing

their self-confidence, enabling them to be more

empathetic, increasing their appreciation of life, and

making them more mature (21). Likewise, Wasserman et al. found that 95 percent of adult survivors of

child or adolescent Hodgkin’s disease identified

positive consequences (115).

Prevention of Cancer Among Adolescents

Most cancers that occur during adolescence could

not have been prevented given the current state of

knowledge. Except for the relationship between

prenatal radiation of a pregnant mother and childhood leukemia (6,79), little is known regarding the

cause of leukemia. The risk of secondary leukemia

increases with certain types of cancer chemotherapy

(110).

Discussions about preventing cancer in adolescents generally focus on the prevention of future

cancers that are linked to engaging in healthcompromising behaviors (e.g., 51). These behaviors,

which may be initiated or established during adolescence, include smoking, drinking alcohol, using

certain contraceptives, eating habits, and tarming.dl

Results of the 1987 National Adolescent Student

Health Survey of more than 11,000 8th and 10th

graders found that these adolescents had a number of

eating practices that may increase their risk of cancer

later in life. These include high consumption of fatty

foods (59 percent reported eating fried foods one to

three times weekly and 39 percent did so more than

three times weekly), and a lack of knowledge about

some risk factors for cancer (e.g., few were aware of

the role of dietary fiber in the prevention of colon

cancer) (74).

Other behaviors common among U.S. adolescents, such as tarming, may increase the risk of

developing cancer later in life. A survey including

126 adolescents, conducted by the American Academy of Dermatology, found for example, that 67

percent of adolescent females and 33 percent of

adolescent males reported intentionally working on

a tan and that they did not take precautions from the

dl~olmants~ smo~ and alcohol use is dkCUSSed in Ch. 12> “Alcohol, Tobacco, and Drug Abuse: Prevention and Services, ” their nutrition and

eating habits are discussed in ch. 7, “Nutrition and Fitness Problems: Prevention and Services, ” and their contraceptive use is discussed in ch. 10,

“Pregnancy: Prevention and Services, ” all in this volume.
Chapter 6-Chronic Physical Illnesses: Prevention and Services .11-177

sun (23). Although similar percentages of adults

reported working on a tan, fewer (23 percent) took

no precautions to protect themselves from the sun.

Seventy-five percent of adolescents (compared to 66

percent of adults) believed tans make people look

healthy. Overexposure to the sun, however, can have

dangerous outcomes. In a study of melanoma in

women, those who reported having five or more

blistering sunburns between the ages of 15 and 20

were more than twice as likely to have developed

malignant melanoma by ages 38 to 65 (the age group

surveyed) as were those who had experienced no

such burns (1 16). This exposure during the adolescent years was found to be a much more important

determinant of melanoma incidence than exposure

after the age of 30. Preventive efforts should focus

on the behaviors of children and adolescents to

reduce their intensive sun exposure.

There is evidence that many U.S. adolescents do

not have accurate knowledge about the etiology,

warning signs, prevention, and treatment of cancer.

A survey of 870 inner-city junior and senior high

school students (mean age = 14) found a significant

lack of understanding about cancer (75). Although

most (approximately 90 percent) recognized the

association between cigarette smoking and cancer,

fewer than half recognized the role of nutrition. Of

the seven warning signs of cancer recognized by the

American Cancer Society (ACS), only the sign of a

lump or bump in the breast or elsewhere was

identified as a warning sign of cancer by more than

half the students.

The study found differences between white and

black adolescents in their understanding of cancer.

Only 9 percent of the black students and 3 percent of

the white students knew that blacks are more likely

than whites to get cancer and to die from cancer. In

addition, fewer black than white students believed

that they could get cancer. Perhaps most critically,

the black adolescents were significantly less likely

than whites to see the value of early treatment for

cancer or to believe that cancer can be cured. Thus,

there appears to be a need, particularly for some

adolescents who may be at highest risk for developing cancer in the future, to increase knowledge about

risk factors, warning signs, and the importance of

early detection and treatment.

In 1985, the ACS appointed a National Public

Education Subcommittee on Youth Education that

developed a ‘‘Plan for ACS Youth Education

Program” (15). ACS initiated a campaign to increase awareness of childhood and adolescent cancer (83) that includes a book by humorist Erma

Bombeck (40) and a “Peanuts” television special

(16). ACS also sponsors a variety of public education programs, including programs targeted at elementary, intermediary, and secondary school students. The programs include educational strategies

designed to promote good health habits among

young people, help them make health-enhancing

lifestyle decisions, and help them understand the

relationships between health behaviors and cancer

risk reduction (2).

Services and Interventions for the

Treatment of Adolescent Cancer

Cancers in adolescents are most frequently discovered by primary care physicians (33). Most

childhood cancers are detected at early stages, as

parents are likely to seek medical care soon after

observing a health problem (1 10). Current methods

of treating cancer generally have to be offered in

tertiary care facilities that provide sophisticated

multidisciplinary care to cancer patients (55). Although much treatment must take place in these

cancer centers, however, the primary care physician

in the community can still play an important role. He

or she can act as a link between the family and the

cancer center, administer certain drug treatments

(particularly during the maintenance phase), and

monitor the adolescent with cancer during followup.

Because cancer centers are often some distance

away from the adolescent home, families frequently incur extensive nonmedical costs when the

adolescent is at the treatment center, such as travel

and lodging costs and lost wages because of time

away from work. It is believed that the use of

community-based care, in coordination with treatment at a tertiary center, has the potential to greatly

reduce these economic costs to the family (55).

Despite the difficulties inherent in undergoing

treatment for cancer, some evidence indicates that

adolescents are generally cooperative partners in

treatment, although little research exists in this area.

One study covering adolescents’ compliance with

treatment, however, found older adolescents to be

less compliant than younger adolescents, suggesting

that the transfer of greater responsibility for treatment from parent to adolescent may be associated

with greater noncompliance in adolescents struggling to gain autonomy (85). Similarly, in a study
11-178. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

with 27 adolescents in remission from cancer (ages

12 to 18), adolescents were rated by nurses as being

moderately cooperative with treatment, though older

adolescents were rated as being less cooperative

than younger adolescents (38). Compliance with

orally administered chemotherapy agents may be

increased if adolescents and parents agree on who is

responsible for administering the medications, although older adolescents may still tend to be less

compliant than younger adolescents even when they

agree with their parents on medication instructions

(85). (85).

There is evidence that while younger children

with cancer may be more comfortable with not fully

understanding the seriousness of their disease,

adolescents appreciate being kept informed throughout their diagnosis and treatment and have a good

understanding of their treatment (115). Efforts to

improve the quality of life of adolescents with

cancer by reducing the negative effects (e.g., loss of

hair, nausea, risk of secondary cancers) of treatments

are greatly needed. Strategies include developing

mechanisms for best identifying leukemia patients at

highest risk of relapse so patients at most risk may

be targeted for more extensive treatments and

patients at least risk will not have to endure longer

courses of therapy (13).

Interventions for the Treatment of Adolescent

Cancer--Substantial support for basic and clinical

cancer research and patient activities comes from

private sources such as ACS. ACS has an affiliation

agreement with the Candlelighters Childhood Cancer Foundation that links over 250 parent self-help

groups for families of children and adolescents with

cancer (56). These groups can provide families a

diverse range of support including funds for wigs or

prostheses, educational information, peer counseling, and a forum for discussion of common concerns.

Supportive services provided by ACS include the

provision of home-care items, transportation services, and patient and family education. Of the

1986-87 ACS budget of $306.23 million, 28 percent

went to research, 19 percent to public education, 13

percent to patient services, and 10 percent to

professional education (2).

Barriers to Treatment for Adolescents With

Cancer—A significant barrier to care for adolescents

with cancer is the current state of available treatment. Although significant advances have been

made in the development of treatments that increase

survivability, the treatments themselves may reduce

the quality of life to the extent that adolescents and

their parents may question their value.

Adolescent medicine specialists, and health care

providers who feel competent to work with adolescents, are relatively few in number.42 Adolescents,

however, have a number of special concerns related

to their treatment for cancer that need to be

addressed. For example, they must adjust to the

impact of the illness and treatment on their relationships with their peers, their sexuality, and their

developing independence. In addition, adolescents’

understanding of the disease and its implications

will be more sophisticated than those of young

children because they are more advanced developmentally and more capable of abstract reasoning.

Costs of Cancer Treatment for AdolescentsEven for adolescents with health care coverage, the

costs of cancer treatment can be staggering. For

adolescents in geographically isolated areas, which

are likely to be farther from pediatric cancer centers,

these problems can be even more burdensome

(3,69). Some families may even lose their homes. A

witness at a hearing of ACS reported that his

13-year-old daughter was hospitalized 63 times in

one year because of an abdominal tumor; the family

was eventually evicted for falling behind in their rent

because of medical bills (3).

Pendergrass et al. followed for 2 years the total

hospital costs for 24 children (no ages specified)

diagnosed with leukemia at a Seattle hospital in

1979 (69). They estimated that the first-year therapy

costs for children with acute lymphoblastic leukemia averaged $12,334, with a range from $2,000 to

$40,825. For the 10 children who completed 2 years

of therapy, costs averaged $21,114 for 2 years, with

a range from $2,958 to $52,343. Many of these costs

were probably covered by insurance. However,

these estimates included only treatment costs within

the site where participants were identified; they did

not include other physician fees or out-of-pocket

expenses for the families. Thus, they are conservative estimates of the actual costs of care for these

children.

42For tier discussion see Ck 15, “Major Issues Pertain@ to the Delivery of Primary and Comprehensive Health Services to Adolescents,” in

vol. III.
Chapter 6-Chronic Physical Illnesses: Prevention and Services .11-179

Data for the study by Pendergrass et al. were

collected in 1979 when bone marrow transplants for

leukemia were extremely rare. Bone marrow transplants have been a major factor in improving

leukemia survival rates. However, for a child with

leukemia who requires a bone marrow transplant and

does not have access to a compatible donor, the

limited information available suggests that costs can

go well beyond what insurance will cover. In

interviews with four transplant centers for a 1990

staff paper, OTA found that the costs of locating an

unrelated donor ranged from $13,810 to $20,475

(1 13). Information is scarce on the costs of the

procedure itself; one transplant center puts the range

at $150,000 to $250,000 (67).

In 1989, researchers ex amined the so-called

‘ ‘incremental’ costs to families of caring for children with cancer (no ages were specified) (37). Cost

categories in the study included direct home costs,

travel costs, durable equipment and other capital

costs, and time costs (i.e., family members giving up

time from work and other activities) but did not

include costs of therapy. In analyzing the three

studies that provided data on such “incremental”

costs, the researchers found that estimated annual

money costs ranged from $1,121 to $4,012 across

the studies; estimated annual time costs ranged from

$1,514 to $4,697. Overall, total incremental costs

(including time costs) represented about 28 percent

of family incomes.

Major Federal Policies and Programs

Pertaining to Cancer Among Adolescents

The National Cancer Institute (NCI) within DHHS

provides the major Federal support for research on

cancer. Currently funded basic research includes

study of the basic biology of normal and malignant

hematopoietic cells to learn more about the origin

and progression of leukemia, studies of drug metabolism in leukemia patients to learn more about

disease and treatment-related changes in these

patients, and studies to predict which patients might

benefit most from additional therapy (1 11). NCI is

also currently funding a followup study of childhood

leukemia survivors through early adulthood to learn

more about the effects (especially endocrinologic

effects) of the disease and its treatment. Other

epidemiologic studies are examining the environmental and genetic risk factors for developing

leukemia (both acute lymphocytic leukemia and

nonlymphocytic leukemia). Other studies focus on

different childhood cancers. One study is assessing

the risk of developing leukemia and other cancers

after intensive chemotherapy and radiation therapy

for Hodgkin’s disease. Another is examining exposure to N-nitroso compounds as a risk factor for

developing brain tumors during childhood and

adolescence, Other studies are examining the effects

of various treatment therapies on different cancers

(111)0

NCI also provides support for programs and

research studies that focus on the physical and

psychological health of cancer patients (1 11). These

include teen support groups to aid adolescent

patients, pain management and stress-reduction

programs for young cancer patients, and programs

that focus on reducing the psychological side effects

of cancer treatments, including a study identifying

and monitoring the effects of cancer and treatment

on the neuropsychologic development of children

with leukemia. Another focus of support for NCI is

on interventions that minimize the social and

academic difficulties of long-term childhood cancer

survivors. One currently funded study is focusing on

increasing school attendance of children with newly

diagnosed cancer. It is anticipated that the provision

of ongoing scholastic and peer involvement will

help to counteract the anxiety and depression

experienced by severely ill patients. Another main

focus of NCI funding is on prevention. This includes

support for antismoking efforts and nutrition studies.

Acne Among Adolescents

Acne vulgaris, or common acne, is a disorder of

the sebaceous (or oil) glands, sebaceous ducts, and

hair follicles that results in skin eruptions. The vast

majority of American adolescents experience acne.

An estimated 90 percent of adolescent males and 80

percent of adolescent females are affected with acne

to some degree (33). Some adolescents experience

only a few occasional pimples; others are plagued by

persistent pustular acne that lasts for years, leaving

disfiguring scars. Each case of acne follows its own

individual course. Because acne is so prevalent

among adolescents and is not life-threatening, many

health care providers, policymakers, and others may

minimize its importance to young people.

According to data collected during the 1985

NAMCS sponsored by the National Center for

Health Statistics, the majority of U.S. adolescents

who visited a dermatologist (60.1 percent) in 1985
//-180 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

did so because of acne (101). The percentage of older

adolescents who went to a dermatologist because of

acne was higher than the percentage of adolescents

ages 10 to 12 who visited a dermatologist because of

acne.

43 About two-thirds (66.4 percent) of visits to

dermatologists by adolescents ages 16 to 18 were for

acne (101). Only 1.2 percent of visits by 16- to

18-year-olds to general practice or family physicians

were for acne, however for older adolescent males,

acne was the most frequent reason for visiting a

physician. Limitations in available data make comparisons by race impossible for specific conditions.

Myths about acne abound. These include beliefs

that acne is caused by the consumption of certain

foods (such as chocolate), by sexual activity or

thoughts, or by poor hygiene. Actually, several

factors are involved in the development of acne.

Rising levels of certain hormones during adolescence increase the activity of oil glands. Heredity

also plays a role; adolescents are more likely to

develop acne if they inherit oily skin that is sensitive

to the effects of hormones. Plugged oil glands are

also a factor; oil glands can become plugged when

cells lining the oil glands or pores shed and stick

together. Finally, skin bacteria are a factor; plugged

pores can become infected when bacteria are present, leading to the development of pustules or cysts

(1,33).

An estimated $120 million is spent each year on

acne treatment, including $100 million on over-thecounter acne medications (114). What portion of this

is spent by or on the behalf of adolescents is

unknown, but it is likely to be considerable given the

high prevalence of acne among adolescents.

There is no cure for acne. The goal of treatment is

generally to control the condition and prevent or

limit scarring (33). A variety of treatments are

available (30,33,84). A topical 5- to 10-percent

benzoyl peroxide solution is a commonly used

drying and peeling agent. It is available over-thecounter as a lotion, or by prescription as a gel.

Another topical product used for more severe acne

is tretinoin, which is available only by prescription.

Antibiotics are also frequently part of the treatment

regimen for severe acne. Oral antibiotics (e.g.,

tetracycline or erythromycin) or topical antibiotics

(e.g., erythromycin or clindamycin) may be used.

Isotretinoin (13-cis-retinoic acid) is a relatively new

treatment for severe cystic acne.

Each of these treatments has negative side effects

(33,84). Benzoyl peroxide and tretinoin produce

drying and peeling. About 2 to 3 percent of people

may be allergic to benzoyl peroxide. Tretinoin can

also be very irritating to the skin, sometimes

resulting in exacerbation of acne during the initial

stages of treatment. Sun exposure increases skin

irritation for adolescents using tretinoin, necessitating either avoidance to sun exposure or use of a

sunscreen. Oral antibiotics can irritate the stomach

and, in young women, increase the chances of

developing vaginal yeast infections. Topical antibiotics may cause a yellowish discoloration of the

skin. Isotretinoin, which should be used for only the

most severe cases of acne, can produce birth defects

if used during pregnancy and should not be used for

anyone who is pregnant or who is likely to become

pregnant. Other side effects of isotretinoin include

cracking and scaling of the lips (90 percent of users),

severe drying of the skin (80 percent of users), and

conjunctivitis (inflammation of the mucous membrane that lines the inner surface of the eyelids and

the forepart of the eye) and difficulty with contact

lens use (40 percent of users) (86).

The course of treatment for acne can be difficult

for adolescents for other reasons. Weeks of treatment are frequently required before improvement is

visible. In addition, some adolescents have difficulty

effectively complying with complicated treatments

that may involve washing their face several times a

day, applying one solution to their skin in the

morning and another at night, and taking oral

antibiotics. Oral antibiotics are most effective when

taken on an empty stomach, necessitating that

adolescents remember to take their medication

either an hour before or 2 hours after meals.

Following such a regimen may be especially difficult for adolescents who snack throughout the day.

Cosmetics, frequently used by girls to cover their

blemishes, may actually exacerbate their acne. Thus,

adolescents may become frustrated and give up on

treatments that take weeks to show any effects, have

undesirable side effects, do not actually cure their

acne, and are complicated and time-consuming to

administer (20).

43~~~um~r of lo t. 12.y~.olds visiting dermatologists was too sm~l to retie a reliable numencd estimate.
Chapter 6-Chronic Physical Messes: Prevention and Services . II-181

Photo a

e

w.,

w“can tidemy of Dermatology

There is no cure for acne, an almost universal problem

among adolescents. An estimated $124 million is spent

each year on acne treatment. Health care providers should

help adolescents understand that treatments designed

to control the condition and prevent scarring maybe

slow to work, cause side effects, or even temporarily

worsen an adolescent’s appearance.

Health care providers may fail to recognize the

difficulties that adolescents experience in adhering

to treatment regimens. It is important that they

emphasize the slow course and complicated nature

of treatment, ensure that adolescents realize there is

no cure, and advise adolescents of potential side

effects, including the possibility of a temporary

worsening in appearance (20),

Dysmenorrhea Among Adolescent Females

Primary dysmenorrhea (menstrual pain in the

absence of anatomic pathology such as endometriosis 44) usually has its onset in the first year or 2

following menarche, but its incidence increases

through the adolescent period (1 1). Over half of

those experiencing dysmenonhea may experience

moderate to severe menstrual cramps.

The 1966-70 NHES conducted by the U.S.

Department of Health, Education, and Welfare

included taking menstrual history of adolescent

females ages 12 to 17 (94). Almost 60 percent of the

adolescents in this study reported some degree of

menstrual pain, and 14 percent reported frequent

school absenteeism due to dysmenorrhea (43).45

Although there are no current national populationbased studies of the prevalence and effects of

dysmenorrhea for adolescent females,46 studies with

small samples indicate that dysmenorrhea remains a

leading contributor to school absenteeism for adolescent females. For example, one-fourth of the 88

high school females surveyed by Wilson and Keye

reported that they had missed classes because of

dysmenorrhea (120). A study involving middleschool students with excessive absences in Boston

found that almost half of these students cited health

problems as a reason for the absence; menstrual pain

was one of the most frequently cited problems (44).

Forty-five percent of 14- to 18-year-old adolescent

females in two Midwestern communities reported

some school or work absenteeism due to menstrual

pain (39), and 59.7 percent of otherwise healthy

females in an independent New England high school

reported dysmenorrhea (1 19).

Even though the prevalence of dysmenorrhea

appears to be high, less than 2 percent of visits to

office-based physicians by adolescent females ages

15 to 18 are for ‘‘abdominal pain, cramps, or

spasms” (which could possibly include menstrual

cramps); fewer than 1 percent are for menstrual

symptoms ‘‘other and unspecified" (101). Although

the numbers are too low to be reliable because

trouble with menstruation was reported for few

adolescent females, 1988 NHIS data indicate that

only 5.9 percent of females ages 5 to 18 (virtually all

of whom must be age 10 or over) experiencing

trouble with menstruation sought medical care. In

comparison, 77.9 percent of women ages 18 to 44

with disorders of menstruation reported seeking

medical care (101) .

‘Dysmenhorrea due to endometriosis or other anatomic pathology is termed seconub?y dysmenorrhea. According to Litt, endometriosis (a condition

in which tissue resembling the uterine mucous membrane occurs aberrantly in various locations in the pelvic cavity) has been underdiagnosed in

adolescent females (47), another reason for paying serious attention to menstrual pain.

ds~e pWenE of 2.5 ~r~nt of females ages 12 through 17 rewfled ‘‘genito- conditions’ (no more specifics given) as having been the

adolescents’ most serious illness (94).

ti~s, for emple, provides awr memwe of mem~ problems experienced by adolescent females because my of ~eProxY r~pondents (e.g.!

mothers) may be unaware that the adolescent is experiencing problems. It seems likely that primarily the most severe difficulties, those resulting in

medical interventio~ will be reported. It is also difficult to use NAMCS data to assess the prevalence of dysmenorrhea because it only captures

information on females who seek medical intervention for their menstrual cramps.
11-182. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Photo credit: Education Week

Menstrual pain (dysmenorrhea) is a frequently cited reason for missing school. Adolescent females may need to be informed that

dysmenorrhea is physically, not psychologically, caused and that it is easily treatable.

Only recently has the medical profession recognized a physiological basis for menstrual pain:

elevated concentration of menstrual prostaglandins

that cause painful uterine contractions. As late as the

1980s, menstrual cramps were believed to be a

psychosomatic complaint caused by poor attitudes

of women about their femininity (11). Psychotherapy was seen as an appropriate response to the

problem.

Now that a physiological basis is known, however, treatment for dysmenorrhea can usually be

straightforward. Nonsteroidal anti-inflammatory

drugs (e.g., salicylates such as aspirin, propionic

acids such as ibuprofen and naproxen sodium)

inhibit the production of prostaglandins and have

been effective in reducing uterine contractions (11).

Ibuprofen, previously available only by prescription,

is now available over-the-counter.47

The low rates at which adolescent females seek

care for dysmenorrhea may be due to beliefs by

them, their mothers, or both that nothing can be done

(39,48). Negative attitudes and erroneous beliefs

may also be supported through misinformation

received from peers and others. Because the medical

community has only recently come to understand the

physiological basis for dysmenorrhea (47), it is

likely that some providers are not adequately informed about the importance of providing relief to

young women suffering from menstrual cramps.

Some of them, for example, may believe that

exercise is an appropriate treatment, although recent

evidence suggests that exercise is more directly

associated with relieving stress which may reduce

the intensity of dysmenorrhea (54). Even when

providers are informed about the issues, they may

not ask appropriate questions during health care

47~u~,itmy~titnewers~dies(COnduCt~titer ibuprofen w~ ~de mom ~(,tely av~~le) wo~d indicate fewer problems with meDShWd p@l

(39). This would only apply if more adolescents were aware tbat menstrual pain can be prevented or ameliorated.
Chapter 6--Chronic Physical illnesses: Prevention and Services . II-183

visits to probe about suffering from this problem and

to make appropriate interventions (39).

Major Federal Policies and Programs

Pertaining to Adolescents With Chronic

Conditions

Federal efforts to address the needs of U.S.

adolescents with chronic conditions include a Federal law requiring that education be provided to all

handicapped children and a Federal law authorizing

the provision of financial assistance to States and

private nonprofit organizations that offer services to

persons with “developmental disabilities. ” These

efforts are managed by various Federal agencies

within the U.S. Department of Education and

DHHS.

Education for All Handicapped Children Act

Educational opportunities for U.S. adolescents

with disabilities have been greatly enhanced by the

Education for All Handicapped Children Act (Public

Law 94-142), which was passed in 1975 an d

amended several times since then (e.g., Public Law

99-457 in 1986, Public Law 101-476 in 1990). This

act is designed to guarantee free and appropriate

public education for all children ages 3 to 21 with

disabilities, including mental retardation; hearing,

speech, vision, or orthopedic impairments; serious

emotional impairments ; autism; traumatic brain

injury; multiple disabilities; specific learning disabilities and other health impairments (35; Public

Law 101-476). Some Federal funds are provided to

support these efforts, but State and local-educational

agencies bear most of the burden.

The Education for all Handicapped Children Act

also authorized a transition-from-school program for

children and adolescents with disabilities. Amendments to the act in 1986 (Public Law 99-457 )

clarified that funded activities may serve students

throughout their school years as well as those who

have left secondary school, and it expanded the

purposes of this provision to include improving

vocational and life skills. The act also authorized

funding for physical education and therapeutic

recreation programs designed to increase community participation among adolescents with disabilities (89).

Developmental Disabilities Assistance and

Bill of Rights Act

Services to persons with developmental disabilities are authorized through the Developmental

Disabilities Assistance and Bill of Rights Act, which

in 1970 amended the Mental Retardation Facilities

and Community Mental Health Centers Construction Act of 1963 (Public Law 88-164) (91). The act

authorizes Federal financial assistance to States and

public and nonprofit agencies for programs that help

people with developmental disabilities to achieve

their full potential through increased independence,

productivity, and integration into the community.

Funded programs also provide assistance to the

families of people with developmental disabilities.

Under the act, the definition of “developmental

disabilities’ is based on functional limitations rather

than specific disorders. These limitations must be

manifest before age 22; be attributable to a mental or

physical impairment; be likely to continue indefinitely; and result in substantial limitations in three or

more major life activities, such as self-care, learning,

receptive and expressive language, and mobility.

Each State is required to have a State planning

council that receives funds under the act. State

planning councils serve as advocates for people with

developmental disabilities and develop a State plan

that identifies unmet service needs and services to be

provided. The act also requires States to have in

place a protection and advocacy system to provide

information and referral services and to investigate

reports of abuse and neglect of people with developmental disabilities. University-affiliated programs

provide interdisciplinary training for people preparing to work with persons with developmental

disabilities, conduct applied research, provide technical assistance to agencies working with people

with developmental disabilities, and provide services for people with developmental disabilities.

Other Federal Efforts

A new disabilities prevention program has been

established within DHHS at the Centers for Disease

Control (34). Efforts will focus on the areas of

developmental disabilities, injuries to the head and

spinal cord, and secondary complications among

people with physical disabilities.

There are some tax code provisions designed to

alleviate the financial burden on the families of

people with disabilities (90). The costs of sending a
//-184 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

dependent with mental or physical disabilities to a

special school may be deducted if the main reason

for using the school is that the school provides

facilities for alleviating the handicap. The dependentcare tax credit can be claimed for expenses incurred

in the care of a physically or mentally disabled

dependent necessary for the primary care provider to

be gainfully employed. This includes expenses for

household services, day-care centers, and other

noninstitutional care.

In addition, the U.S. Surgeon General has sponsored several campaigns and conferences on children and adolescents with special health care needs

(formerly known as “crippled children’ (see 24,

49,100). The 1989 Surgeon General’s Conference

focused specifically on issues for individuals with

special health care needs making the transition

between childhood and adulthood (49). A main

focus of DHHS’s Bureau of Maternal and Child

Health is the dissemination of funds for programs

assisting adolescents with disabilities.48

Conclusions and Policy Implications

Available data suggest that there may be more

U.S. adolescents with physical health problems than

is generally assumed. The most recent intensive

health examination survey of a number of adolescents was the National Health Examination Survey

(NHES) completed in 1970. This survey found that

about 22 percent of U.S. adolescents had some

illness, deformity, or physical handicap affecting

normal growth, development, or function (94,95).

Although not all of these were serious and chronic

conditions, they were judged to interfere with

healthy adolescent development in some way.

As discussed in this chapter, OTA estimates

(using Gortmaker and Sappenfield’s work) that

roughly 5 percent of today U.S. adolescents

experience chronic physical conditions that make

them physically unable to carry on major activity

(e.g., attending school) or limit the amount or kind

of major activity they can perform.

Little can be done during adolescence to prevent

many of the serious chronic physical illnesses of

adolescence.49 In the absence of effective preventive

interventions, attention to treatment and to issues

affecting the quality of life of affected adolescents is

particularly important. Although adolescents with

chronic illnesses and disabilities experience many of

the same problems as their nondisabled peers, such

adolescents face a number of additional problems.

These range from concerns that are specific to

certain chronic illnesses (e.g., the devastating effects

of chemotherapy and radiation associated with

cancer treatment) to concerns that are associated

with a variety of chronic illnesses (e.g., problems

related to having to be absent from school, difficulties in socializing with peers, and substantial economic costs for families and for society). Adolescents with some chronic illnesses or disabilities may

have limited options for employment and marriage,

may be unable to (or choose not to) have children,

and may experience discrimination in obtaining life

and health insurance.

Another problem is that even for families with

adequate health insurance, many of the often substantial costs associated with care of adolescents

with chronic conditions are not covered. As discussed elsewhere in this Report, there is generally a

scarcity of personnel trained to provide services to

adolescents and services for adolescents tend to be

fragmented. 50 The problems of fragmentation are

compounded for adolescents with a serious chronic

condition, who are typically in need of a broad range

of often specialized services. Additional personnel

trained to identify the needs of adolescents with

chronic illnesses and disabilities, and to provide

them with services, are needed.

Some chronic physical health problems of U.S.

adolescents are so common that they may be

accepted by parents, health care providers, and

policymakers as “normal” and not worthy of

mention or intervention. Adolescents, on the other

hand, may find them extremely troubling. Acne and

dysmenorrhea are examples. The vast majority of

U.S. adolescents experience common acne which,

48 For f~r di~cu~~ion of tie role of tie B~eau of Matem~ and Child H~& ~ adolescent heal~ Sm ch. 19, “The Role of Federal Agencies in

Adolescent Health,” in Vol. Ill.

@As noted ~her, ~my physic~ h~~ problems due [o inj~es are preventable. For f@er discussio& S= ch. 5, “Accidental hlJUrieS: prevention

and Services, ‘‘ in this volume.

50sm ch. 15, “Major Issues pert aining to the Delivery of Primary and Comprehensive Health Services to Adolescents, ” and ch. 19, “The Role of

Federal Agencies in Adolescent Heal@” in Vol. III.
Chapter 6--Chronic Physical Illnesses: Prevention and Services ● II-185

although not physically disabling, negatively affects

the day-to-day lives of many adolescents. Evidence

from a variety of sources suggests that at least half

of adolescent females report dysmenorrhea (painful

menstruation) and about 1 in 7 miss school because

of this pain. Dysmenorrhea is a problem that, in most

cases, could be alleviated through the use of certain

over-the-counter drugs. It appears that adolescents

are not routinely made aware of current information

about the causes of these and other disorders of

importance to them, or of the fact that treatment is

available.

There is no single comprehensive source of

information about the physical health status of U.S.

adolescents. Rather, a variety of sources must be

used to identify the most important physical health

problems facing adolescents. National surveys sponsored by the National Center for Health Statistics in

DHHS that provide information on the health of

adolescents include NHIS, NHDS, and NAMCS, but

these data sources have a variety of limitations. Most

do not include large enough samples of adolescents

to provide reliable data on low-prevalence chronic

conditions. Furthermore, NHDS and NAMCS measure utilization of services (e.g., the number of

adolescents with hospital stays or visits to physicians’ offices) rather than need. Thus, adolescents

who do not seek care for services, or who use

alternative services, are not included in the surveys.

These data may disproportionately exclude racial

and ethnic minority adolescents and poor adolescents who may not have access to services.51

National surveys do provide some information on

differences in health status or health care utilization

among adolescents of different ethnic or racial

groups, between males and females, and among

adolescents of varying socioeconomic status, but

much of this information is not reliable for policymaking purposes because of limitations in these

data sources (e.g., small sample sizes of minority

adolescents). There are virtually no populationbased data on the health status of minority adolescents and their utilization of health services. Even

when minority groups are oversampled in some

national surveys, the number of minority adolescents remains small. Similar problems exist for

describing the health of adolescents living in poverty. Although some useful data are collected on

socioeconomic status and health,52 sufficient data

are rarely collected to allow for analyses to determine the nature of relationships between socioeconomic status and health. Additional information is

particularly needed on the health status of these

groups of adolescents and their utilization of services.

As described elsewhere in this Report, programs

related to adolescents with chronic illness and

disability can be found in a wide range of Federal

agencies and departments.53 These include the U.S.

Department of Education and, within DHHS, the

Centers for Disease Control; the National Cancer

Institute; the National Heart, Lung, and Blood

Institute; the National Institute of Allergy and

Infectious Diseases; the National Institute of Arthritis and Musculoskeletal and Skin Diseases; the

National Institute of Neurological Disorders and

Stroke; and the Office of Human Development

Services. There is, however, no central place in the

Federal Government that coordinates programs for

children and adolescents with chronic illness or

disability.

In summary, policy changes to improve the

physical health of U.S. adolescents might include:

● improved data collection,

● additional support for coordinated services and

services to improve the quality of life for

adolescents with serious chronic physical conditions, and

. health education on issues of importance to

adolescents.

NHANES III currently in the field will oversample children, but includes relatively few adolescents

and will not include institutionalized adolescents.

NAMCS, NHDS, and NHIS (which are conducted

more regularly than the infrequent NHANES) could

oversimple so that more adolescents of a greater

racial, ethnic, and economic diversity are included.

Population-based interview surveys would be improved if they asked adolescents about their own

health problems rather than relying on parents as

51swCh, lg,‘ ‘Issues hhe Delivery of Services to Selected Groups of Adolcsccnts, ’ in VO1. In.

5zsome data, for ~xmplc, ~e Collec[ed as pm of tie Natio~ Health Intewicw Survey. However, tis su~eY is 1imited ‘cause adO1escents

themselves arc not asked about their health problcms.

s~sm Ch, 19, 1‘~c ROIC of Federal Agencies in Adolescent Health, ’ In VOI. III.

-.~~+7 (1 111 ’11 i QI !
II-186 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

reporters of this information and if they included

problems of importance to adolescents.

Adolescents who have serious chronic physical

conditions are in need of a broad range of often

specialized services. Additional personnel trained to

identify the needs of adolescents with chronic

illnesses and disabilities, and to provide them with

services, are also needed. Many adolescents with

chronic physical illnesses may be in need of

supportive or mental health services, for example.

Although recent Federal efforts have addressed

the needs of children and adolescents with special

health care needs, there is no central place in the

Federal Government that coordinates programs for

adolescents with chronic illness or disability. More

active support for the development and evaluation of

programs, as well as for efforts to coordinate

available programs, is needed.

Finally, health education for adolescents could be

improved if it addressed health issues of importance

to adolescents and provided information on how to

get access to medicine and services.

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Chapter 7

NUTRITION AND FITNESS

PROBLEMS: PREVENTION

AND SERVICES

Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . ., , . . . . . . . . . . . . . . . ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Background on Adolescent Nutrition and Fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Adolescents’ Nutritional and Physical Fitness Needs.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Definitional Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Nutritional Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Physical Fitness and Activity Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

Adolescents’ Nutrition and Fitness Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

Nutritional Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

Inadequate Dietary Fiber . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

Excessive Consumption of Fat, Cholesterol, Sodium, and Low-Nutrient Density Foods... 205

Low Levels of Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obesity or overweight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . $ . . . . . . . . . . . . .

Consequences of Adolescent Nutrition and Fitness Problems . . . . . . . . . .

Immediate Consequences of Nutritional and Fitness Problems During

Risk of Chronic Diseases Later in Life..... . . . . . . . . . . . . .

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Adolescents With Particular Nutritional and Fitness Problems

Pregnant Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Adolescent Athletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Adolescents With Eating Disorders.. . . . . . . . . . . . . . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . .,

. . . . . . . . .

. . . . . . . . .

Adolescents With Chronic Conditions and Physical Disabilities . . . . .

Adolescents With Mental Retardation or Developmental Disabilities .

Emotionally Ill Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prevention and Treatment of Nutrition and Fitness Problems . . . . . . . . . . . .

Adolescents’ Nutritional Choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Influencing Adolescents’ Nutritional Choices . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . 206

. . . . . . . . . . . . . . . . . . . 208

. . . . . . . . . . . . . . . . . . . 208

. . . . . . . . . . . . . . . . . . . 209

Adolescence . . . . . . . 209

. . . . . . . . . . . . . . . . . . . 210

. . . . . . . . . . . . . . . . . . . 211

. . . . . . . . . . . . . . . . . . . 211

. . . . . . . . . . . . . . . . . . . 211

. . . . . . . . . . . . . . . . . . . 212

. . . . . . . . . . . . . . . . . . . 213

. . . . . . . . . . . . . . . . . . . 214

. . . . . . . . . . . . . . . . . . . 215

. . . . . . . . . . . . . . . . . . . 215

. . . . . . . . . . . . . . . . . . . 215

. . . . . . . . . . . . . . . . . . . 215

. . . . . . . . . . . . . . . . . . . 215

. . . . . . . . . . . . . . . . . . . 216
Health Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216

Food Labels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Menus in Schools and Institutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .; . . . . . . . . . . . . . . 217

Influencing Adolescents’ Physical Activity Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Physical Education in Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Community Facilities for Physical Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Interventions To Prevent or Reduce Adolescent Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

Major Federal Programs Related to Nutrition and Fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

U.S. Department of Agriculture

. . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

U.S. Department of Health and Human Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

Centers for Disease Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220

National Institutes of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

. . . . . . .

Chapter preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

Boxes

Box Page

7-A. Federal Data Collection Efforts Related to Adolescent Nutrition . . . . . . . . . . . . . . . . . . . . . . . . 194

7-B. Biological Functions of Dietary Substances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196

7-C. Broad Nutritional Guidelines That Provide Guidance Beyond Recommended Daily

Allowances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

7-D. Healthy People 2000 Objectives Pertaining to Adolescents’ Physical Activity

and Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204

Figures

Figure Page

7-1. Percentage of U.S. Students in lst Through 12th Grade Receiving Daily Physical Education,

1984-86 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

7-2. Prevalence of Anemia Among U.S. Women During the Third Trimester of Pregnancy,

by Race and Age, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212

7-3. Prevalence of Anemia Among U.S. Women During the Third Trimester of Pregnancy,

by Race and Trimester of Enrollment in Public Health and Nutrition Programs, 1987 . . . . . . 212

Tables

Table Page

7-l. Weight and Height of U.S. Males and Females Ages 10 to 18 . . . . . . . . . . . . . . . . . . . . . . . . . . 198

7-2. NAS Recommended Dietary Allowances for Protein, Vitamins, and Minerals for

U.S. Males and Females Ages ll to 24, 1989 . . . . . . . . . .,,.... . . . . . . . . . . . . . . . . . . . . . . . . . 199

7-3.NAS Estimated Ranges of Safe and Adequate Daily Dietary Intakes of Additional Viatmins

and Minerals for Adolescents Ages 11 and Over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199

7-4. NAS Recommended Daily Energy Intakes for Males and Females Ages ll to 24 of

Median Weights and Heights, 1989... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

7-5. Average Daily Nutrient Intake as a Percentage of the 1980 RDAs Among U.S. Adolescents

Ages 9 to 18,1977-78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

7-6. Nutritional Values of Seven Sample Fast-Food Meals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

7-7. Examples of Chronic Diseases and Conditions With Nutrition and Fitness

Implications Among U.S. ChildrenAgesOto 20, 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

7-8. Participation in the National School Breakfast and School Lunch Programs, 1983-84

School Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Chapter 7

NUTRITION AND FITNESS PROBLEMS:

PREVENTION AND SERVICES1

Introduction

Adolescence is a period of biological and social

change, and because of the changes that they

undergo (e.g., in their size, body composition, body

functions, physical abilities, and life styles) and

other individual factors, adolescents as a group and

as individuals have special nutritional and, possibly,

fitness needs. Nutrition and physical activity during

adolescence can influence the process of physical

growth and development. Evidence concerning the

impact of adolescent dietary patterns on the occurrence of chronic diseases in adulthood is very

limited, but there is some evidence to suggest that

dietary patterns are important factors in the occurrence of some major chronic diseases (e.g., atherosclerotic cardiovascular diseases and hypertension,

certain forms of cancer, obesity, non-insulindependent diabetes, and dental caries) and that

dietary modifications can reduce the risk of some of

these diseases (152).

The changing nutritional needs and physical

abilities of adolescents as a group are addressed in

this chapter, as are the nutritional and other needs of

certain subgroups of adolescents (e.g., adolescents

with diabetes, adolescents with physical disabilities). Also described in this chapter are selected

Federal programs related to the nutritional health

and physical fitness status of U.S. adolescents. The

chapter ends with conclusions and implications for

public policy.

Background on Adolescent Nutrition

and Fitness

Adolescents’ Nutritional and Physical

Fitness Needs

Definitional Issues

Good nutrition is a somewhat elusive concept not

easily defined or determined. It is generally agreed,

however, that good nutrition embraces the principles

of sufficiency, variety, balance, and moderation

(59a). Especially in large population groups, research tools cannot capture or interpret all the

interrelated aspects of food intakes and nutritional

outcomes; most studies instead focus on substitute

measures (e.g., specific nutrient consumption or

dietary attitudes).

Physical fitness is defined in various ways. In the

not too distant past, a person with obvious motor (or

athletic abilities)--defined in terms of muscle

strength, agility, speed, and power—was considered

‘‘physically fit. ’ Recently, however, the concept of

physical fitness has been undergoing a major

change. According to a 1987 American Academy of

Pediatrics statement, physical fitness is now considered to include five components: 1) muscle strength,

2) muscle endurance, 3) flexibility, 4) body composition (i.e., ratio of lean body mass to fat), and 5)

cardiorespiratory endurance (4). Many available

studies focus on proxy measures of fitness, such as

performance on standardized tests of fitness.

Several major Federal sources of data on nutritional status, food and nutrient consumption, and

other information related to adolescent nutrition are

identified in box 7-A.

Nutritional Needs

The human body requires for health the intake of

water, amino acids from protein, vitamins, minerals,

fatty acids, and sources of calories (protein, carbohydrate, and fat) (226) (see box 7-B).

A physiologic diet provides intakes of each

essential nutrient between the two thresholds of

minimal requirement and maximal tolerance (186).

The minimal requirement is defined as the smallest

quantity of an essential nutrient that “maintains

normal mass, chemical composition, morphology,

and physiologic functions of the body and prevents

any clinical or biochemical sign of the correspond1~1~ ~~pter is not ~ ~x~u~tive ~o~pendium of ~1 ~d~le~cent ~u~tion ~d fi~ess issues. ~tead, is p~ose is to f~us on Wht appear tO be

the major problems associated with nutrition and fitness affecting many American adolescents.

me focus of this OTA Repo~ for reasons noted in Vol. I, Summa-y ad PoZicy Implications, is on 10- through 18-year-olds. Some of the data

presented in this chapter are for other age groupings, because data for 10 through 18-year-olds are not readily available.

-II-193--
II-194 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 7-A—Federal Data Collection Efforts Related to Adolescent Nutrition

Several federally sponsored national surveysl gather information on health and nutritional status measurement.s, 2 food and nutrient consumption measurements, food composition measurements, dietary knowledge and

attitude assessments, food supply determinations, sociodemographic and economic measurements, and other

relevant data. A number of the surveys sponsored by the U.S. Department of Health and Human Services and the

U.S. Department of Agriculture are discussed below. Several of the surveys are components of the National

Nutritional Monitoring System, a Federal assessment system that allows continuous nutrition monitoring through

complementing, periodic surveys.

U.S. Department of Health and Human Services (DHHS):3

● National Health and Nutrition Examination Survey (NHANES): NHANES is one component of the National

Nutrition Monitoring System. This survey, conducted by the National Center for Health Statistics (NCHS)

in DHHS, obtains health-related data by means of direct physical examination, clinical and laboratory tests,

and related measurement procedures (232). A major goal of NHANES I (1971-74) was to measure and

monitor indicators of the nutritional status of the America people through dietary intake data, biochemical

tests, physical measurements, and clinical assessments for evidence of nutritional deficiency. The target

population was the civilian, noninstitutionalized U.S. population ages 1 through 74. NHANES II (1976-80)

had a nutrition component that was nearly identical to the NHANES I. Neither NHANES I nor NHANES

II had an adequate adolescent sample. NHANES III is now in progress. It is collecting some adolescent-specific data, but results are not expected until 1994.

. Hispanic HANES (1982-84): NCHS conducted this survey on about 76 percent of the Hispanic adult

population (187).

● National Health lnterview Survey (NHIS): This survey, conducted by NCHS, uses personal household

interviews to collect data on personal and demographic characteristics, utilization of health resources, and

a variety of health topics from a sample of the civilian, noninstitutionalized U.S. population. It will include

a special supplement on adolescent health in 1991, 1995, and 2000.

. Total Diet Study: This study, by the Food and Drug Administration, gathers information on intakes of

pesticides, toxic substances, radionuclides and industrial chemicals, as well as or intakes of iodine, iron,

sodium, potassium, copper, magnesium, and zinc, for males and females ages 6 to 11 months, 2 years, 14

to 16 years, 25 to 30 years, and 60 to 65 years.

. Youth Risk Behavior Surveillance System (YRBSS) (to be implemented in 1991, 1995, and 2000): This

system, recently developed by the Centers for Disease Control in DHHS, will monitor the prevalence of

IFor a M@ of F~e~ nutrition monito@ and weihnce activities, see NwrT”fion Monitoring in the United Srates: The Directory

of Federal Num”tion A40ru”toring Activities (243).

2~ ~en~, & v~idi~ ~d ~li~iliy of ~~ts of dietary and of nutritional Shlhls USCSSmnts VW (~~ds -y ~ we~-t~~ but

are limited (58)). Also, errors of inteqmtation of dietary intake data are common (18).

3F~er dew on tie JX-lHS system are provided in a report on the National NutritioMI Motito@ syst~ (256).

ing deficiency state’ (186). In children and adoles- Nutritional needs during adolescence correlate

cents, the minimal requirement also must meet an

additional criterion: it must maintain an optimal rate

of growth (186). The maximal tolerance for an

essential nutrient is an important consideration for

individuals taking dietary supplements, which may

be harmful at certain levels. Factors that influence

the minimal requirement and maximal threshold for

a nutrient include rate of growth, age, exercise,

chemical composition of the diet, presence of certain

diseases or physical conditions (e.g., diabetes, pregnancy), and intake of prescription drugs (186).

closely with biological maturity (140). Adolescents

should consume diets providing more total nutrients

than younger children (131,203), because adolescents typically have a larger body and different body

composition (e.g., a different ratio of lean body mass

to fat). Adolescents experience gains in height and

weight that alter their nutritional needs (see table

7-l). Females typically experience a pubertal height

spurt between ages 10 and 13, and males experience

a height spurt between ages 12 and 15 (200). This

growth requires nutrients as structural materials.

Changes in physiologic function that occur during
Chapter 7—Nutrition and Fitness Problems: Prevention and Services ● II-195

priority risk behaviors among samples of school-aged adolescents by collecting data from a periodic

school-based survey combined with special supplemental data from NHIS on youth risk behavior.

U.S. Department of Agriculture (USDA):

● Nationwide Food Consumption Survey (NFCS): This survey is one component of the National Nutrition

Monitoring System. Conducted by USDA’s Human Nutrition Information Service every 10 years, NFCS

collects information on the general and low-income U.S. population ages O to 75 years and older (213a). The

most recent survey, conducted in 1987-88, included the collection of information on foods used by

households and eaten by individuals.

● Continuing Survey of Food Intakes by Individuals (GSFII): This survey, like NFCS, is part of the National

Nutritional Monitoring System. It is conducted by USDA’s Human Nutrition Information Service. Initiated

in 1985, it is designed to measure levels and changes in the food and nutrient content and nutritional

adequacy of U.S. diets on a continuing basis (213a). In 1985 and 1986, the CSFII included all-income and

low-income samples of women 19 to 50 years of age and their children 1 to 5 years of age. In 1985, the survey

also included men 19 to 50 years of age. The CSFII was not conducted in 1987 and 1988. The 1989, 1990,

and 1991 samples included men, women, and children of all ages. All CSFII samples are drawn from

households in the 48 coterminus States and include a basic survey (households with incomes at any level)

and a low-income survey (households with incomes at or below 130 percent of the Federal poverty level).

The kinds and amounts of food ingested at home and away from home by individual household members

are reported for 3 consecutive days using a l-day recall in an in-person interview and a 2-day diary.

. Diet and Health Know/edge Survey (DHKS): This survey, begun in 1989 as a followup to CSFII, targets

“food managers” in households participating in CSFII. Its purpose is to link an individual’s knowledge and

attitudes about diet and health to his or her actual dietary behavior.

. National Evaluation of School Nutrition Programs: This survey, conducted only occasionally, provides

information on U.S. adolescents’ eating patterns and use of school nutrition programs.

Federally sponsored national surveys have several positive features:

● the surveys provide population-based parameters of current nutritional status,

. the surveys identify some groups at risk and their nutritional problems; and

* the surveys contribute useful population-based information for national planning purposes.

On the other hand, federally sponsored national surveys have a number of limitations including the following:

* Neither NHANES nor NFCS provides data on energy expenditures and fitness status.

* Subgroup sample sizes are not large enough to permit analyses and cross-tabulations using several variables

(e.g., income, race, and sex); that is, adolescents with combinations of problems are not sufficiently targeted.

. Because of high nonresponse rates among very low-income, non-English-speaking people and because

adolescents living in institutional settings are not included in the surveys, some problems may be

underestimated.

. Nutritional status data are collected only periodically.

adolescence also alter adolescents’ nutritional re- of factors that include differences in body composiquirements. U.S. females, for example, typically

begin menstruating at age 121

/2. Females who start

menstruating have an increased requirement for iron

due to menstrual losses (200,211). Changes in

lifestyle, especially in physical activity, may also

affect adolescents’ nutrient needs (142). Male or

female adolescents who regularly participate in

vigorous physical activity, for example, increase

their energy needs.

Nutritional needs for male and female adolescents

of the same age are typically quite different because

tion and function (90). But even adolescents of the

same sex and age may have different nutritional

needs. Adolescents mature at different rates, sometimes as a consequence of genetic endowment and

sometimes as a result of environmental factors (e.g.,

chronic undernutrition slows height and weight

growth and slightly delays puberty). Furthermore, as

discussed later, some adolescents have diseases or

special conditions (e.g., diabetes, thyroid conditions, or pregnancy) that alter their nutritional needs

by changing the absorption, metabolism, or excretion of particular nutrients (212).
II-196 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 7-B—Biological Functions of Dietary Substances

Protein—Dietary protein provides a mixture of amino acids to replace the body’s continuous degradation of these

substances and is also a metabolic fuel for energy. Sufficient protein intake is important for body growth, hair

growth, blood and organ mass, muscle development, and proper balance of hormones and body fluids.

Vitamins

Vitamin A—A group of compounds essential for vision, growth, cellular differentiation and proliferation,

reproduction, and integrity of the immune system.

Vitamin D—Essential for proper formation of the skeleton and for mineral equilibrium.

Vitamin E—Inhibits the oxidation of essential cell constituents and prevents the formation of toxic oxidation

products. Primary deficiency of vitamin E is not found in otherwise healthy humans because of the wide

distribution of the vitamin in foods, but secondary deficiency (which may result from intestinal

malabsorption) is associated with reproductive failure, muscular dystrophy, and neurological abnormalities.

Vitamin K—Essential for the formation of proteins involved in the regulation of blood clotting, and for the

biosynthesis of some other proteins found in the plasma, bone, and kidney.

Vitamin C—Required for the formation and synthesis of collagen (an abundant protein of connective tissue).

Deficiency may affect immune responses, wound healing, iron absorption, and allergic reactions. Often

vitamin C deficiency results in scurvy, a serious disease in which the weakening of collagenous structures

leads to capillary hemorrhaging.

Thiamin (B-1)-Involved in the breakdown of carbohydrates. Deficiency can lead to beriberi, a disease affecting

the cardiovascular and nervous systems and characterized by symptoms including mental confusion, muscle

weakness, enlarged heart, and congestive heart failure.

Riboflavin (B-2)-Participates in a variety of oxidation-reduction reactions and essential to the structure of some

enzymes. Among the symptoms of deficiency are sore throat, excess blood and fluid in the mucous

membranes, and angular stomatitis.

Niacin-Also involved in oxidation-reduction reactions. Deficiency is associated with skin rashes, swelling and

reddening of the tongue, dermatosis, diarrhea, and dementia.

Vitamin B-6--Important in the metabolism of amino acids. Deficiency leads to dermatitis and depression in adults

and seizure in infants.

Folate-Designates a compound that plays an important role in amino acid metabolism and nucleic acid synthesis.

Deficiency leads to impaired cell division and alterations of protein synthesis.

Vitamin B-12—Essential to metabolism. Deficiency can cause pallor, weight loss, diarrhea, optic neuritis, and

mental changes.

An important dietary standard used in the United specific nutrients, based on nutritional studies and

States is the recommended dietary allowances (RDAs), expert judgment.3 They are neither minimal requireestablished by the Food and Nutrition Board of the ments nor necessarily optional levels of intake.

National Academy of Sciences (NAS) (153). The Rather, they are “the levels of intake of essential

1989 RDAs for protein, vitamins, and minerals for nutrients that, on the basis of scientific knowledge,

U.S. males and females ages 11 to 14, ages 15 to 18, are judged by the Food and Nutrition Board to be

and ages 19 to 24 are specified in table 7-2. RDAs adequate to meet the known nutrient needs of

are recommendations for daily dietary intakes of practically all healthy people” (153).4

sl~ ~n~CiPl~, ~A~ ~~ b~~ on Vfiou ~& of evidence: 1) swdies of subjects maintained on diets containing 10W or deficient levels of a nu~ent,

followed by correction of the deficit with measured amounts of the nutrient; 2) nutrient balance studies that measure nutrient status in relation to intake;

3) biochemical measurements of tissue saturation or adequacy of molecukw function in relation to nutrient intake; 4) nutrient intakes of fully breastfed

infants and of apparently healthy people from their food supply; 5) epidemiological obsemations of nutrient status in populations in relation to intake;

and 6) in some cases, extrapolation of data from animal experiments. In practice, there are only limited data on which estimates of nutrient requirements

Call be based (153).

4~& apply t. he~~y ~emom o~y and do not cover SpeciaJ nutritio~ needs ~Sing from metabolic disorders, chronic diseases, Or Other ltlediCid

conditions or drug therapies (153).
Chapter 7—Nutrition and Fitness Problems: Prevention and Services ● II-197

Minerals

Calcium—Essentia.l for bone mineral formation. Bone undergoes constant resorption and formation throughout life.

In childhood and adolescence, dietary calcium helps to build strong bones; in adults, when bone resorption

exceeds formation, it slows the rate of bone loss.

Phosphorus—An essential component of all cell protoplasm, aiding in biochemical synthesis and energy transfer.

Phosphorus is a constituent of nervous tissue and bone.

Magnesium-Modulates numerous biochemical and physiological processes. Deficiency may cause growth failure,

behavioral disturbances, weakness, tremor, seizures or cardiac arrhythmias.

Iron—A constituent of blood and a number of enzymes. Anemia and reduced resistance to infection are among the

symptoms of deficiency.

Zinc-A constituent of enzymes involved in most major metabolic pathways, Zinc intake affects appetite, growth,

skin, and the immune system.

Iodine—Essential part of the thyroid hormones. Deficiency can cause swelling of the thyroid gland (goiter), and

excessive intake can cause depression of thyroid activity.

Lipids

Fats—Fats are an important energy source and help to facilitate the intestinal absorption of vitamins A, E, and D.

Saturated and monounsaturated fats, however, are not essential to the diet because they can be synthesized

by the body. Polyunsaturated fats are essential components of the diet, functioning as precursors to important

structural lipids such as those found in cell membranes.

Cholesterol—Cholesterol is an important component of all cell membranes and a precursor to steroid hormones and

bile acids in the liver, but is not essential to the diet because it can be synthesized by the body.

salt---serves as the primary regulator of extracellular body fluid volume, It is also important in regulating acid-base

balance and the membrane potential of cells, and is involved in active transport across cell membranes.

Calories—A calorie is a unit of quantity of heat, used to express the energy value of food. Energy requirements

vary according to body size and composition, and level of physical activity. The level of energy intake from food

balances energy expenditures and allows for necessary or desirable levels of physical activity. In children and

pregnant or lactating women energy is also needed for the deposition of tissues or secretion of milk. If calorie intake

is consistently above or below an individual’s requirement, changes in body weight and composition will result.

SOURCES: Office of Technology Assessment 1991, based on the following sources: National Academy of Sciences, National Research

Council, Recommended Dietary Allowances, IOth ed. (Washington DC: Natiomd Academy Press, 1989); E. Braunwald, K.J.

Isselbacher, R.G. Petersdorf, et al. (eds.), Harrison’s Pn”nciples oflnrernul Medicine, 1 lth ed. (New York NY: McGraw-Hill Book

Co., 1988).

In practice, there are only limited data on which height and weight (153). Recommended energy

estimates of nutrient requirements can be based intakes for U.S. males and females ages 11 to 24 of

(153). Traditionally, RDAs have been established

for essential nutrients only when there are sufficient

data to make reliable recommendations. For several

nutrients for which there is insufficient information

on which to base an RDA, the NAS Food and

Nutrition Board publishes estimated safe and adequate ranges of daily intakes, as shown in table 7-3.

In addition to listing RDAs for protein, vitamins,

and minerals, the NAS publication Recommended

Dietary Allowances lists recommended daily energy

intake levels (caloric intake) for persons of median

median heights and weights, by age and sex, are

shown in table 7-4. The principal dietary sources of

energy are carbohydrates, fat, and protein (153).

Energy needs vary from person to person. An

individual’s energy requirements depend on how

much energy the individual expends at rest, in

physical activity, and as a result of the body’s

adaptive response to heat (153). These, in turn, are

affected by variables that include age,5 sex, body

size and composition, genetic factors, energy intake,

physiologic state (e.g., growth, pregnancy, lactation), coexisting pathological conditions, and ambi5Rest1ng enern expendltue is ~]o@y correlated ~ifi le~ body mass, ~d MS V~CS by age, Activi~ pattern,s dSO VMY by age.
11-198 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 7-l—Weight and Height of U.S. Males and Females Ages 10 to 18a

Males, by percentile

Weight, in kg (lb) Height, in cm (in)

Age 5th 50th 95th 5th 50th 95th

10

11

12

13

14

15

16

17

18

24,33

26.80

29,85

33.64

38,22

43.11

47.74

51.50

53.97

31.44 (69.2)

35.30 (77.7)

39.78 (87.5)

44.95 (98.9)

50.77 (111.7)

56.71 (124.8)

62.10 (136.6)

66.31 (145.9)

68.88 (151.5)

45.27

51.47

58.09

65.02

72.13

79.12

85.62

91.31

95.76

127.7

132.6

137.6

142.9

148.8

155.2

161.1

164.9

165.7

137.5

143.3

149.7

156.5

163.1

169.0

173.5

176.2

176.8

(54.1)

(56.4)

(58.9)

(61.6)

(64.2)

(66.5)

(68.3)

(69.4)

(69.6)

148.1

154.9

162.3

169.8

176.7

181.9

185.4

187.3

187.6

Females, by percentile

Weight, in kg (lb) Height, in cm (in)

Age 5th 50th 95th 5th 50th 95th

10 24.36 32.55 (71.6) 47.17 127.5 138.3 (54.4) 149.5

11 27.24 36.95 (81.3) 54.00 133.5 144.8 (57.0) 156.2

12 30.52 41.53 (91.4) 60.81 139.8 151.5 (59.6) 162.7

13 34.14 46.10 (101 .4) 67.30 145.2 157.1 (61.9) 168.1

14 37.76 50.28 (1 10.6) 73.08 148.7 160.4 (63.1) 171.3

15 40.99 53.68 (1 18.1) 77.78 150.5 161.8 (63.7) 172.8

16 43.41 55.89 (123.0) 80.99 151.6 162.4 (63.9) 173.3

17 44.74 56.69 (124.7) 82.46 152.7 163.1 (64.2) 173.5

18 45.26 56.62 (124.6) 82.47 153.6 163.7 (64.4) 173.6

a~edata in this table Werecollected from nationality respective samples of individuals in three studies

conducted by the National Center for Health Statistics of DHHS between 1962 and 1974.

It is not intended that the figures in this table necessarily be considered standards of normal growth

and development.

SOURCE: Adapted from P.V.V. Hamiil, T.A. Drizd, C.L. Johnson, et al., “Physical Growth: National

Center for Health Statistics,” American Journaiof Clinid Nutnlion 32:607-609, 1979, cited

in National Academy of Sciences, National Research Council, Dietand Hedfh;/n@cations

for Reducing Chronic Disease Risk (Washington, DC: National Academy Press, 1989).

Reprinted by permission.
Chapter 7—Nutrition and Fitness Problems: Prevention and Services ● II-199

Table 7-2—NAS Recommended Dietary Allowances (RDAs) for Protein, Vitamins, and

Minerals for U.S. Males and Females Ages 11 to 24, 1989a

RDAs for males (by age) RDAs for females (by age)

Nutrient and unit of measurement 11-14 15-18 19-24b 11-14 15-18 19-24b

Protein, gmc . . . . . . . . . . . . . . . . . . . . . . . 45

Vitamins

Vitamin A, micrograms REd

. . . . . . . . . 1,000

Vitamin D, micrograms . . . . . . . . . . . . . 10

Vitamin E, mg . . . . . . . . . . . . . . . . . . . . . 10

Vitamin K, micrograms . . . . . . . . . . . . . 45

Vitamin C, mg . . . . . . . . . . . . . . . . . . . . . 50

Thiamin, mg . . . . . . . . . . . . . . . . . . . . . . 1.3

Riboflavin, mg . . . . . . . . . . . . . . . . . . . . . 1.5

Niacin, mg NEe . . . . . . . . . . . . . . . . . . . . 17

Vitamin B-6, mg . . . . . . . . . . . . . . . . . . . . 1.7

Folate, micrograms . . . . . . . . . . . . . . . . 150

Vitamin B-12, micrograms . . . . . . . . . . 2.0

Minerals

Calcium, mg . . . . . . . . . . . . . . . . . . . . . . 1,200

Phosphorus, mg . . . . . . . . . . . . . . . . . . . 1,200

Magnesium, mg . . . . . . . . . . . . . . . . . . . . 270

Iron,m g . . . . . . . . . . . . . . . . . . . . . . . . .. 12

Zinc, mg... . . . . . . . . . . . . . . . . . . . . . . . 15

Iodine, micrograms . . . . . . . . . . . . . . . . 150

Selenium, micrograms . . . . . . . . . . . . . 40

59

1,000

10

10

65

60

1.5

1.8

20

2.0

200

2.0

1,200

1,200

400

12

15

150

50

58 46

1,000

10

10

70

60

1.5

1.7

19

2.0

200

2.0

800

10

8

45

50

1.1

1.3

15

1.4

150

2.0

1,200 1,200

1,200 1 ,200

350 280

10 15

15 12

150 150

70 45

44

800

10

8

55

60

1.1

1.3

15

1.5

180

2.0

1,200

1,200

300

15

12

150

50

46

800

10

8

60

60

1,1

1.3

15

1.6

180

2.0

1,200

1,200

280

15

12

150

55

aN~ritional requirements Vaw among itiividuals as a consequence of numerous genetic and environmental

circumstances: RDAs are intended to provide for the needs of most healthy individuals living in the United States under

normal environmental stresses (186).

bThe focus of this OTA Report is on I@ through 18_year+lds. RDAs for 1 ~ to 2&year+lds are pmvid~ in this table

for the purpose of comparison.

cHealth~ ~ult~ require nine ~s~ential amino acids in varying amounts each day. Dietary protein provides a rYliXtUre Of

amino acids for endogenous protein synthesis and is also a metabolic fuel for energy (1 86).

dRE - retinol ~uivalents, One RE is equal to 1 microgram of retinol or 6 m~rograms C)f beta<arotene.

e= - niacin equivalent. C)ne NE is equal to 1 mg of niacin or 60 mg of dietary tryptophan.

SOURCE: Adapted from National Academy of Sciences, National Research Council, Recommended Dietary

A//owances, IOth ed. (Washington, DC: National Academy Press, 1989). Reprinted by permission,

Table 7-3—NAS Estimated Ranges of Safe and

Adequate Daily Dietary Intakes of Additional

Vitamins and Minerals for U.S. Adolescents

Ages 11 and Overa

Vitamin or Estimated range of safe and

mineral adequate daily dietary intake

Vitamins

Biotin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 to 100 micrograms

Pantothenic acid . . . . . . . . . . . . . . . . . . . . . 4 to 7 mg

Trace elementsb

Copper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5 to 2.5 mg

Manganese . . . . . . . . . . . . . . . . . . . . . . . . . 2.0 to 5.0 mg

Fluoride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5 to 2.5 mg

Chromium . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 to 200 micrograms

Molybdenum . . . . . . . . . . . . . . . . . . . . . . . . 75 to 250 micrograms

aFor wtamins and minerals for which there is insufficient information on

which to base an RDA, NAS publishes estimated ranges of safe and

adequate daily dietary intakes.

bAccording to fWS, since the toxic levels for many trace elements may be

only several times usual intakes, the upper levels for the trace elements

given in this table should not be habitually exceeded.

SOURCE: Adapted from National Academy of Sciences, National Research Council, Recommended Dietary Allowamxs, 10th ed.

(Washington, DC: National Academy Press, 1989), p. 284.

Reprinted by permission.

ent temperature (153). While RDAs for protein,

vitamin s, and minerals are high enough to meet an

upper level requirement encompassing individual

variability, the recommended energy allowance

reflects the average population requirement for each

age group (153) and will not be sufficient for an

individual who regularly engages in strenuous

physical activity. Raising the recommended energy

intake level to accommodate individuals with an

upper level requirement, however, would be inappropriate because it could lead to obesity in persons

with average requirements. Noting the great variability in the timing and magnitude of the adolescent

growth spurt and in adolescent activity patterns,

NAS emphasizes that its recommended energy

intake levels for adolescents can be adjusted individually to take such variability into account (153).

From birth to age 10, the energy needs of males

and females are not very different (153). After age

10, separate allowances are made for males and
11-200. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 7-4—NAS Recommended Energy Intakes for Males and Females Ages 11 to 24

of Median Weights and Heights, 1989a

Males Females

Energy intakes Energy intakes

Median Median Calories Total Median Median Calories Total

weight height per kg calories weight height per kg calories

Ageb

(kg) (cm) of body weight per day (kg) (cm) of body weight per dayc

Age 11-14 . . . . . . . . . 45 157 55 2,500 46 157 47 2,200

Age 15-18 . . . . . . . . . 66 176 45 3,000 55 163 40 2,200

Age 19-24 . . . . . . . . . 72 177 40 2,900 58 164 38 2,200

aEnergy requirements of indivtiuals are affected by several variables, including level of physical activity, age, sex, body size and composition, genetic factors,

physiologic state (e.g., growth, pregnancy, lactation), coexisting pathological conditions, and ambient temperature. Recommended energy allowances, in

cxmtrast to RDAs for other nutrients (see table 7-2), are intended to meet the average needs of individuals.

%he focus of this OTA Report is on 10- through 18-year-olds. Recommended energy intakes for 19- to 24-yea r-olds are provided in this table for the purpose

of comparison.

cFor prWnant females and for females who are breastfeeding, the recommended energy intakes are higher (300 calories more Per day for Pre9nant females

in the second and third trimesters of pregnancy and 500 calories more per day for lactating females in the first year).

SOURCE: Adapted from National Academy of scienees, National Research Council, Recommended Dietary A//owances, 10th ed. (Washington, DC: National

Academy Press, 1989), p. 33. Reprinted by permission.

females because of differences in the age of puberty,

evolving activity patterns, and body composition.

On average, energy needs for adolescent males are

higher than for females. Pregnant and lactating

females have higher food energy needs than other

females, as shown in table 7-4.

Data on the role of diet as a causal or contributing

factor in chronic diseases have led some groups to

issue dietary recommendations derived through

approaches other than those used in developing

RDAs for specific nutrients (153). Broad nutritional

guidelines that provide guidance beyond that provided by RDAs were issued in the NAS report Diet

and Health.. Implications for Reducing Chronic

Disease Risk (152), in The U.S. Surgeon General’s

Report on Nutrition and Health (242), and in

Nutrition and Your Health: Dietary Guidelines for

Americans published by the US. Department of

Agriculture (USDA) and the U.S. Department of

Health and Human Services (DHHS) (227). Those

guidelines are summarized in box 7-C.

Among other things, these guidelines suggest

restricting intakes of fat, saturated fat, cholesterol,

sodium, sugar, and alcohol. Populations with high

fat diets have more heart disease, certain types of

cancer, and obesity (226). A diet low in saturated

fatty acids and cholesterol can help maintain a

desirable level of blood cholesterol, possibly reducing the risk for heart disease (226). Eating a diet with

less salt (which contains sodium) may help some

people reduce their risk of developing hypertension

(high blood pressure). Sugars supply calories but are

limited in essential nutrients and may increase the

risk of tooth decay. Drinking alcohol is linked with

a variety of chronic and other health problems (e.g.,

liver disease, accidental injuries).6

The guidelines in box 7-C also suggest that diets

include plenty of vegetables, fruits, and grain

products. Vegetable and fruits are good sources of

vitamins A and C, folic acid, fiber and minerals

(226). Breads and cereals provide B vitamin s, iron,

protein, and dietary fiber. Over the last decade,

several organizations have recommended increasing

the intake of complex carbohydrates or dietary fiber

(153). The consumption of a fiber-rich diet promotes

normal elimination and may have other beneficial

effects (e.g., reducing blood cholesterol levels,

preventing colon cancer and diabetes) (153).

Finally, it should be noted that USDA and DHHS’

Dietary Guidelines for Americans recommends

maintaining a healthy weight (227). Being too fat or

too lean (a less common problem in the United

States) increases the risk of various health problems.

Available knowledge also suggests that whether

one’s weight is ‘ ‘healthy’ depends on how much of

one’s body weight is fat, where in the body the fat is

located, and whether one has weight-related medical

problems or a family history of such problems (226).

6~oleKent~$ den~ he~~ s~~s is discuss~ in ch. 8, c *Dent~ and Oral Health Problems: l%ventiOII and Services, ’ ti ~s volume;

use of alcohol is discussed in ch. 12, ‘‘Alcohol, Tobacco, and Drug Abuse: Prevention and Services, in this volume.
Chapter 7—Nutrition and Fitness Problems: Prevention and Services . II-201

Box 7-C—Broad Nutritional Guidelines That Provide Guidance Beyond Recommended

Daily Allowances (RDAs)

National Academy of Sciences’ Diet and Health Report (1989):

This report made recommendations for quantities of nutrients and numbers of suggested servings from some

food groups, specifically:

● Limit intake of fat to less than 30 percent of total calories.

. Limit intake of saturated fatty acids to less than 10 percent of total calories.

. Limit cholesterol intake to under 300 mg daily.

. Limit salt intake to under 6 grams daily.

. Maintain protein at moderate levels, not more than twice recommended daily allowance (R-DA).

● For those who drink alcoholic beverages, limit intake to less than 1 oz of pure alcohol per day. 1

● Maintain optimal intake of fluoride.

● Avoid the use of dietary supplements in levels greater than RDA.

● Have 5+ servings of vegetable and fruit combinations, especially green and yellow vegetables and citrus

fruits.

● Have 6+ daily servings of a combination of breads, cereals, legumes, and other starches and complex

carbohydrates.

U.S. Surgeon General’s Report on Nutrition and Health (1988):

This report endorsed USDA’s Dietary Guidelines for Americans (those that were current at the time) and also

recommended the following:

● that fluoridated community water systems, or other appropriate sources of fluoride be used to prevent tooth

decay;2

● that those who are particularly vulnerable to dental caries should limit their consumption and frequency of

foods high in sugar;2

● that adolescent females should increase consumption of foods high in calcium, including low-fat dairy

products; and

● that adolescents and women of childbearing age, especially those in low-income families, be encouraged to

consume foods that are good sources of iron.

USDA and DHHS’ Dietary Guidelines for Americans (October 1990):

. Eat a variety of foods.

● Maintain healthy weight.

● Choose a diet low in fat, saturated fat, and cholesterol.

● Choose a diet with plenty of vegetables, fruits, and grain products.

● Use sugars in moderation.

● Use salt and sodium in moderation.

● If you drink alcoholic beverages, do so in moderation. 1

The published guidelines provide more information on each guideline, including details on what the guideline

means, how it is important to health, and some tips on using the guideline.

l~e co~~ption of alcohol by U.S. adolescents is discussed inch. 12, “Alcohol, Tbbacco, and Drug Abuse: Prevention and Services,’

in this volume.

*S= Ch. 8, “Den~ and Ord He~ti Problems: PTevCIItiOII and Services “ in this volume for a discussion of the importance of fluoride ,

to adolescents’ dental health and other topics related to adolescents’ dental health.

SOURCES: National Academy of Sciences, National Research Council, Diet and Health: Implications for Reducing Chronic Disease

(Washington DC: National Academy Press, 1989); U.S. Department of Health and Human Services, Public Health Service, Ofl%e

of the Surgeon General, Surgeon General’s Report on NutrMon and Health (Washingto% DC: U.S. Government Printing Offke,

1988); and U.S. Department of Agriculture and U.S. Department of Health and Human Services, Nutrition and Your Health: Dietary

Guidelinesfor Americans, Home and Garden Bullet@ No. 232 (Hyattsville, MD: 1990).
11-202. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Researchers are developing more precise ways to

measure healthy weight.7

Physical Fitness and Activity Needs

Numerous recent studies have suggested that

physical fitness and/or physical activity8 have, or

potentially have, positive impacts on health and

longevity (22,22a,33,33a,106a,171,174b,241). It is

important to note, however, that these studies have

had methodological flaws and have almost been

conducted with adult samples. During adolescence,

physical activity is thought to influence growth and

development of skeletal bone, muscle, and fat (142).

There appears to be a reciprocal relationship between physical activity and obesity or overweight

(see below).

Adolescents’ Nutrition and Fitness Problems

A lack of data on contemporary adolescents and

a paucity of systematic research on the impact of

varying levels of nutrients and physical activity and

fitness on health (including adolescent health) (254a)

make conclusions about the nutrition and fitness

problems of U.S. adolescents difficult to draw. Some

survey data suggest that if one uses available

nutritional and fitness guidelines as a standard,

many U.S. adolescents have inadequate diets and

engage in low levels of physical activity. Not

coincidentally, a substantial minority are also overweight or obese. These problems may occur more

often in some groups of adolescents, especially

low-income adolescents or those in particular racial

or ethnic groups.9 Recent national data regarding the

incidence or prevalence of these problems among

U.S. adolescents are not available (see box 7-A), and

national information about specific groups of adolescents (e.g., racial or ethnic minority adolescents,

low-income adolescents) is practically nonexistent.

Nutritional Deficiencies

Essential nutrients are proteins, minerals, carbohydrates, fat, and vitamins that are necessary for

growth, normal functioning, and maintaining life;

they must be supplied by food, because they cannot

be synthesized by the body (box 7-B). Table 7-5

shows U.S. adolescents’ intake of food energy,

protein, vitamins, and minerals in 1977-78 as a

percentage of the 1980 RDAs.10

USDA’s 1977-78 Nationwide Food Consumption

Survey found that most U.S. adolescents got more

than enough protein (see table 7-5). More recent data

also confirm that intakes of protein by U.S. adolescents typically meet or exceed the RDA (1 11).

USDA’s 1977-78 Nationwide Food Consumption

Survey also found that, on average, U.S. adolescents’ intakes of vitamins A, B 12, and C, thiamin,

riboflavin, and niacin, were sufficient or more than

sufficient. On the other hand, USDA’s 1977-78

Nationwide Food Consumption Survey (224) found

that U.S. adolescents’ energy intakes (calories

consumed) in the late 1970s were, on average, lower

than the RDA levels.

The data in table 7-5 suggest that the nutrients

U.S. adolescents are most likely to be getting

insufficient quantities of include vitamin B-6, iron

and calcium. Females ages 9 to 18 tended to

consume less iron and calcium than males, but

males, too, consumed less than the 1980 RDA. The

RDA for iron in 1989 was lower than in 1980, but

recent data support the finding that iron is one of the

nutrients most likely to be deficient in U.S. adoles70veWeighf is somct~= d~m~~Wy mass index (BMl)-i.e., weight in kilograms divided by height k meters squmd-greater ~or ~u~

to the 85tlI percentile of a similar population group. Obesiry, a more serious problem is defined in various ways. One deftition is BMI greater than or

equal to the 95th percentile of a similar population group. Another deftition is weight at least 20 percent over “normal weight. ” Measuring triceps

skinfolds is another way of measuring obesity.

8physic~fi~ne~s is ~ a~~~ufe tit Shodd tX &s@@hed from physical ucfivify, which is a br?hUviOr. Physical activiv has been fo~d to be ~

important determinant of physical fitness. To some exten4 therefore, physical fitness can be considered to be an objective murker for habitual physical

activity (and vice versa), but physical fitness and physical activity are not the same thing (22a).

Whe health problems of low-income adolescents and racial and ethnic minority adolescents are discussed further in ch. 18, “Issues in the Delivery

of Services to Selected Groups of Adolescents,‘‘ in Vol. III. Also discussed in that chapter is the general paucity of data and research on low-income

and racial and ethnic minority adolescents.

l~e fist e~tion of tie NAS publi~tion Reco~endedDiefa~A//owances was pub~shed iII 1943. since t.hc~ nine revised editions have appeared,

the most recent in 1989. The 1980 RDAs are similar to the 1989 RDAs, but there are some differences. In 1980, for example, the RDA for iron was 18

mg per day as opposed to 15 mg per day in 1989 (150). For a discussion of other differences, see the 1989 NAS publication Recommended Dietary

Allowances (153).
Chapter 7—Nutrition and Fitness Problems: Prevention and Services ● //-203

Table 7-5—Average Daily Nutrient Intake as a Percentage of the 1980 RDAs Among

U.S. Adolescents Ages 9 to 18, 1977-78a b

Male Female

Vegetarian Nonvegetarian Vegetarian Nonvegetarian

Nutrient (N= 20) (N= 3,462) (N= 31) (N= 3,600)

Food energyc . . . . . . . . . . . . . . . . . . 98% 86% 91% 82%

Protein . . . . . . . . . . . . . . . . . . . . . . . . 203 193 170 160

Vitamins

Vitamin A . . . . . . . . . . . . . . . . . . . . 182 123 121 112

Thiamin . . . . . . . . . . . . . . . . . . . . . . 166 121 143 134

Riboflavin . . . . . . . . . . . . . . . . . . . . 171 149 118 111

Niacind . . . . . . . . . . . . . . . . . . . . . 150 122 118 111

Vitamin B6 . . . . . . . . . . . . . . . . . . 123 94 81 72

Vitamin B12 . . . . . . . . . . . . . . . . . 191 205 142 148

Vitamin C . . . . . . . . . . . . . . . . . . . . 225 173 172 150

Minerals

Calcium . . . . . . . . . . . . . . . . . . . . . . 107 97 87 74

Iron . . . . . . . . . . . . . . . . . . . . . . . . . 121 91 90 76

Magnesium . . . . . . . . . . . . . . . . . . 97 80 115 103

Phosphorus . . . . . . . . . . . . . . . . . . 151 133 129 115

ane 19s0 RDASI150J aresirnilartothe 1989 RDAs (153) in many respects, but there are some differences. For

example, the 1980 RDAforironwas 18mg., while the 1989 RDAforironwas 15mg. See text fordiscussion.

bhe percentages in this table are basedon data from the U.S. Department of Agriculture’s 1977-1978 Nationwide Food

Consumption Survey (224).

cRecommend~ energy intake levels are ievels to meet average needs, unlike RDAs for other nutrients, which are

believed to meet the needs of the vast majority of healthy individuals.

dRDA is for preform~ niacin rather than niacin equivalents.

SOURCE: Adapted from National Academy of Sciences, National Research Council, Diet and Health: Implicdions for

Reducing Chronic Disease Risk (Washington, DC: National Academy Press, 1989). Reprinted by

permission.

cents’ diets, especially among females (122,142).

Females’ iron needs are particularly high. In addition, exercise may increase the need for iron (128),

and iron deficiency during physical training is more

common in females than males (see section on

female adolescent athletes below).

In 1989, the NAS Food and Nutrition Board’s

Subcommi ttee on the Tenth Edition of the RDAs

urged that special attention be paid to calcium

intakes throughout childhood to age 25 to reduce the

risk of osteoporosis later in life (153). However,

another NAS committee, the Committee on Diet and

Health, found that the evidence was not sufficient for

drawing conclusions about the influence of dietary

patterns on osteoporosis (152). As opposed to the

effects of exercise on iron stores, exercise increases

the retention of calcium in the body (23,98), as

measured by the mineral content in bones; peak bone

mineral density has been found to be enhanced by

large calcium intakes and large energy expenditures

(102).

According to data from other studies, levels of

vitamin C, folic acid, thiamin, and riboflavin are low

in some adolescents (47,123,191,228,23 1,234). Levels of manganese and copper are unknown because

food composition data are incomplete (152,168).

Physical activity may deplete zinc stores, but the

evidence is unclear (52).

For most U.S. adolescents, vitamin and mineral

deficits are subclinical and do not require professional intervention (59a). In the few cases where

deficiency is commonly observed (e.g., iron deficiency in females), treatment with supplements may

be necessary.

Inadequate Dietary Fiberll

Data on intakes of dietary fiber by U.S. adolescents are incomplete, but some observers have

suggested that intakes are probably lower than

recommended (2,5). On the other hand, Healthy

People 2000 noted that one expert panel (of the Life

Sciences Research Office of the Federation of

American Societies for Experimental Biology) indicated that levels of dietary fiber appropriate for

adults may not be appropriate for children (no ages

specified, and so Healthy People 2000 did not make
//-204 . Adolescent Health—Volume II: Background and the Electiveness of Selected Prevention and Treatment Services

Box 7-D—Healthy People 2000 Objectives Pertaining to Adolescents’ Physical Activity and Nutrition

Healthy People 2000 is the Nation’s most prominent statement on health promotion and disease prevention

objectives for the U.S. population (241). This report, published by the U.S. Department of Health and Human

Services, contained a number of objectives for the year 2000 pertaining to adolescents’ nutrition and physical

activity and fitness. The report also provided baseline data when they were available (see below). In addition to the

health status, risk reduction, services, and protection objectives listed below, Healthy People 2000 enumerated

objectives for personnel needs, surveillance and data systems, and research (241). These latter objectives were not

specific to adolescents, but meeting them would be important to meeting the health status objectives for adolescents.

Nutrition Objectives for the Year 2000

Health Status and Risk Reduction Objectives

Reduce dietary fat intake to an average of 30 percent of calories or less and average saturated fat intake to

less than 10 percent of calories among people ages 2 and older (no baseline data cited for adolescents or

children).

Increase calcium intake so at least 50 percent of youth ages 12 through 24 and 50 percent of pregnant and

lactating women consume three or more servings daily of foods rich in calcium (no baseline data cited for

adolescents).

Decrease salt and sodium intake so at least 65 percent of home meal preparers prepare foods without adding

salt, at least 80 percent of people avoid using salt at the table (baseline: 54 percent of women aged 19 through

50 who served as the main meal preparer did not use salt in food preparation; no baseline data cited for

adolescents’ use of salt).

Services and Protection Objectives:

●

●

●

●

●

Increase to at least 5,000 brand namesl the availability of processed food products that are reduced in fat

and saturated fat (baseline: 2,500 items reduced in fat in 1986).

Increase to at least 90 percent the proportion of restaurants and institutional food service operations that offer

identifiable low-fat, low-calorie food choices, consistent with the Dietary Guidelines for Americans

(baseline: about 70 percent of fast food and family restaurant chains with 350 or more units had at least one

low-fat, low-calorie item on their menu in 1989).

Increase to at least 90 percent the proportion of school lunch and breakfast services and child care food

services with menus that are consistent with the nutrition principles in the Dietary Guidelines for Americans

(baseline data available in 1993).

Increase to at least 75 percent the proportion of the Nation’s schools that provide nutrition education from

preschool through 12th grade, preferably as part of quality school health education (baseline data available

in 1991).

Increase to at least 75 percent the proportion of primary care providers who provide nutrition assessment

and counseling and/or referral to qualified nutritionists or dietitians (baseline: physicians provided diet

counseling for an estimated 40 to 50 percent of patients in 1988).2

Physical Activity and Fitness Objectives for the Year 2000

Health Status and Risk Reduction Objectives:

●

●

●

Increase to at least 75 percent the proportion of children and adolescents aged 6 through 17 who engage in

vigorous physical activity that promotes the development and maintenance of cardiorespiratory fitness 3 or

more days per week for 20 or more minutes per occasion (baseline: 66 percent for youth aged 10 through

17 in 19843).

Reduce to no more than 15 percent the proportion of people aged 6 and older who engage in no leisure-time

physical activity (no baseline data available for adolescents or children).

Increase to at least 40 percent the proportion of people aged 6 and older who regularly perform physical

activities that enhance and maintain-muscular strength, muscular endurance, and flexibility (no baseline data

available for any age group).

1A b- item is d~m~ ~ ~ ~~c~fivor ~d/or si~ of a specfic b~d@ is &piMy the consumer tit of purchase (241).

2~s Obj=tive~~~line &@ ci~ me not spwific to a&kscmW. For a discussion of Xcare providers’ behaviors with

adolescents, see ch. 15, “Major Issues in the Delivery of RirnaIY and Comprehensive Services to Adolescents,” in Vol. III.

s~e SOWW ci~d for this value was the National Children and Youth Fimess Study I.
Chapter 7—Nutrition and Fitness Problems: Prevention and Services . II-205

Services and Protection Objectives:

● Increase to at least 50 percent the proportion of children and adolescents in 1st through 12th grade who

participate in daily school physical education (baseline: 36 percent in 1984-86).

. Increase to at least 50 percent the proportion of school physical education class time that students spend

being physically active, preferably engaged in lifetime physical activities (baseline: students spent an

estimated 27 percent of class time being physically active in 1983).

● Increase to at least 50 percent the proportion of primary care providers who routinely assess and counsel their

patients regarding the frequency, duration, type, and intensity of each patient’s physical activity practices

(baseline: physicians provided exercise counseling for about 30 percent of sedentary patients in 1988).

● Increase community availability and accessibility of physical activity and fitness facilities.4

Combination Nutrition and Physical Activity and Fitness Objectives for the Year 2000

Health Status and Risk Reduction Objectives:

. Reduce overweight to a prevalence of no more than 15 percent among adolescents ages 12 through 19

(baseline: 15 percent for adolescents ages 12 through 19 in 1976-80).5

. Increase to at least 50 percent the proportion of overweight people aged 12 and older who have adopted

sound dietary practices combined with regular physical activity to attain an appropriate body weight (no

baseline provided for adolescents),

4~e~e ~omendatiom were not adolesunt-spcflc.

s~e “~um used for adolescents wem “the gender-specific 85th percentile values of the 1976-80 National Health and Nutrition

Examination Sumey (NHANES II) corrected for sample variation” (241).

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Health, Heahhy PeopZe

2000: Narionul Health Promotion and Disease Prevention Objectives, DHHS Pub. No. (PHS)91-50213 (Washingto% DC: U.S.

Government Printing OffIce, 1991).

recommendations on dietary fiber for children or

r

adolescents (box 7-D) (241 ).

~4 z ““’ ~,’, ~~

Excessive Consumption of Fat, Cholesterol,

Sodium, and Low-Nutrient Density Foods

The diets of most U.S. adolescents in national

surveys fail to meet the recommendations of the

NAS report Diet and Health (see box 7-C) because

they are excessive in total fat, saturated fat, choles-

“r ‘“’

?/

terol, and sodium (46,64,1 11,153,159,189).

It is not surprising to find that adolescents’ diets

are high in fat and cholesterol. NAS reports that food

patterns have changed significantly in the United

States (152). Between 1909 and 1985 the percentage

of calories available in the food supply from fats

increased from 32 to 43 percent (152). NAS recommended that children over 2 years old should

consume no more than 30 percent of calories in fat.

Recent studies have found that school meals are

often very high in fat (37,70,164). Fast-food meals

or snacks consumed by adolescents are often high in

total and saturated fat, cholesterol, sodium, and

sugar (135). Table 7-6 shows the nutritional values

of seven sample fast-food meals.

Approximately 25 percent of total calories consumed by U.S. adolescents, almost regardless of

Photo credit: Benjamin Smith

Current data on the food consumption patterns and

nutritional status of U.S. adolescents, especially

subgroups of adolescents such as racial and ethnic

minorities and low-income adolescents, are limited. The

most recent comprehensive information about what U.S.

adolescents eat is from 1977-78. These data suggest that

adolescents’ diets contain sufficient amounts of most

essential vitamins and minerals and more than enough

protein, but not enough total calories, vitamin B6, iron, and

calcium. But more recent information suggests that

adolescents’ diets may be too high in fat, cholesterol,

and sodium.
11-206. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

income, sex, or race (142), come from high calorie

foods that are relatively low in protein, vitaminS, and

minerals (“low nutrient density” foods). Snacking,

or foods consumed ‘‘outside of traditional meals, ”

provides 20 to 35 percent of adolescents’ total

energy intakes (46,145,224), but several studies

show that the nutrient density is usually lower for

snacks than for meals (57). Because recent data are

not available, and data from the late 1970s suggest

that adolescents generally consume sufficient proteins, vitamins, and minerals (with the exception of

vitamin B6, calcium, and iron) (see table 7-5), it is

not clear how much of a nutritional problem—

beyond fat intake-snacking represents.

Low Levels of Physical Activity

Like their nutritional needs, the physical abilities

of adolescents differ from those of younger children.

The changes that occur with puberty involve not

only increased linear growth and mass but also

physiological changes that improve physical and

athletic ability. The onset of puberty is associated

with an increase in aerobic and anaerobic power (97)

and tolerance of exercise in the heat (13) and in the

cold (202).

As noted above, there is considerable concern

about levels of physical activity among U.S. adolescents on average (91a,174a,241). Detailed, accurate

studies have not been carried out to show trends in

activity patterns or the effects of age on activity

during adolescence, but low levels of physical

activity throughout adolescence have been discerned from recent surveys and semiquantitative

measures of fitness (173,182).

Enrollment and participation in daily physical

education classes decrease somewhat in late adolescence. Figure 7-1, based on results from the National

Children and Youth Fitness Studies,12 shows the

percentage of U.S. students in 1st through 12th

grades enrolled in daily physical education classes in

1984-86 (182,183, 241). Only about 20 percent of

the time is spent in moderate or vigorous activity

during a class (15).

Results from the National Children and Youth

Fitness Studies indicate that 59percent of 5th to 12th

graders reported engaging in appropriate physical

Figure 7-l—Percentage of U.S. Students in

1st Through 12th Grade Receiving Daily Physical

Education, 1984-86

30

20

10

0

Iz

12345 6 7 8 9 10 11 12

Grade in school

SOURCE: U.S. Department of Health and Human Serviees, Public Health

Service, Office of the Assistant Secretary for Health, Hea/thy

People 2000: National Health I?omotion and Disease Prevention @jectfves, DHHS Pub. No. (PHS)91-50213 (Washington,

DC: U.S. Government Printing Office, 1991), based on the

National Children and Youth Fitness Study I (students in 5th

through 12th grade) and the National Children and Youth

Fitness Study II (students in Ist through 4th grade).

activity year round (182).13 Of the time these

adolescents spent in physical activity outside of

school physical education classes (84 percent of

their average weekly minutes of participation in

physical activities), nearly 47 percent of students

reported engaging in appropriate activities that

could be carried over into adulthood (182).

Results from the National Children and Youth

Fitness Studies also indicate that U.S. children and

adolescents’ physical fitness is related to their

mothers’ physical activity and inversely to the

amount of time children watch television (182).

Studies of adults show that adult women of lower

socioeconomic status engage in less fitness-related

activity than women of higher socioeconomic status

(68), and that exercise levels are similar among

members of the same family (63). Taken together,

these observations suggest that low-income adolescents may be less likely to be engaging in fitnessrelated activities. Lower participation by lower

socioeconomic status individuals may be more a

matter of opportunity than inclination; thus, schools

could play an important role in providing occasions

lz~e Natio~ c~~en and Youti Fi@ws S~dies (NCYFS) were surveys of 5th to 12th grade students (NCYFS I) md 1 st through4tb fpde smdmts

(NCYFS II) (182,183,241).

13APProPr~afe physical ucfivi~ was defm~ in this swey as physical activity involving large muscle grOUpS at ~intemity r~a60 Per~nt or

greater of an individual’s cardiovascular capacity engaged in at least three times per week for at least 20 minutes.
Chapter 7—Nutrition and Fitness Problems: Prevention and Services . II-207

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//-208 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

for exercise by lower socioeconomic status adolescents.

A recent study of the effects of television on

children and adolescents shows that adolescents

spend many hours outside of school watching

television—an average of 23 hours per week from

1976 to 1980 (86). Watching television may affect

the amount of time adolescents spend engaging in

physical activities.14

Obesity or Overweight

Depending on the measurement used, the prevalence of overweight and obesity in U.S. adolescents

ranges from 15 to 22 percent (86,241).15 Obesity

may have genetic origins (26,3 1,208), but it is also

associated with diet and physical activity. The

family environment and the community are important in explaining obesity in children and adolescents (166). Family involvement in active lifestyles

and moderation in eating patterns is usually critical

in preventing and avoiding obesity. Children in

obese families expend less energy than those in lean

families, possibly because they copy sedentary

family lifestyles (10). Obese adolescents have lower

than usual levels of physical activity (21), and even

when obese adolescents are physically active, they

are less so than their leaner peers (30).

Obesity in adolescents may be associated with

other factors, such as socioeconomic status, rate of

biological maturity, or race. Fatness and sedentary

habits are more common in adults of lower socioeconomic status (78). Early maturing females tend to be

fatter and are more likely to become obese as adults

(79). Black female adolescents appear to be overweight more often than white female adolescents

(116,1 17,233). However, this information may be

confounded in part when considering that black

body composition during adolescence differs from

whites; black individuals have a higher bone and

muscle mass so that overweight may not always

mean overfatness at levels of moderate overweight.

The risk of early obesity in Mexican American

adolescents, especially for the central or trunkal type

of obesity (highly associated with heart disease and

diabetes mellitus), is extremely high (117,236).16

Obesity is prevalent in some American Indian tribes

(20a,152), but data on obesity in American Indian

adolescents are very limited (20a).

Conclusions that many adolescents are overweight—

and that fatness may be increasing among adolescents (53,54,55,87)17—may seem inconsistent with

findings that U.S. adolescents’ energy intakes are,

on average, lower than recommended. It may be that

U.S. adolescents are more sedentary than is assumed

by NAS when formulating its recommended energy

allowances.

Conclusions

Current national data on the food consumption

patterns of U.S. adolescents are limited. Available

evidence suggests that many U.S. adolescents do not

follow the general dietary guidelines set forth in

publications such as the NAS report Diet and

Health: Implications for Reducing Chronic Disease

Risk (152) or in USDA and DHHS’ Nutrition and

Your Health: Dietary Guidelines for Americans

(227) (see box 7-B). Specifically, it appears that U.S.

adolescents tend to consume excessive amounts of

fat, saturated fat, cholesterol, sodium, and foods with

low nutrient density. Recent studies have found

school meals to be very high in fat,

Available evidence from the late 1970s suggests

that while U.S. adolescents’ diets generally provide

enough protein, they tend to be deficient in some

specific nutrients (e.g., iron, calcium, and vitamin

B6) ( 152). This same source suggests, however, that,

on average, U.S. adolescents consume more than

sufficient amounts of other vitamin s, minerals, and

14s& Ch. 4, c(Schools and Discretionary Time, ‘‘ in this volume for a discussion of what adolescents do during their time away from school.

1SA5 noted e~lier, o~sity and ovewei@t can be defined in different ways, Obesi~ can be defined as BMI greater than or equrd to tie 95dI Perantde

of a similar population group (usually by age); or it can be defined as 20 percent or more over “normal” weight, Overweight can be defined as BMI

greater than or equal to the 85th percentile of a similar population group. Measuring triceps skinfolds is another method of measuring obesity. A matter

of contentio% the method used to measure the ratio of body fat does affect prevalence and incidence rates of obesity in a population (86,91,132,241).

Because of the rate of physiological change and consequent effect on fat distribution patterns during childhood and adolescence, some measures may

not accurately reflect body fat in adolescents. Also, some studies refer to ‘obese’ and ‘superobese’ rather than ‘overweight’ and “obese’ adolescents

(86).

16~e5e data ~ve not ken conect~ for sociWconomic status levels; however, cefi~ ~OUpS of Hispanics experience relatively high levels

poverty. For further discussion, see ch. 18, “Issues in the Delivery of Semices to Selected Groups of Adolescents, ” in Vol. III.

]yHowever, ~o~a s~dy which us~ tie sae dam set m many of ~ese studies but different methods for measuring the aKIIOUIIt of body fat did IIOt

show any secular increases in BMI in adolescents (91). Inconsistent conclusions maybe due to the different indices of obesity employed, and differences

in age distributions and sample designs. However, no study suggests that the prevalence of obesity is decreasing among adolescents (142).
Chapter 7—Nutrition and Fitness Problems: Prevention and Services . lI-209

protein. Data on average nutrition in contemporary

U.S. adolescents will become available in the

mid- 1990s, but smaller regional studies are needed

to determine nutritional deficiencies in some groups

of adolescents.

Physical activity levels of most adolescents decline throughout adolescence. The best opportunity

for physical activity for some adolescents, particularly low socioeconomic status adolescents, may be

during school hours. But physical education classes

during school currently provide little opportunity for

actual physical activity.

Available evidence suggests that from 15 to 22

percent of U.S. adolescents are overweight or obese

(86,241). Diets high in fats and low levels of

physical activity are factors, in conjunction with the

family environment and, possibly, genetic factors.

Low-income adolescents and adolescents in some

racial or ethnic groups are more likely to be

overweight or obese than others.

Consequences of Adolescent Nutrition and

Fitness Problems

Malnutrition, low levels of physical activity,

obesity, and other nutrition and fitness problems

experienced by U.S. adolescents have immediate

consequences (e.g., failure to grow, decreased resistance to disease, lack of energy, obesity) and may

also have long-term consequences. This section

reviews evidence for both the immediate and longterm consequences of nutrition and fitness problems

during adolescence.

Immediate Consequences of Nutritional and

Fitness Problems During Adolescence

Immediate Consequences of Nutritional Problems--The biological functions of selected dietary

substances in humans were reviewed in box 7-B

earlier in this chapter. Insufficient caloric intake can

lead to death by starvation and insufficient intake of

vitamins and minerals can lead to diseases such as

scurvy or pellagra. Fortunately, starvation and diseases caused by vitamin and mineral deficiencies are

rare in this country (226).

Adolescents whose caloric intakes are too high

may experience weight gain, leading to overweight

or obesity. Those whose caloric intakes are low may

experience weakness, weight loss, physical inactivity, and less than optimal growth (186).18 Excessive

leanness is associated with health problems and

premature death. Meal skipping is associated with

lower intakes of several nutrients on a daily basis.

Recent data suggest that 5 percent of U.S. adolescents, especially females, are chronic meal skippers

(142). This finding may be cause for concern

because low calorie diets (e.g., under 1,800 calories)

may make it difficult to meet intake standards for

some essential nutrients, such as iron and calcium,

without supplementation.19

As noted in box 7-B, iron deficiency may result in

anemia, causing decreased physical ability, impaired body temperature regulation, lowered resistance to infection, and alterations in behavior and

intellectual performance (49). Calcium intake and

absorption are necessary for adequate bone growth

during adolescence (152). Zinc deficiency has not

been found to impair the capacity for aerobic

exercise in animals (128), but strength may be

affected (1 14).

Immediate Consequences of Low Levels of

Physical Activity—During adolescence, physical

activity can influence growth and development of

skeletal bone, muscle, and fat (142). Health values

of childhood physical activity include relationships

to obesity (see below) and to physical fitness and

functional capacity (196). In adults, participation in

high-intensity aerobic exercise has been shown to

improve self-concept (130) and this may also be true

for adolescents.

Immediate Consequences of obesity-----obesity

has immediate and delayed effects on social development and health (100,142). Poor body image and

a decreased sense of personal worth are common

among obese adolescents, especially if obesity dates

from childhood (34,59,175). Obesity further encourages the tendency towards physical inactivity (10,142)

and is associated with an increased risk of hypertension and high blood cholesterol (see below) (20,54,

71,85,180,246).

18~olawnt~ ~i~ he ~at~g dl~o~de~~ ~orexla newo5a ad bulimia (dlscuss~ below) expedience weight ]OSS and other p

threats to their health.

l% 1989, tie NAS Food ~d Nu~ti~n Bo~d reco~ende(j hat individ~]s eat diets composd of a variety of foods rather hIl rely On

supplementation or fortification (153).
11-210. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Risk of Chronic Diseases Later in Life

Some nutritional and fitness behaviors during

adolescence, though not immediately threatening to

the adolescent population, may be associated with

chronic diseases later in life.

In a recent comprehensive review of the effects of

diet on health, an NAS committee drew the following conclusion:

A comprehensive review of the epidemiologic,

clinical, and laboratory evidence indicates that diet

influences the risk of several major chronic diseases.

The evidence is very strong for atherosclerotic

cardiovascular diseases and hypertension and is

highly suggestive for certain forms of cancer (especially cancers of the esophagus, stomach, large

bowel, breast, lung, and prostate). Furthermore,

certain dietary patterns predispose to dental caries

and chronic liver disease, and a positive energy

balance produces obesity and increases the risk of

non-insulin-dependent diabetes mellitus. However,

the evidence is not sufficient for drawing conclusions about the influence of dietary patterns on

osteoporosis and chronic renal disease (152).

The NAS committee also cautioned as follows,

however:

Most chronic diseases in which nutritional factors

play a role also have genetic and other environmental

determinants, but not all the environmental risk

factors have been clearly characterized and susceptible genotypes usually have not been identified.

Furthermore, the mechanisms of genetic and environmental interactions involved in disease are not

fully understood. It is evident that dietary patterns

are important factors in the etiology of several major

chronic diseases and that dietary modifications can

reduce such risks. Nevertheless, for most diseases, it

is not yet possible to provide quantitative estimates

of the overall risks and benefits (152).

It is important to note that the NAS committee did

not specifically review the effects of adolescents’

dietary patterns on health during adulthood. There is

in general very little information on such effects.

While more research on the impact of adolescent

dietary patterns on adolescents’ immediate and

future health is clearly needed, the available research

on diet and chronic disease suggests that adolescents

might be well advised to follow prudent dietary

recommendations and should receive continuing

education about links between diet and health as

such information becomes available.

Risk of Obesity—Though most obese adolescents do not become obese adults, it is difficult to

predict (except for the most obese) who will persist

in their obesity (242). It appears, however, that the

risk of continued adult obesity rises the longer an

adolescent remains obese (85). Continued obesity is

especially likely to be associated with increased

risks of later hypertension, high serum cholesterol

and coronary artery disease, adult-onset diabetes

mellitus, gall bladder disease, an increase in certain

forms of cancer, and other medical problems (85,133,

237).

Risk of Coronary Artery Disease-Coronary

artery disease in adults is highly associated with high

cholesterol levels—particularly high low-densitylipoprotein (LDL) levels and low high-densitylipoprotein (HDL) levels—physical inactivity, and

high blood pressure (139,206,251). The Pathobiological Determinants of Atherosclerosis in Youth

(PDAY) and the Bogalusa Heart studies have

recently shown that high LDL and low HDL levels

in adolescence are associated with artery-narrowing

plaque (139) and that high cholesterol levels may

follow an adolescent into adulthood (251).

Recently, an expert panel on blood cholesterol

levels in children and adolescents at the National

Cholesterol Education Program of the National

Institutes of Health suggested selective cholesterol

screening of some children and adolescents (i.e.,

those who have a family history of premature

cardiovascular disease or at least one parent with

high blood cholesterol) (237). But in one study, the

predictive value of the occurrence of high cholesterol in adolescence for high cholesterol in adulthood is questioned; of children with cholesterol

concentrations exceeding the 75th percentile, 75

percent of the females as adults and 56 percent of

males as adults did not qualify for intervention using

the National Cholesterol Education Program criteria

(118).

There is no evidence that fitness during adolescence has a direct effect on adult health, but

establishing lifetime activities (e.g., walking, running, and cycling) during adolescence may encourage continued adult participation in physical activity

(196). Increased physical activity in adults has been

associated with an overall decreased risk of coronary

heart disease (22,146,162,163,171,197).

Risk of Diabetes--Diabetes is the most common

of the serious metabolic diseases (69). Type I
Chapter 7—Nutrition and Fitness Problems: Prevention and Services . II-211

(insulin-dependent) diabetes usually begins in adolescence. Type 11 (non-insulin-dependent) diabetes

usually begins in middle life or beyond.

The development of Type I diabetes occurs when

an environmental event (e.g., a viral infection)

triggers an autoimmune reaction in a genetically

susceptible individual (69).

The development of Type II diabetes is less well

understood (69). The disease runs in families,

however, and the typical patient is overweight. As

noted above, an NAS committee concluded that a

positive energy balance (i.e., too many calories)

produces obesity and thus increases the risk of Type

II diabetes (152).

Risk of Cancer—Excess dietary fat and low

intakes of plant foods and vitamin C are the dietary

factors most strongly linked to increased risk of

some cancers20 (152). Generally, increased weight

relative to height is associated with increased risk of

cancer (195 ). Caloric expenditure or some other

factor associated with physical activity in recreation

or employment may be associated with decreased

risk of some cancers (73,76,82,245).

Risk of Osteoporosis--Begin too thin is linked

with osteoporosis in women and thinness is associated with poor nutrient (e.g., calcium) intakes (226).

However, the relationship of dietary calcium to

osteoporosis is uncertain (152,226). It does appear,

however, that higher intakes of calcium and iron by

women, especially during adolescence and early

adulthood can increase bone mass and delay the

onset of fractures later in life. The level of bone mass

achieved at skeletal maturity (generally in the

mid-twenties) is a major factor modifying the risk

for fractures (152).

Conclusions

The consequences of adolescents’ nutrition and

fitness problems may directly affect individuals

during adolescence or later in life. Some adolescents

experience immediate effects, such as poor bone

growth due to calcium deficiency, lack of energy due

to iron-deficiency anemia, impaired resistance to

infection, or obesity due to a combination of

genetics, diet, and sedentary behavior.

Little research has been directed toward the

effects of adolescent dietary and physical activity

patterns on adult chronic disease, but some evidence

suggests that the ultimate consequences of a longterm pattern of poor nutrition and low levels of

physical activity may be life-threatening. As a

consequence, the recent consensus document, Hea1thy

People 2000, made the recommendations shown in

box 7-D.

Adolescents With Particular Nutritional and

Fitness Problems

Some adolescents have special nutritional and

fitness problems. As discussed below, adolescents

who are pregnant or lactating need increased energy

intakes and other nutrients. Adolescent athletes also

have special nutritional needs and subsequent problems. Other adolescents with special needs include

adolescents with eating disorders such as anorexia

and bulimia and adolescents with serious chronic

physical or mental conditions and disabilities who

may have either difficulty making proper nutritional

choices, decreased mobility, or decreased access to

facilities that provide exercise assistance.

Pregnant Adolescents21

The diets of pregnant younger adolescents are

often deficient in energy, calcium, and iron. Special

problems with nutritional implications include gestational diabetes, pregnancy-induced hypertension,

inadequate prepregnancy weight, inadequate weight

gain during pregnancy, and iron-deficiency anemia

(24).

Anemia during pregnancy is associated with

premature delivery, low birth weight, and fetal death

(80,148). The Centers for Disease Control’s (CDC)

1987 Pregnancy Nutrition Surveillance System gathered hematologic data (which define anemia) on

63,709 low-income pregnant women from ages 15 to

39 (230). CDC found that the prevalence of anemia

during the third trimester of pregnancy was higher in

pregnant adolescents (ages 15 to 19) than in other

age groups, and for all age groups, black women had

a higher prevalence than white women (see figure

7-2).

2oAvailablc evidence from epidemiologic ad animal research suggests that a high fat intake is associated with increased risk of cancers of the CO1OU

prostate, and breast ( 152). Vitamin C may protect against stomach cancer (1 52). NAS found the evidence for protective effects of dietary fiber inconsistent

(152).

zlFor f~er discussio~ see ch. 10, ‘‘Pregnancy and Parenting: Prevention and Services,’ in this volme.
//-212 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 7-2—Prevalence of Anemia Among U.S. Women

During the Third Trimester of Pregnancy,

by Race and Age, 1987a

Percentage

50

T---– 1

40

30 I

2 0

1 0

o ‘-

15-19 20-24 25-29 30-34 35-39

Age (years)

_ White ~ Black

aData are lg87 data from the Centers for Disease control’s pregnancy

Nutrition Surveillance System.

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, Centers for Disease Control, “Anemia During Pregnancy in bw-lnmme V&men, United States, 1987,” Morbidity

and Mortality Weekly Repori 39(5):73-76, Feb. 9, 1990.

According to the CDC study, there is some

evidence that participation in public nutrition programs (e.g., the Special Supplemental Food Program

for Women, Infants, and Children (WIC)22) may

improve iron nutrition status and reduce the prevalence of anemia in all age groups of low-income

pregnant women (see figure 7-3). The WIC program

focuses on low-income pregnant and lactating women

and on children under age 5. Only 3 percent of those

participating in WIC are pregnant, breastfeeding, or

postpartum females under age 18.23

Adolescent Athletes

Participating in activities that require a certain

weight or body type may in some cases lead

adolescents to engage in unhealthful behaviors, For

example, activities that require thinness for either

aesthetic or performance purposes (e.g., wrestling,

gymnastics, dance) may cause adolescents to become undernourished, bulimic, anorexic, or amenorrheic (females), and affect testosterone levels

(males) (136). Activities that require greater body

mass may lead adolescents to use steroids or become

susceptible to fraudulent health food claims (29,66).

Figure 7-3-Prevalence of Anemia Among U.S. Women

During the Third Trimester of Pregnancy, by Race and

Trimester of Enrollment in Public Health and Nutrition

Programs, 1987a

40 i m.5

First Second Third

Trimester of enrollment

~’ White ~ Black

aData are 1987 data from the Centers for Disease Control’s pregnancy

Nutrition Surveillance System.

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, Centers for Disease Control, “Anemia During Pregnancy in Low-Income VWmen, United States, 1987,” Morbidly

arrd Morta/ify Week/y Report 39(5):73-76, Feb. 9, 1990,

It is not clear to what extent coaches or physical

education teachers currently work with adolescents

so that they avoid unhealthful practices and obtain

adequate levels of essential energy and nutrients.

Female Athletes-Female athletes may become

amenorrheic, which can be detrimental to bone

health; consequently these females can experience a

higher prevalence of scoliosis (249) and stress

fractures (17,121). They are also inclined toward

vegetarianism (201), resulting in weight loss, and

excessively low-fat fiber-rich diets which increase

fecal loss of estrogens and reduce circulating estrogens (84,94). The quality of their diet itself’ could

help induce amenorrhea by altering reproductive

hormone levels. Female athletes, more than males,

are also likely to be iron deficient (158,178).

Male Athletes--Surveys of adolescents attending high school show an increasing consumption of

illegal anabolic steroids24 to increase muscle mass

and strength for athletic competition (29). The use of

anabolic steroids in adult strength-trained athletes

affects blood lipid profiles; there is a 55-percent

decline in HDL-cholesterol and a 25-percent in22s= the ~ection &]ow on F~er~ ~rogms pefl~fig IO adolescent nutrition and fi~ess for a discussion of other Federal nutrition programs. AISO

see ch. 10, ‘‘Pregnancy and Parenting: Prevention and Semices, ‘‘ in this volume for discussion of Federal programs available to pregnant adolescents.

~See ch. 19, “The Role of Federal Agencies in Adolescent Healti” in Vol. III for more discussion of Federal agencies’ emphasis on adolescents.

~~e ~ti-Drug Abuse Act of 1988 (Public Law 100-690) made unapproved use of anabohc steroids illegal.
Chapter 7—Nutrition and Fitness Problems: Prevention and Services ● II-213

Photo credit: Katherine Criss

Participating in activities that require a certain weight or

body type may in some cases lead adolescents to engage

in unhealthful behaviors such as having diets that are

too low in essential nutrients.

crease in total cholesterol, indicating a possible

higher risk for cardiovascular disease (95,250).

These drugs also impair the metabolism of glucose

(41,83) and favor net accretion of body protein,

especially as muscle mass (66). Immediate effects

such as acne, baldness, reduced libido, breast

growth, impaired sexual function (257), and affective and psychotic symptoms (170) may present

more persuasive arguments against their use by

adolescent males as opposed to the more long-term

effects such as cardiovascular disease.

Adolescents have much higher rates of sports

injuries than younger children (75, 179).25 Older

adolescents (ages 16 to 19) experience more sports

injuries requiring treatment than do other age groups

(50). Overall, according to one survey of adolescents, males experience the most (almost 75 percent)

sports-related injuries (129). Females, however,

experience more injuries related to specifc activities

and sports than males participating in the same

activity or sport at a similar rate (9,169). According

to Bar-Or, adolescent athletes and their coaches

should be warned of the risk for low bone mineral

stores (irrespective of calcium intake), fractures, and

hypothermia or hyperthermia while exercising in

cold or hot temperatures (16). The American Academy of Pediatrics Committee on Sports Medicine

and Committee on School Health recommends that

all coaches should be certified (4). Only 16 percent

of high schools nationwide have a certified athletic

trainer or comparable professional on staff (42).

Adolescents With Eating Disorders

Two serious eating disorders that afflict U.S.

adolescents are anorexia nervosa and bulimia. Anorexia nervosa is a mental disorder characterized by

an intense fear of becoming obese and a refusal to

eat, leading to a significant weight loss (at least 25

percent of body weight) (6). Bulimia is a mental

disorder characterized by a compulsion to binge and

then purge the body by self-induced vomiting or use

of laxatives (6). Adolescents with bulimia, most of

whom are females, may experience weight fluctuations of more than 10 pounds.

Anorexia nervosa and bulimia present serious

threats to adolescents’ physical health, including

dehydration, hormonal imbalance, and depletion of

important minerals (1 1,25,77,92,99,106,112), Without treatment, including psychological counseling,

medical treatment, and dietetic advice, some adolescents with anorexia may die. Bulimia can have

serious consequences for adolescents’ later physical

development.

One recent survey suggests that the prevalence of

anorexia among U.S. females ages 15 to 19 is 0.5

percent (126). The prevalence of bulimia in the U.S.

population is estimated to be 2 percent (143).

Adolescents with anorexia nervosa or bulimia need

psychological counseling and medical treatment.

Adults who teach, coach, or train adolescents should

recognize signs of the eating disorders in their

charges and refer those at risk for treatment. Student

health services in schools should similarly be able to

assist students with these problems.

‘See ch. 5, ‘‘Accidental Injuries: Prevention and Services, ” in this volume.
II-214 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 7-7—Examples of Chronic Diseases and Conditions With Nutrition and Fitness

Implications Among U.S. Children Ages O to 20, 1980

Prevalence per

1,000 children ages

Disorder O to 20 years Nutrition and fitness implications

Arthritis. . . . . . . . . . . . . . . . . . . . . . . .

Asthma . . . . . . . . . . . . . . . . . . . . . . . .

Central nervous system injury . . .

Cerebral palsy . . . . . . . . . . . . . . . . .

Chronic renal failure . . . . . . . . . . . .

Cleft lip or palate . . . . . . . . . . . . . . .

Congenital heart disease . . . . . . . .

Cystic fibrosis . . . . . . . . . . . . . . . . . .

Diabetes mellitus . . . . . . . . . . . . . . .

Down’s syndrome . . . . . . . . . . . . . .

Leukemia . . . . . . . . . . . . . . . . . . . . . .

Mental retardation . . . . . . . . . . . . . .

Muscular dystrophy . . . . . . . . . . . . .

Spina bifida . . . . . . . . . . . . . . . . . . . .

Phenylketonuria . . . . . . . . . . . . . . . .

Blindness . . . . . . . . . . . . . . . . . . . . . .

2.20

38.00

2.15

2.50

0.08

1.50

7.00

0.20

1.80

1.10

0.11

25.00

0.06

0.40

0.10

0.60

Feeding difficulties, obesity, diet-drug interactions, mobility inhibited, possibly altered

growth

Mobility may be inhibited

Feeding and mobility difficulties

Feeding and mobility difficulties

Therapeutic diets required, wasting and delayed

growth common

Feeding difficulties if not repaired

Therapeutic diets may be required if severe,

mobility affected, diet-drug interactions,

growth retardation

Therapeutic diets needed, diet-drug interactions,

growth retardation

Therapeutic diets needed, diet-drug interactions,

possible growth retardation, exercise must

be planned

Feeding difficulties if severe, obesity, growth

retardation

Anorexia at some stages, diet-drug interactions,

growth retardation

Feeding difficulties if severe, obesity, emaciation, growth retardation

Special forms and routes of feeding required,

diet-drug interactions, feeding and mobility

difficulties, growth retardation

Therapeutic diets required, obesity, mobility

problems

Therapeutic diets required, growth retardation

Feeding difficulties, obesity, mobility problems

SOUR”CE: Adapted from S.L. Gortmaker and W. Sappenfield, “ChronicChildhood Disorders: Prevalence and Impact,”

Pediatric Clinics of North Amedca 31 :3-18, 1984. Reprinted by permission.

Adolescents With Chronic Conditions and Physical

Disabilities

Serious chronic conditions and disabilities often

have nutritional or fitness consequences for adolescents (see table 7-7).26 Chronic conditions and

disabilities that are indirectly associated with hypoactivity (abnormally low levels of activity) include massive obesity, asthma, diabetes, blindness,

Down’s syndrome, and mental retardation of other

types (14,194,199,209).

Adolescents with disabilities that preclude walking tend to be fatter and less active than normal

adolescents. Low physical activity may explain the

lower aerobic ability and greater fatness found in

blind adolescents (194). Although near normal

aerobic fitness can be achieved, most blind adolescents lack sighted guides and adequate facilities to

allow independent exercise (194). There are limited

opportunities for adolescents with physical and

developmental disabilities to engage in fitnessrelated activities, although there is considerable

evidence that such activity would benefit such

adolescents (160).

Nutrition counseling and interventions can help

minimize or eliminate preventable causes of poor

growth. Unfortunately, schools and school food

services often lack technical skills or money to

implement special health, food, and educational

services often needed by disabled adolescents (93).

The role of nutrition could be stressed in the care of

disabled and chronically ill adolescents by, for

example, including a nutritionist on the health care

team or emphasizing nutrition in physical training

programs.

26s~ ch. 6, ‘Chronic Physical Illnesses: Prevention and Services, ‘‘ in this volume for a discussion of the difficulties faced by many adolescents with

serious chronic conditions and disabilities.
Chapter 7—Nutrition and Fitness Problems: Prevention and Services .11-215

4

Photo credit: Jill Slater

Typically, physical fitness opportunities for children and

adolescents with physical disabilities are limited. These

early adolescents at the Kentucky School for the

Deaf belong to a soccer team.

Phenylketonuria—Phenylketonuria is a genetic

disorder of amino acid metabolism that is characterized by the inability to metabolize the amino acid

phenylalanine (156,219). Although no abnormalities are apparent at birth, blood levels of phenylalanine rise rapidly after protein feedings are begun, and

if diagnosis and dietary treatment is not begun

within 30 days of birth, severe mental retardation

will result (181).

Phenylalanine-restricted diets are known to enhance normal intellectual development in children

with phenylketonuria. Studies suggest that continuation of such therapeutic diets throughout adolescence could maintain a child’s intellectual achievement (38,124).

Juvenile-Onset Diabetes—As noted earlier, there

are two major types of diabetes. Type I (insulindependent) diabetes typically has its onset in childhood or adolescence. Age 14 is the peak age for

incidence of disease (69).

Insulin is required for treatment of all type I

patients (69). In addition, adolescents with type I

diabetes must follow a specified dietary regimen.

Therapeutic diets, in conjunction with exercise and

drug therapy, control some of the complications of

type I diabetes (such as insulin shock, diabetic

ketoacidosis, coma, and hypoglycemic reactions)

(74). In adolescents, as well as adults, dietary

cooperation is sometimes enhanced if the patient is

occasionally allowed a special treat (e.g., a dessert

ordinarily forbidden) with the understanding that

resumption of the diet will begin the next day (69).

Studies suggest that overweight diabetic adolescents

could improve their carbohydrate metabolism by

exercising regularly (144,176).

Adolescents With Mental Retardation or

Developmental Disabilities

Mental retardation may be associated with secondary malnutrition, due to difficulties in feeding, or

to inadequate care (12). Thus, the nutritional status

of mentally retarded adolescents, living both in and

outside of institutions, is of concern. According to

teachers and parents, participation of mentally

retarded adolescents in physical fitness programs

has good psychological effects (199).

Emotionally Ill Adolescents

Some emotional disorders, or their treatments,

have nutritional implications (e.g., some antidepressant drugs can affect the appetite). Nutritional

guidance could be integrated into settings for mental

health services provision. In adults, participation in

high-intensity aerobic exercise has been shown to

improve self-concept (130) and reduce depression

(213). The possibility that aerobic exercise could be

a beneficial addition to programs for troubled

adolescents should be explored.

Conclusions

Certain populations of adolescents have special

nutritional and fitness needs which may require

attention by the adolescents themselves, their families, and the professionals around them. Heightened

awareness of the importance of nutrition and fitness

to the overall health of these adolescents (e.g.,

through nutrition education or physical education

for the adolescents, or training programs for family

and professionals) and providing opportunities to

achieve nutrition and fitness goals (e.g., food programs or access to physical activity facilities) could

help alleviate or prevent some problems experienced

by these adolescents.

Prevention and Treatment of Nutrition

and Fitness Problems

Adolescents’ Nutritional Choices

The National Adolescent Student Health Survey

in 1987 found that 37 percent of 8th and 10th graders

ate breakfast every day (the survey period was the

“previous week’ ‘), 51 percent ate lunch every day,
11-216 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

and 68 percent ate dinner every day (7). In contrast,

16 percent never ate breakfast during the past week,

6 percent never ate lunch, and 1 percent never ate

dinner. Females ate fewer meals in a week than

males, and 10th grade females ate fewer meals than

8th grade females. The survey found that most (89

percent) of the surveyed 8th and 10th grade students

who reported eating breakfast ate their breakfast at

home, though some (7 percent) ate at school (7).

Those who ate lunch, however, typically obtained it

at school (72 percent v. 19 percent bringing lunch

from home). Fewer 10th graders than 8th graders

brought lunch from home (13 percent v. 19 percent)

though more ate lunch someplace other than at

school (13 percent v. 4 percent).

The National Adolescent Student Health Survey

also showed that most 8th and 10th grade students

snack (only 12 percent ate no snacks the day before),

and further, that most (61 percent) of the snacks

consumed were ‘junk food’ (chips, soda, candy, ice

cream, or cake) rather than nutritious snacks (fruits,

vegetables, nuts, juice, milk, yogurt, or cheese) (7).

Male and female snacking behaviors were about the

same.

As adolescents grow older, competing demands

on their interests and energy and potent social forces

(including peer pressures, busy schedules, and sports

concerns) rise in importance (1 19,125,136,198,204,

253), while the importance that adolescents attach to

nutrition may decline (125). In one study, 45 percent

of junior high school students felt that nutrition is

‘‘very important, ’ as compared with 36 percent of

senior high school students (125). Interestingly,

nutrition decreased in importance at the same time

that perceived control over nutritional choices increased. Fifty-six percent of junior high school

students reported that they themselves have the most

influence over what they eat, as compared with 74

percent of senior high school students (125).

Adolescents sometimes emphasize factors other

than health or nutrition in making food choices (44).

For example, weight was of great concern among

adolescents surveyed in 1989, especially females;

nearly half of all 11th and 12th grade students

surveyed had been on a diet at least once, and the

vast majority who had dieted did so for cosmetic

rather than health reasons (125). Societal stresses on

the cosmetic aspects of fitness are extreme and lead

some adolescents to attempt to control weight and

appear fit by restrictive (and potentially harmful)

dieting (34) rather than by a combination of diet and

physical activity. Increasingly, female adolescents

are concerned about their weight at younger ages

(113).

Influencing Adolescents’ Nutritional Choices

Health Education

In 1985, only 12 States had mandated nutrition as

a core content area in school health education (241).

But, of the 80 percent of 8th and 10th graders

surveyed in 1987 who had at least one health

education class, 74 percent had received nutritional

instruction in that class (7); this finding suggests that

there is substantial dissemination of at least some

nutrition information. In addition, community-based

programs can reach targeted adolescent populations

(e.g., pregnant adolescents not in school). USDA’s

Food and Nutrition Service has prepared nutrition

advice and information, which is available for

groups with special nutritional needs (222). Food

and nutrition-related services in rural areas could be

expanded and links with already existing services

could be explored (e.g., the Cooperative Extension

Service of USDA has offices in almost every county

which is supported by a State office) (222). State

health departments provide nutrition education materials, nutrition counseling, and nutrition consultation to targeted populations and to programs developed for them.

But increasing knowledge about proper nutrition

alone does not necessarily improve eating habits.

Although 67 percent of 11th and 12th grade students

reported that saturated fat and cholesterol should not

be eaten in excess, this knowledge had only a slight

influence on consumption of foods high in these

constituents (125). The manner in which the information is presented may influence its impact. For

example, adolescents regard nutrition education

curricula that neglect food preferences and other

motivational factors as boring and irrelevant (33).

Other school-based health promotion activities have

been effective, however. For example, one schoolbased approach resulted in the short-term reduction

of cardiovascular disease risk factors in 10th graders

by modifying diet and exercise (1 10).

Marketing science experts recognize that adolescents have special wants, and they tailor appeals to

the youth market to meet them (81). Appropriate

motivation and modifications in the social environment help to persuade adolescents and adults to give
Chapter 7—Nutrition and Fitness Problems: Prevention and Services . II-217

more priority to healthful food choices when they

decide what to eat (253).

Food Labels

Data from the National Adolescent Student

Health Survey in 1987 suggest that adolescents in

the 8th and 10th grades are able to apply basic skills

in solving nutrition-related consumer problems but

lack certain specialized consumer information which

would permit them to make wise food choices (7).

Further, only 27 percent had previously received any

education or instruction during school in interpreting food labels. The current national debate on the

content of food labels (108,149) highlights the

importance of information in making informed

nutritional choices. In addition to recommending

Federal regulations regarding nutrition labeling, a

recent Institute of Medicine report calls for regulations that would require fast-food restaurants to

provide nutrition information to consumers (149).

Menus in Schools and Institutions

Many schools incorporate the principles of USDA

and DHHS Dietary Guidelines for Americans (227)

in their meal planning (241). Nevertheless, it has

been reported that school meals are high in fat

(37,70,164). Modifying school menus appears to

command some public support (216). One study

successfully altered the diets of students by modifying the menu and the way foods were prepared (the

polyunsaturated-to-saturated fat ratio of the diet of

students who were served fat-modified diets increased significantly) (61).

Low-income adolescents in participating schools

can receive breakfast and lunch at school free or at

a reduced price (see section below on Federal

programs). USDA prepares recipes for schools to

use in planning their meals. Evaluations of these

meal programs have shown that they have a positive

overall effect on the nutritional intake of the

participants (216), although as noted above, they

may be high in fat.

Conclusions

Nutrition education, either as a component of

school health education curricula or more targeted

outreach programs, is available from a number of

sources and most adolescents appear to receive some

nutrition education, at least while they are in school.

There is little information about the effect of

nutrition education on adolescent dietary behaviors,

though some studies show that there are effective

interventions. Providing nutritional foods in meals

provided by schools may provide as much benefit to

adolescents as nutrition education does.

Influencing Adolescents’ Physical

Activity Levels

Physical Education in Schools

As noted above, students attend physical education classes in decreasing numbers throughout

adolescence. Further, these classes do not provide

much opportunity for physical activity (20 percent

of class time) (13). The emphasis in physical

education classes is on competitive sports rather

than on activities and skills that can be more easily

carried over to later years (e.g.,swimming, tennis,

and cycling) (13,196). Although there is little

adolescent specific information on the effects of not

participating in so-called ‘‘lifetime” physical activity during adolescence, there is a general consensus

that adolescents could benefit from additional physical activity (e.g., 3,241).

Community Facilities for Physical Activities

Several observers have suggested that every

adolescent should have access to public facilities

and community programs that encourage safe,

beneficial, enjoyable physical activity (177,184).

Many adults believe that greater availability of

exercise facilities would help them become more

involved in regular exercise (241). To OTA’s

knowledge, adolescents have not been asked about

their recreational needs or preferences. A 1986

survey of municipal and county park and recreation

departments found that the average number of

citizens per managed acre was well within the

standards set by the National Recreation and Park

Association (138). But the numbers of trails (for

hiking, jogging, bicycling, or cross-country skiing),

pools, tennis courts, and basketball courts per citizen

are below those suggested by the National Recreation and Park Association (138), and the DHHS

publication Healthy People 2000 recommends that

communities establish additional opportunities for

engaging in physical activity (box 7-D) (241).

Conclusions

Opportunities for adolescents to participate safely

in physical activity are hampered by the current

construction of school physical education classes,

the lack of certified physical education teachers and
II-218 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Photo credits: Education Week (top photo);

Benjamin Smith (bottom photo)

Some observers concerned about adolescent health have

noted that opportunities for physical activity during

adolescence tend to emphasize competitive sports (top)

rather than activities and skills that can be more easily

carried over to later years (bottom).

coaches, and the lack of community facilities for

physical activity.

Interventions To Prevent or Reduce

Adolescent Obesity

The effectiveness of specific treatment interventions to help obese adolescents appears to be

dependent on a multiple approach that includes diet,

exercise, behavioral techniques, and the support of

families, communities, or peers (93a,97a,247). Further, some interventions to prevent obesity take an

environmentally based approach meant to narrow

the range of adolescents’ food choices (61,97a).

Powerful predictors of success in fitness and

obesity control include afterschool activities of

adolescents at home and in the community (165).

When parents and children participate in obesity

control programs together and incorporate all program elements (e.g., behavior modification practices), they can be fairly effective (28). An example

of a family-based program is Shapedown, which

involves behavior modification, physical activity,

modest reduction in food intake, and attention to the

families’ and adolescents’ views of themselves

(141a).

Clinical treatment of obesity has been found to be

effective when it includes the traditional emphasis

on increased physical activity with modest decreases

in energy inputs combined with behavioral techniques (62), including self-monitoring diet and

exercise, control of stimuli that precede eating, and

reward of desirable behaviors.

One review of various treatment schemes for

pediatric obesity suggests that the most effective

school-based programs include exercise, nutrition,

and behavior modification (248). Five elements are

important for school-based programs: physical education programs, classroom education, the school

lunchroom, the school health office, and liaison with

home and community programs. Obese adolescents

need help in setting realistic targets for fatness and

weight loss (57,59,97a). Support programs using

younger and older peers, with frequent reinforcement of progress from teachers, physical education

instructors, school nurses, and others are also

important (207).
Chapter 7—Nutrition and Fitness Problems: Prevention and Services . II-219

Major Federal Programs Related to

Nutrition and Fitness

U.S. Department of Agriculture

USDA is the Federal agency with major responsibility for Federal nutritional programs, including the

collection of data on topics listed in box 7-A and the

provision of food services for low-income people.

USDA’s Human Nutrition Information Service

conducts and interprets applied research in food and

nutrition. Its responsibilities include monitoring

food and nutrient content of American diets, assessing dietary status and trends in food consumption,

understanding food choice influences, maintaining

the national nutrient data bank on the nutrient

content of foods, and developing information and

techniques for making informed food choices.

USDA’s Food and Nutrition Service administers

the Federal Food Stamp Program and Child Nutrition Programs (including National School Lunch

and Breakfast Programs, the Summer Food Service

Program, the Special Supplemental Food Program

for Women, Infants, and Children27 and the Child

Care Food Program).

The Food Stamp Program is a program that

provides low-income individuals and families with

children with noncash transfers which can be used

only for food. Eligibility is based on family income.

The amount of the benefit for each family is

calculated based on a number of family-dependent

factors (e.g., work and child care expenses) and on

the cost of the Thrifty Food Plan (based on an

inexpensive, but nutritionally sound diet). For those

participating, the program has been associated with

significant improvements in dietary intake (217).

But, according to USDA’s 1977-78 Nationwide

Food Consumption Survey,28 only 12 percent of

low-income households spending at the full food

stamp allotment obtained 100 percent of their

recommended dietary allowances, and only a third

obtained at least 80 percent (217).

Adolescents ages 15 to 17 make up 34 percent of

the participants in the Food Stamp Program, but all

eligible adolescents may not benefit. In 1979, less

than 60 percent of all poor households participated

in the Food Stamp Program (216).

Other food programs directly affecting adolescents are the School Breakfast and School Lunch

programs, which provide meals for low-income

school children free or at a reduced price depending

on family income. The programs have been shown

to increase the amount of food consumed by

participants, as a supplement for family meals rather

than as a substitute (216). A 1981 USDA study

found that students from families qualifying for free

or reduced-price meals were dependent on the

National School Lunch Program for between 34 and

49 percent of their daily nutrient intake (217).

Forty-three percent of individuals in the National

School Lunch Program and 24 percent in the School

Breakfast Program are adolescents ages 13 to 18,

(see table 7-8). In 1983,92 percent of all elementary

and secondary schools participated in the National

School Lunch Program (214), but the School Breakfast Program was available in only about a third of

all schools (215). Schools that participate in the

School Breakfast Program are generally located in

low-income areas (215).

U.S. Department of Health and

Human Services

Within DHHS, nutrition research and monitoring

are principally conducted by two Public Health

Service agencies: the Centers for Disease Control

and the National Institutes of Health (see below).

These make up the Department’s major effort related

to the nutrition of adolescents. Other nutritionrelated services are provided to adolescents by the

Bureau of Maternal and Child Health in the Health

Resources and Services Administration of DHHS,29

by the Indian Health Service, and by the Office of

Human Development Services. The Office of the

Assistant Secretary for Health compiles DHHS’

Health Objectives for the Year 2000 (found in the

recent DHHS publication, Healthy People 2000),

which include nutrition- and physical activityrelated policy objectives (box 7-D).

27~e Swlal Supplement Food ~ou~ for Women, Infants, and Children (WIC) was mentioned in an eulier smtion about Pre~t ~ole~n~.

28Da~ from the 1987.88 Nationwide Food Comumption Survey were not available as of mid-1991.

2~e Bweau of ~tem~ ~d ~]d H~lth provides nu~tioml support princip~ly in the form of bl~k grants to States for the prOviSiOn Of nU~tiOnld

semices. Also, funds for training public health nutritionists and research and program development projects are disseminated through the sp=ial

programs of regional and mtioml significance (SPRANS) program.
//-220 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 7-8-Participation in the National School Breakfast and National School Lunch Programs,

1983-84 School Year

Number of students participating Number of students

in the program at participating on an Average daily

least once per week Participation average day (ADP) participation

(thousands) rate (thousands) (ADP) rate

School Breakfast Programa

All students . . . . . . . . . . . . . . . . . . . . . . . . . . .

Meal price status

Free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Reduced . . . . . . . . . . . . . . . . . . . . . . . . . .

Full . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Grade level

1-3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4-6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7-9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10-12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

School Lunch Program

All students . . . . . . . . . . . . . . . . . . . . . . . . . . .

Meal price status

Free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Reduced . . . . . . . . . . . . . . . . . . . . . . . . . .

Full . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Grade Ievel

1-3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4-6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7-9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10-12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3,609

2,564

222

823

1,316

1,337

614

342

30,078

9,763

1,816

18,497

8,327

8,535

7,373

5,841

24.2?!

53.9

20,6

9.0

31.3

31.5

17.4

11.6

77.570

96.2

91.4

69.4

87.9

85.0

76.0

61.0

2,733

2,107

157

469

1,049

1,027

425

232

25,550

9,319

1,658

14*574

6,916

7,644

6,230

4,761

18.3%

44.3

14.6

5.1

25.0

24.2

12.0

7.8

65.9%0

91.8

83.4

54.7

73.0

76.1

64.2

49.7

aAStudent iSapartiCipant inthe%hwlBre~~tprOgram (School Lunch Program)ifhe orsheselects oneormore breakfasts (h.mches)dur ingaweek.The

partk@ationrafeisthenumberofparticipantsdivided bythetotalnumberofstudentsin schoolsthatoffertheprogram.The numberofstudentsparticipating

on an average day (ADP) is calculated as one-fifth the reported number of meals served in a week. The ADP rate is the ADP divided by the total number of

students in schools that offer the program.

SOURCE: U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis and Evaluation, “Characteristics of the National School Lunoh and

School Breakfast Program Participants,” Washington, DC, January 1988.

Centers for Disease Control

CDC works to promote sound nutritional habits

through comprehensive school health programs.

CDC’s efforts include: 1) building consensus regarding priority nutrition intervention issues for the

purpose of developing national guidelines; 2) collaborating with USDA to ensure that these guidelines incorporate the perspective of the Nutrition

Education and Training Program and National

School Lunch and Breakfast Programs; and 3)

reviewing State policies relevant to nutrition intervention in schools and to school breakfast and lunch

programs.

In addition, as noted earlier, CDC is developing the

Youth Risk Behavior Surveillance System (YRBSS)

to monitor trends in the prevalence of priority risk

behaviors among youth at the national and State

levels (see box 7-A). CDC also supported the 1987

National Adolescent Student Health Survey (7). The

National Center for Health Statistics in CDC conducts the National Health and Nutrition Examination Survey (NHANES) and the National Health

Interview Survey (NHIS) (see box 7-A), which

collect nutrition and health data on adolescents.

National Institutes of Health

National Heart, Lung, and Blood Institute

(NHLBI)--In April 1991, NHLBI issued the Panel

Draft Report of the National Cholesterol Education

Program, which called for all Americans over 2

years of age to adopt a low saturated fat, low

cholesterol diet. Also, NHLBI is conducting a

multicenter monitoring project to compare risk

factors, such as hyperlipidemia and blood pressure,

in black and white adolescent females.

National Cancer Institute (NCI)--NCI is supporting, through a collaboration between NCI and

the American Cancer Society, a school-based nutrition education project to improve adolescent health.

A curriculum for intermediate and secondary school

students is being pilot tested in four regions. A

companion manual for food service providers is also

being tested as an aid in making school lunch
Chapter 7—Nutrition and Fitness Problems: Prevention and Services . II-221

programs consistent with USDA and DHHS’ Dietary Guidelines for Americans (227).

Conclusions and Policy Implications

Conclusions about U.S. adolescents’ nutritional

and fitness status are difficult to draw for several

reasons. Current national data on U.S. adolescents’

nutrition and fitness are not available. Research on

nutrition and on fitness is hampered by inconsistent

outcome measures and other methodological problems (225).

Extrapolating from available information, OTA

concludes that the most prevalent nutritional problems among today’s adolescents are overweight or

obesity, iron deficiency anemia, and eating disorders. Obesity is often associated with low levels of

physical activity and poor self esteem. Obese

adolescents may be at increased risk of heart disease,

hypertension, diabetes (particularly if obesity is

continued during adulthood) and certain cancers.

For female adolescents, especially female athletes

and females who are pregnant, iron deficiency

anemia is a particular problem, because it decreases

physical ability, resistance to infection, and intellectual performance. During pregnancy, anemia can

also affect the health status of the fetus (low

birthweight, premature delivery, and fetal death).

Calcium, another mineral often deficient in adolescent diets, is important for achieving peak bone

growth. Female adolescents with anorexia nervosa

or bulimia are at great risk of experiencing health

problems and even death.

Some evidence suggests that the diets of American adolescents are high in fat and sodium. High-fat

diets can contribute to obesity in the short term, and,

if such diets persist, to the occurrence of some

cancers (e.g., colon and breast), coronary heart

disease, and non-insulin-dependent diabetes later in

life (152). Some adolescents with physical disabilities or chronic diseases (e.g., diabetes) require

special attention to meet their nutritional and physical activity needs. Some diseases and medications

can affect the absorption of nutrients, and sometimes, therapeutic diets can help control diseases

(e.g., diabetes). The availability of special health,

food, and education services in schools and school

food services for these adolescents is often limited.

U.S. adolescents’ ability to make good nutritional

choices and decisions about physical activity for

themselves may be influenced by the information

Photo credit: Benjamin Smith, Washington, DC

Very often, adolescents have little control over the food

available to them. Congress could support efforts to

provide better nutritional choices to adolescents.

provided to adolescents (or lack of it) about the

foods they eat and the effects of physical activity.

Nutritional information about school menus and fast

food meals may not be routinely available to

adolescents (although some fast food restaurants

make or plan to make nutritional information more

accessible at point of purchase). Many health

education classes include nutrition education as a

component, but it is not clear that these classes alone

significantly influence the eating habits of adolescents. Some evidence suggests that education curricula that take adolescents’ preferences into account

may be better received than curricula that do not.

Most adolescents get breakfast and lunch from home

or school, so food choices (at least for these two

meals) may be dependent on whoever buys the

groceries or plans the menus. There have been

several calls to improve the nutritional content of

school (37) and ‘‘fast food’ (27a) meals.

Access to fitness-promoting activities is apparently a problem for adolescents. Enrollment in

physical education classes declines somewhat during the adolescent years; in any event, school-based

physical education classes appear to provide little

opportunity for actual physical activity.

For adolescents in general, there is little information about the specific benefits of physical activity;

for example, there is no research to suggest that

physical activity during adolescence leads to continued activity as an adult. It is clear, however, that

increased physical activity could help overweight
//-222 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

adolescents reduce their weight and thereby reduce

the immediate psychological consequences of obesity and the potential risk of future chronic diseases.

Specific policy options regarding adolescents’

nutrition, physical activity, and physical fitness are

listed in Volume I.

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Chapter 8

DENTAL AND ORAL

HEALTH

PREVENTION AN

PROBLEMS:

D SERVICES

Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

Background on Adolescents’ Dental and Oral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

Biological Factors That Affect Adolescents’ Dental and Oral Health . . . . . . . . . . . . . . . . . . . . . . 231

Trends in the Incidence and Prevalence of Adolescents’ Dental and Oral Health Problems . . . 232

Dental Caries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

Periodontal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

Malocclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

Factors Associated With Adolescents’ Dental and Oral Health Problems . . . . . . . . . . . . . . . . . . . 236

Adolescents in Racial and Ethnic Minority Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

Adolescents With Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

Adolescents in Juvenile Justice Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

Adolescents With Certain Behaviors or Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

Prevention of Adolescents’ Dental and Oral Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

Preventive Interventions for Major Dental Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

Prevention of Dental Caries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

Prevention of Periodontal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

Prevention of Malocclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

Dental Health Education and Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

Dental Health Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

Adolescents’ Knowledge of and Attitudes Toward Dental Health . . . . . . . . . . . . . . . . . . . . . . . 244

Interventions and Services for the Treatment of Adolescents’ Dental and Oral Health Problems . 245

Interventions for the Treatment of Adolescents’ Dental Health Problems . . . . . . . . . . . . . . . . . . . 245

The Dental Service Delivery System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

Federal Programs Pertaining to Adolescents’ Dental and Oral Health . . . . . . . . . . . . . . . . . . . . . . . . 245

Public Health Service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

Health Care Financing Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

Chapter preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Boxes

Box Page

8-A. Overview of Three Dental Problems: Dental Caries, Periodontal Disease, and

Malocclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

8-B. Federal Sources of Data on Adolescents’ Dental and Oral Health . . . . . . . . . . . . . . . . . . . . . . . 241

Figures

Figure Page

8-1. Caries-Free Adolescents and Mean DMFS Scores Among U.S. School Children

Ages 10 to 17, 1979-80 and 1986-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

8-2. Percentage Decrease From 1980 to 1987 in Caries Prevalence Among U.S. School Children

Ages 5 to 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

8-3. Distribution of Components of Age-Specific Mean DMFT Scores for White and Nonwhite

U.S. School Children Ages 10 to17,1979-80 and 1986-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

8-4. Periodontal Health Status of U.S. Schoolchildren Ages 14 to17, by Gender and Race,

1986-87 . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 238

8-5. Gingival Treatment Needs of White and Nonwhite U.S. Adolescents Ages 10 to17,

. . . . . . . .

1979-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

8-6. Percentage of U.S. Adolescents Ages 12 to 17 With a Dental Visit in the Past Year,

by Family Income, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

8-7. Dental and Oral Health Expenditures by the U.S. Department of Health and Human Services,

Fiscal Year 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

Tables

Table Page

8-1. Selected Dental Treatment Needs of White and Nonwhite U.S. Adolescents

Ages 10 and 17,1979-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238

8-2. Malocclusion Among U.S. Adolescents Ages 12 to 17, by Race and Gender, 1970 . . . . . . . . 239

8-3. Distribution of Malocclusion Among U.S. Adolescents Ages 12 to17,

by Race and Gender, 1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

8-4. Oral Hygiene Among U.S. Adolescents Ages 12 to 17 as Measured by the Simplified

Oral Hygiene Index (OHI-S) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

8-5. Behaviors and Conditions With Potential Effects on Adolescents’ Dental and

Oral Health . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

8-6. Characteristics of U.S. Adolescents Ages 12 to 17 Who Do and Do Not Have

Private Dental Insurance, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
Chapter 8

DENTAL AND ORAL HEALTH PROBLEMS:

PREVENTION AND SERVICES

Introduction

For the last three decades, dentistry has emphasized population-wide public oral health measures to

prevent dental caries (e.g., fluoridation of water

supplies) and the treatment of dental cariesl in

younger children, assuming that early interventions

would achieve the best short- and long-term effects

(4). This emphasis has clearly proved successful. In

the last 20 years, the prevalence of dental caries in

all age groups, including adolescents ages 10

through 18, has declined dramatically (97).

As a consequence of the success of preventive

measures in reducing dental caries and of dentistry’s

focus on the treatment of dental caries in younger

children, however, many aspects of the dental and

oral health of adolescents have been neglected (l).

Traditionally, many dental professionals have tended

to regard adolescence as a quiescent period with few

dental needs, a continuation of childhood in which

earlier dental intervention carried the patient to

adulthood in good oral health (20). In fact, however,

adolescence is a unique time, in terms of dental

considerations, during which:

●

●

●

●

dental caries rates increase from childhood

(18);

the first signs of periodontal disease2 occur

(20);

up to a third of facial growth occurs (during a

relatively short growth spurt) (34); and

most orthodontic therapy occurs.

Furthermore, the transition from childhood to

consenting adulthood and responsibility for care,

along with issues such as differences in dental

disease patterns and care-seeking behaviors of

specific groups of adolescents, and unmet dental

treatment needs, make adolescence a pivotal period

with respect to dental and oral health.

This chapter covers several topics pertaining to

the oral health of U.S. adolescents, beginning with

physiologic and anatomic changes that affect adolescents’ teeth and related structures and the prevalence of major dental problems in 10- to 18-yearolds. 4 It also identifies a number of factors that are

associated with adolescent dental health problems.

Prevention of dental and oral health problems is

addressed, along with the dental service delivery

system. Finally, the Federal Government’s role in

oral health is discussed, and conclusions and policy

implications are presented.

Background on Adolescents’

Dental and Oral Health

Biological Factors That Affect Adolescents’

Dental and Oral Health

Puberty is the initiation of adolescence, and

several of the physical developmental changes that

characterize puberty are mirrored in a person’s oral

cavity (mouth). From the standpoint of oral health,

three types of changes during adolescence are

particularly important:

. the transition from primary to permanent teeth,

. skeletal growth, and

. hormonal change,

The first few years of adolescence are a dynamic

time in terms of dentition (teeth). Between the ages

of 10 and 12, a person’s entire set of primary teeth

has been replaced with permanent successors, second or 12-year-old molars have erupted, and only the

third molars remain to develop and erupt (27). By

ages 12 or 13, an individual’s permanent teeth are

usually stable.

Skeletal growth during adolescence has implications for orthodontic treatment. The face grows

l~en(a/ ~an’eS cm ~ dcflned ~~ ~c ]oc~lzcd, ~rogresslvc decay of a too~, starting on ~C sUrfacC and, if un~catcd, extending tO the inner tOOt

chamber and resulting in infection.

zrcrlodontu/ di~ea~e is any disease of tie tissue surrounding the teeth. The two most prevalent periodontal diswcs are gi~gi~’ifi’~ (i~ammation

confined to tbc gums) and periodontitis (infl amrnation of both the gum and the other supporting structures of the teeth).

~Orth(jd(jnticL~ 1s the area of dentistry concemcd with the bite and how teeth mesh toge~cr.

dFor tie PUWOSC of ~is Rcw~, OTA has focused on adolescents ages 10 through 18. Data pertaining to dentil healfi are not readily available ‘or

this age group. For that rcascm, some of the data cited in this chapter do not conform precisely to this agc grouping.

-11-231 -
//-232 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

significantly during adolescence, completing almost

all of the vertical growth that affects tooth position,

facial contour, and space available for teeth (66).

Orthodontic treatment must take skeletal growth

into account during this period.5

Hormonal changes seem to affect the susceptibility of adolescents to gingival problems (74) (e.g.,

because hormones interact with local irritating

factors such as plaque and calculus). Like other

aspects of adolescents’ dental health, however, the

relationship between hormonal changes and gingival problems is poorly understood.

Trends in the Incidence and Prevalence of

Adolescents’ Dental and Oral Health Problems

The major dental diseases and conditions affecting adolescents (indeed, all age groups) are dental

caries, periodontal disease, and malocclusion. These

three problems and various indexes used to measure

the extent of these problems are discussed in box

8-A.

Over the last three decades, adolescents have

experienced some dramatic changes in dental disease patterns—the most impressive of which is the

drop in prevalence of dental caries during the last 20

years.

7 Malocclusion has also undergone a transition

in recent decades, from a condition caused to a

significant degree by premature tooth loss due to

dental caries and subsequent crowding of teeth to a

condition that is largely inherited (la).

Dental Caries

For most U.S. adolescents, the situation with

respect to dental caries seems to have changed

significantly for the better in recent years. Data

collected among U.S. school children by the National Institute of Dental Research (NIDR) in the

U.S. Department of Health and Human Services

(DHHS) suggest that the prevalence of dental caries

as measured by the DMFS index8 has been diminishing among 10- to 17-year-olds (see figure 8-l). Also,

they suggest that the percentage of caries-free

adolescents has been increasing (see figure 8-l).

Although the prevalence of dental caries still

remains higher among adolescents than among

younger children, data from the NIDR surveys

shown in figure 8-2 indicate that 10- to 17-year-old

school children in this country experienced a 20- to

40-percent decline in the prevalence of dental caries

from 1980 to 1987 (97).

The data from the NIDR surveys of U.S. school

children conducted in 1979-80 and 1986-87 suggest

that dental caries of permanent teeth is slowly, but

consistently, decreasing in the U.S. adolescent

population as a whole. Despite the overall improvements, however, it is important to note that dental

caries remains a significant dental problem for

certain groups of adolescents.9

Figure 8-3 shows data from the NIDR surveys that

compare white and nonwhite adolescents with

respect to the distribution of components of agespecific mean DMFT scores. 1011 In both surveys,

the D component of the DMFT index (decayed teeth)

accounted for a higher percentage of age-specific

mean DMFT among nonwhite adolescents than

among white adolescents. This means that nonwhite

adolescents had a higher percentage of untreated

caries than white adolescents. The M component of

the DMFT index (missing teeth) accounted for a

larger and far more rapidly increasing percentage of

mean DMFT among nonwhite adolescents ages 10

Sunfotimtely, n. Precise predictor of faci~ growth exists, and while such growth can be tracked and extremes identiled, the development of useti

tools to help plot an adolescent’s fd orthodontic status remains elusive (19).

bpluque is a soft &pOSit of bacteria and otier materials on the surface of a tooth. Calculus is a hard deposit of calcium phosphate and mbonate witi

organic matter on the surfaces of the teeth.

T’rhe main data so~ces OTAUSed to describe trends in the prevalence of dental caries in adolescents are national surveys Of school ctildren @orm~

by or for the Federal Government-e.g., National Institute of Dental Research: National Caries Program, The Prevalence of Dental Caries in United

States School Children, 1979-80 and Oral Health of U.S. Children: The National Survey of Dental Caries in U.S. School Children, 1986-87 (94,97).

These data sources have limitations described in box 8-B. One of the primaty limitations is that natioml survey data do not adequately portray the caries

experience of particular subgroups of adolescents with unique circumstances or risks, such as poor or disabled adolescents or adolescents who do not

attend school.

8~e D~FCJ index ~d the D~f7T ind~ are Used to measure the prev~cncc of den~ caries and are described ill bOX 8-A .

gsee the following section on “Factors Associated With Adolescents’ Dental and Oral Health Problems. ”

lone D~ index is described in bOX 8-A.

1 l~ese smey &ta differentiate o~y ~~~nwhite and nonw~te pop~atio~. see box 8-B for Werdiscussion of the knitations of Ftdtial SOUrCeS

of data on dental and oral health.
Chapter 8--Dental and Oral Health Problems: Prevention and Services ● II-233

Box 8-A-Overview of Three Dental Problems: Dental Caries, Periodontal Disease, and Malocclusion

Three major dental diseases and conditions affect adolescents: dental caries, periodontal disease, and

malocclusion. These problems, and indexes commonly used to measure the prevalence or other aspects of these

problems, are described below.

Dental Caries-Dental caries is the localized, progressive decay of a tooth, beginning on the tooth’s outer

enamel surface and, if left untreated, extending to the inner tooth chamber. Dental caries is a condition to which

individuals of all age groups and races are susceptible, but the rate of dental caries is highest among adolescents

(l).

Far more is known today about dental caries than even a decade ago. Basically, dental caries is an infectious

condition that requires a combination of a susceptible host, cariogenic bacteria, and a diet high in carbohydrates;

over an extended period of time (usually at least several months), the acid produced by bacterial metabolism leads

to the decalcification of the tooth.

One especially virulent form of caries that affects a small portion of adolescents is rampant caries. Rampant

caries involves extensive breakdown of enamel and dentin, and pulpal pathosis. It devastates the dentition and

creates pain. This rapidly progressing condition can occur in individuals with or without a significant history of

dental caries. Not all patients who experience high caries activity experience rampant caries, but the destruction of

rampant caries puts those patients with the condition in the high caries activity group.

The DMFT and DMFS Indexes: Two indexes are commonly used to measure the prevalence of dental caries.

One of these, the DMFT index, measures the average number per person in a specified population of Decayed

permanent teeth in need of a filling or extraction, Missing permanent teeth that have been removed as a result of

caries, and Filled permanent teeth. The other index, the DMFS index, measures the average number per person in

a specified population of Decayed permanent tooth surfaces, Missing permanent teeth, and Filled (or restored)

Surfaces of permanent Teeth. The DMFS index is a somewhat more sensitive measure of the prevalence of dental

caries, because it identifies caries on several sites of each tooth. The technique of examination for the both the DMFS

and the DMFT index is described in a variety of references (79,97). Sometimes, the separate components of the

DMFT or DMFS index are used as a measure of service utilization (e.g., the F component is an indication of dental

treatment of decayed teeth, and the M component may suggest what type of dental care has or has not been received

(i.e., a high M component suggests that teeth were extracted as a result of untreated decay).

Treatment: The treatment for dental caries varies, depending on the condition’s severity. Although dental caries

in its mildest form affects only the tooth’s enamel and causes lesions that may not require treatment, dental caries

that progresses beyond the tooth’s enamel to the inner tooth may cause lesions that necessitate a filling or dental

restoration, pulpall therapy, or even removal of the tooth. The focus in this chapter is on carious lesions requiring

treatment.

Periodontal Disease--Periodontal disease includes several diseases of the tissue surrounding and supporting

the teeth (76). The two most prevalent periodontal diseases are gingivitis and periodontitis. Gingivitis, by far the

most common, is inflammation of the gingiva (gum) only; and is by itself relatively innocuous. Periodontitis is

inflammation of both the gums and other supporting structures of the teeth (e.g., the outer bone of the tooth socket,

the outer layer of the root of the tooth, and the soft tissues that attach these structures to one another). Unlike

gingivitis, periodontitis is associated with the destruction or loss of the supporting structures of the teeth.

Periodontitis does not develop in the absence of gingivitis, but gingivitis does not always lead to periodontitis.

Bacterial infection is an essential factor in both gingivitis and periodontitis (76).

Periodontal disease is more common and more severe among adults than among adolescents. Periodontal

problems are generally fewer and less severe than dental caries problems among adolescents, rarely leading to tooth

loss during this age period. Nevertheless, adolescents are affected by a variety of acute and chronic periodontal

problems, ranging from mild gingivitis to frank periodontal disease. One chronic periodontal condition peculiar to

adolescence is localized juvenile periodontitis, which causes the loss of alveolar bone supporting permanent teeth

and the weakening of the dentition. Thought to be caused by the organism Haemophilus (Actinobacillus)

actinomycetemcomitans, or a combination of organisms, iodized juvenile periodontitis is insidious and is not

necessarily present with inflammation as is gingival disease. It occurs in a small percentage of adolescents,

IDen~ pulp is tic soft sensitive tissue that falls the Cilamti Of tie tooti.

Continued on next page
//-234 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 8-A--Overview of Three Dental Problems: Dental Caries, Periodontal Disease, and Malocclusion—

Continued

usually early on. The superficial gingival tissue of a person with localized juvenile periodontitis can appear normal,

so the condition is often missed or diagnosed late in its course.

The Simplified Oral Hygiene Index (OHI-S): The OHI-S is a measure of oral cleanliness and plaque control,

with a low score denoting good oral hygiene. Good oral hygiene can improve periodontal health (76).

Periodontal Health Measures: The periodontal health of 14-to 17-year-old school children in 1986-87 was

assessed using two measures-gingival bleeding upon probing and periodontal attachment loss (11,12,97).

Bleeding gums are generally the result of mild gingivitis. Periodontal attachment loss is a measurement of

periodontal destruction--the loss or destruction of the supporting structures results in the formation of pathologic

spaces or pockets around the teeth. These pockets are measured in millimeters using a “periodontal probe” (97).

Treatment: Uncomplicated gingivitis is usually easy to treat with nonsurgical methods such as plaque removal

(76). Daily plaque removal is considered optimally conducive to gingival health. The treatment of more serious

periodontal disease may involve periodontal surgery or nonsurgical methods such as the “Keyes technique” (76).

Malocclusion—Malocclusion is the malpositioning of maxillary (upper jaw bone) and mandibular (lower jaw

bone) teeth, a condition that can have both esthetic, functional, and emotional implications (l). There is no clear

relationship between malocclusion and either periodontal disease, dysfunction of the temporomandibular joint, or

other oral problems.

Malocclusion is largely due to genetic factors, although individuals who experience premature primary tooth

loss due to dental caries may later experience orthodontic problems as a result. In its minor and even moderate

manifestations, malocclusion seldom creates pain and is rarely disfiguring. In its more severe form, malocclusion

causes functional problems in chewing, may predispose one to periodontal conditions (due to the inability to clean

between teeth), and can create significant emotional problems (due to diminished self-confidence and self-esteem)

(l).

Treatment: Many malocclusions of a minor variety can be prevented, intercepted, or corrected by the

supervision of a dentist and provision of space maintenance appliances or minor orthodontic treatment. The

correction of more major malocclusions typically requires major orthodontic treatment.

Orthodontic Treatment Priority Index (TPI): Determining the prevalence and severity of malocclusion is a

complicated procedure and is, ultimately, subjective. Survey data reflect the judgment of orthodontists who have

examined patients and a variety of records, including radiographs and models of teeth. From this information, a

score, or orthodontic TPI, is determined The orthodontic TPI score is a score ranging from O (normal occlusion)

to 10 (very severe occlusion, with treatment mandatory). A TPI score of 4 to 6 is considered a definite malocclusion,

but treatment is elective.

SOURCES: OffIce of ‘Ikchnology Assessment 1991, based on the following souxces: American Academy of Pediatric Dentistry, “Guidelines

for Dental Health of the Adolescent,” Chicago, IL, May 1986; M. Bha$ “Periodontal Attachment IJXS in 14- to 17-Year-Old U.S.

School Chil&ew” Program and Abstracts, American Association for Public Health De@istry, November 1989; M. Bhat and J.

Bruneile, “Gingival Status of 14- to 17-Year-Old U.S. School ChildreIL” Journal of Dental Research 68:955, June 1989; U.S.

Congress, OfiIce of lkchnology Assessment, Periodontal Disease: Assessing the Effectiveness and Costs of the Keyes

Technique+-Wealth Technology Case Study #5, OTA-BP-Ii-9 (W@iI@W DC: U.S. Government Printing Office, May 1981); U.S.

Department of Healt4 IMucatioQ and Welfare, Public Health Service, National Center for Health Statistics, Decayed, Missing and

FiZledTeethAmong Chif&en, DHEWPub. No. (HSM)72-1003 (Washington DC: U.S. Government Printing Office, August 1972);

and U.S. Department of Health and Human Services, Public Health Service, National Institutes of Heal@ National Institute of

Dental Research Oral Health of U.S. Children: The National Survey of Dental Caries in U.S. School Children, 1986-87, NIH Pub.

No. 89-2247 (Wtshingtom DC: U.S. Government Printing OffIce, September 1989).

to 17 than among their white counterparts. This adolescents are filled than decayed teeth of nonwhite

means that nonwhite adolescents lost more teeth to adolescents.

caries than white adolescents. Finally, the F compo- table 8-1 shows differences in selected dental

nent of the DMFT index (filled teeth) represents a treatment needs due to caries for white and nonwhite

greater percentage of the DMFT index for white 10- and 17-year-olds in 1979-80. In every category,

adolescents ages 10 to 17 than for nonwhite adoles- the needs of nonwhite adolescents exceeded those of

cents. This means that more decayed teeth of white white adolescents. The racial disparity in treatment
Chapter 8—Dental and Oral Health Problems: Prevention and Services . II-235

Percent

caries-free

60

50

40

30

20

10

0

Figure 8-l—Caries-Free Individuals and Mean DMFS Scores Among U.S. School Children

Ages 10 to 17, 1979-80 and 1986-87a b

10 11 12 13 14 15 16 17

Age

-1979-8 0

Mean DMFS

score

12{

10

8

6

4

2

0

1

10 11 12 13 14 15 16 17

Age

~ 1986-87

aThe data shown in this figure are from two national school-based surveys conducted by the National Institute of Dental Research in 1979-80 and 19 W-87.

~he DMFS index measu~es t he mean number per person of Decayed pe;manent toot h s_urfaces, Missing permanent teeth, and Filled Surfaces of permanent

teeth.

SOURCE: Office of Technology Assessment, 1991, based on the following: 1979-80 data: U.S. Department of Health and Human Services, Public Health

Service, National Institutes of Health, National Institute of Dental Research, National Caries Program, The Prevalence of L?enta/ Caries in United

States Schoo/Chi/dren, 1979-80, NIH Pub. No. 82-2245 (Washington, DC: U.S. Government Printing Office, 1982). 1986-87 data: U.S. Department

of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental Research, Ora/ l-/ea/th of U.S.

Children: The Alational SwveyofDenta/ Caries in U.S. School Children, 1986-87, NIH Pub. No. 8%2247 (Washington, DC: U, S. Government Printing

Office, September 1989). -

needs was more pronounced among 17-year-olds

than among 10-year-olds.

While major school-based studies show an overall

decrease in caries prevalence, other smaller studies

point to a changing pattern and distribution of dental

caries. Though uncommon, rampant caries12 affects

a small portion of adolescents, devastating the

dentition and creating pain, Perhaps as many as

one-fifth of school children get as much as half of the

dental caries in the population (35). Studies of naval

recruits, many of whom are older adolescents, show

similar findings-5 percent of those individuals

account for 38 percent of new caries (44). Although

the caries-active group is small, it represents a group

which seems resistant to most preventive measures

that benefit the population in general.

Periodontal Disease

National representative data from NIDR’s schoolbased surveys paint a generally positive picture of

periodontal health for most American adolescents

ages 14 to 17 (12,95). Although many school

children do experience some gingival inflammation

(signified by bleeding gums upon probing), very few

have more serious problems (e.g., periodontal attachment loss of more than 2 mm). Older studies also

suggest that many school children need moderate

gingival treatment and improved oral hygiene (62,63,

95).

According to the NIDR 1986-87 school-based

survey, nonwhite adolescents ages 14 to 17 tended

to have slightly worse periodontal health than white

adolescents (see figure 8-4). The percentage of

nonwhite adolescents with periodontal attachment

loss greatly exceeded the percentage of white

adolescents with periodontal attachment loss.

Localized juvenile periodontitis (see box 8-A)

affects an estimated 0.1 to 2.3 percent of U.S.

adolescents (69). If untreated, the condition can

cause significant periodontal destruction, including

bone and tooth loss.

MaloccIusion13

A review of available data on malocclusion found

that the condition tends to worsen in adolescence

(57). Crowding increases, some orthodontic probIIRamPan[ ~arie$ iS ~ ~apld]y ~rowcsslng fom of dental CMCS which by definition inVOIVeS extensive bre*down of enamel and dentin, ‘d Pulpd

pathosis, and can occur in patients with or without a sigmflctant caries history.

I ~BC)x 8-A ~lscusscs ~a]occluslon, ~ong ~1~1 its trca~cnt ~d measuremcn[. ~cvcn[ive services are discussed in a later SeCtlOn.
II-236 Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 8-2—Percentage Decrease From 1980 to 1987

in Caries Prevalence Among U.S. School Children

Ages 5 to 17a

Percent

decrease

50 ‘-————

r 7

40

30

20

10

n

I

- 5 6 7 8 9 10 11 12 13 14 15 16 17

Age

All

aThe data shown in this figure are from two national school-based surveys

cmnducted by the National Institute of Dental Research in 1979-80 and

1986-87.

SOURCE: Office of Technology Assessment, 1991, based on the following:

1979-80data: U.S. Department of Health and Human Services,

Public Health Service, National Institutes of Health, National

Institute of Dental Research, Natiorra/ Caries Program, The

Prevalence of Dental Caries in United States School Children,

1979-80, NIH Pub. No. 82-2245 (Washington, DC: U.S. Government Printing Office, 1982). 1986-87 data: U.S. Department of

Health and Human services, Public Health Serviee, National

Institutes of Health, National Institute of Dental Researeh, Qa/

HeaJth of U.S. ChiMen: The National Survey of Denta/ Caries in

U.S. Schoo/ ChMren, 1986-87, NIH Pub. No. 89-2247 (Washington, DC: U.S. Government Printing Office, September 1989).

lems worsen, and others become apparent later in

adolescence. Estimates of malocclusion in the adolescent population available from the National

Center on Health Statistics in DHHS are based on

national data from 1970 (81).

Table 8-2 shows data from 1970 on the average

orthodontic Treatment Priority Index score for U.S.

adolescents ages 12 to 17 by sex and race.14 White

male adolescents had the highest Treatment Priority

Index score (5.2), and black male adolescents had

the lowest (4.6). These scores fall into a range in

which there is a definite malocclusion but treatment

is elective.

Table 8-3 shows a breakdown of the orthodontic

Treatment Priority Index scores for all U.S. adolescents ages 12 to 17 in 1970. About 13 to 16 percent

(about 3.6 million adolescents in 197015) had severe

to very severe malocclusion.

Factors Associated With Adolescents’

Dental and Oral Health Problems

Federal sources of data on the dental health

problems of adolescents include national surveys by

NIDR, as well as other national surveys conducted

by various agencies in DHHS (see box 8-B). These

national surveys, as a whole, have yielded limited

information about subgroups of the population.

Available data on racial differences in dental disease

patterns, for example, differentiate only between

whites and nonwhites. The national surveys are not

designed to explain why racial differences in dental

disease patterns may occur by, for example, also

collecting information on family income level or

insurance status. Race, family income, and insurance status, along with education, age, sex, and

perceived need, have been shown to be correlated

with the use of dental services (31,82), and consequently associated with dental disease patterns.

Also, past history of dental disease, oral hygiene

behaviors, and diet may affect dental disease patterns.

Adolescents in certain racial and ethnic minority

groups, disabled adolescents, and adolescents in

institutions seem to experience greater dental disease than other adolescents. But the data on these

groups of adolescents are very limited, reflecting the

national data’s descriptiveness, and are shallow in

terms of explaining differences in disease patterns

and use of dental services. Despite the limitations of

the data and the possibility of misinterpretation, it is

important to understand that, for whatever the

reasons, some adolescents have a greater need for

dental care than others. Understanding the reasons is

important for designing interventions appropriate

for those adolescents.

Adolescents in Racial and Ethnic Minority Groups16

Data from the 1979-80 NIDR survey of school

children suggest that nonwhite adolescents in this

country experience more unmet need for dental

ld~e orthodontic Treatrnerrt Priority Index is described in ~x 8-A.

15Bw~ on us, ~~ent of comae, B~~~ of the Census, es~tes of the U.S. residents u of J~y 1, 1989, the equiv~ent number of

adolescents age 12 to 17 currently affected by severe or very severe malocclusion would be between 2.6 and 3.2 million.

16some ~omms of &@ on den~he~~ ~epmate different ethnic or mci~ minority groups so titthe ties prevalence or other aspects Of Ord health

are more closely related to that group. In most cases, however, minority groups are lumped together with various titles such as ‘ ‘minorities’ or ‘‘blacks

and others, ” The data below describe some minority groups studied in more detail.
Chapter 8—Dental and Oral Health Problems: Prevention and Services . II-237

Figure 8-3-Distribution of Components of Age-Specific Mean DMFT Scores for White and

Nonwhite U.S. School Children Ages 10 to 17, 1979-80 and 1986-87a b

Percent of Distribution of components for

mean DMFT

score white school children

Percent of Distribution of components for

mean DMFT nonwhite school children

‘core C d

1 00%

75%

60%

25%

0% 1 0

c d c d cd c d c d c d

1 00% cd c d

75%

50%

25%

‘

% 10 11

c d c d cd c d c d c d

17

I

4

11 12 13 14

Age

12 13 14 15 16 17

Age

Components of age-specific mean DMFT score

= Decayed teeth = Missing teeth m Filled teeth

aThe data s.ho~n in this fiaure are from two national school-based surveys conduct~ by the National Institute of Dental Research in 1979-80 and 1988-87.

hhe DM17 index measu;es the mean number per person of Decayed, ‘Missing, and F;lled permanent Teeth.

c1 979-80.

dl 986-87.

SOURCE: Office of Technology Assessment, 1991, based on the following: 1979-80 data: U.S. Department of Health and Human Services, Public Health

Service, National Institutes of Health, National Institute of Dental Research, National Caries Program, The Prevalence of Dental Can”es in United

States Schoo/Chi/dren, 1979-80, NIH Pub. No. 82-2245 (Washington, DC: U.S. Government Printing Office, 1982). 1986-87 data: U.S. Department

of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental Research, Oral Health of U.S.

Children: The National Survey of Dental Caries in U.S. School Children, 1986-87, NIH Pub. No. 89-2247 (Washington, DC: U.S. Government

Printing Offica, September 1989).

treatment than their white peers (see table 8-1).17 In 1983-84, the Indian Health Service in the

Because of these needs, nonwhite adolescents expe- Public Health Service of DHHS conducted a study

rience undesirable effects from dental conditions— of Indian children on reservations and in other areas

restricted-activity days,

18 bed-disability days, 19 

and served by the Indian Health Service and found that,

lost school days—to a greater degree than their overall, American Indian children have twice the

white peers do (88). amount of dental caries as the national average (90).

The mean DMFT score for 13- to 19-year-olds

In 1986-87, according to NIDR, 22 percent of ranged from a low of 9.4 in Southwestern Indians to

10-year-olds needed restoration (filling) of perma- a high of 12.7 in those from the Northwest. The F

nent teeth (94). For white 10-year-olds, the figure (filled teeth) component of the DMFT, an indicator

was slightly under 19 percent; for nonwhite 10-year- of treated caries, ranged from 50 to 77 percent (i.e.,

olds, though, the percentage was over 32 percent. that half to three-quarters of decayed teeth were

The need for restoration of permanent teeth changes filled).

through adolescence. In 1986-87, over 12 percent of

all 17-year-olds needed restorations—8 percent of A study in Colorado showed that children of

white 17-year-olds and 29 percent of nonwhite migrant workers between ages 11 and 15 had a

17-year-olds (97). DMFS rating of 5.87, exceeding the DMFS rate of

ITAv~~bl~ &ta differentiating or~ he~~ status by mce do not tie socioeconomic s@tus or otier, possibly confounding, faCtOrS iIltO ~COUIlt. For

example, a 1982-84 survey of Mexican-Americans (not specifically adolescents, however) found that an individual’s level of awulturation was

significantly associated with the prevalence of gingivitis and periodontal pocketing (i.e., those with low acculturation status had signiilcantly higher

disease levels than those with high acculturation status) (45a).

18Re~tn’cted-acti~j~ &y~ are days on which a person’s activity is restricted by lllneSS Or inJlllY.

19Bed-dj~abf/i~ days me &ys on which a person spends more ~half the day in bed because of dhleSS Or iDJUry.
II-238 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 8-l-Selected Dental Treatment Needs of White and Nonwhite U.S. Adolescents

Ages 10 and 17, 1979-80a

Percent of adolescents In need of:

Tooth Pulpal Tooth Need for

extractions therapy replacement crowns

Age (years) White Nonwhite White Nonwhite White Nonwhite White Nonwhite

10 . . . . . . . . . . . . . . . . 0.5 2.8 1.2 1.8 1.1 1.8 2.0 2.3

17 . . . . . . . . . . . . . . . . 2.1 10.4 1.3 6.9 6.7 17.9 3.5 10.8

a~alogous data were not reported k 1986-87 (97).

bpermanent tooth extractions due to disease.

SOURCE: U.S. Department of Health and Human Servioes, Public Health Service, National Institutes of Health,

National Institute of Dental Research, Den&/ Treatment Needs of Untied States Ch//&en, 1979-80, NIH

Pub. No. 83-2246 (Washington, DC: U.S. Government Printing Office, December 1982).

Figure 8-4-Periodontal Health Status of U.S. School Children Ages 14 to 17, by Gender and Race, 1986-87

- - - Percent with gingival bleeding Percent with periodontal attachment loss (2mm or more) - - -

80%

1 61.6%

60%

40%

20%

. . . . . . . .

72.1%

“‘“ Males Females White Nonwhite AU

Mean percent of sites with gingival bleeding 10%

8%

6%

4%

2%

o%

Males Females White Nonwhite All

40%

30%

20%

10%

0%“

0.6

0.5

0.4

0.3

0.2

0.1

n

I 40.6% I

‘“ Males Females White Nonwhite All

Mean periodontal attachment loss (in mm)

1

“ Males Females White Nonwhite All

SOURCE: Office of Technology Assessment, 1991, based on the following: Glnglval status: M. Bhat, “Pedodontal Attachment LOSS in 14- to 17-Yaar-Oid

U.S. School Chlldr6n,” Program and Abstracts, American Assodatlonfor Public Haalth Dentistry, Richmond, VA, 1989; Periodontal attachment:

M. Bhat and J. Bfunelle, “Gingival Status of 14- to 17-Year~ld U.S. School Children,” Journal of Dental Reseamh 68S55, June 1989.

the general U.S. population of that age (16). A study Figure 8-5 shows the gingival treatment needs of

in Minnesota showed that by age 13, 73 percent of white and nonwhite U.S. adolescents ages 10 to 17

the occlusal (biting) surfaces of migrant children’s in 1979-80 using a scoring system from O (low need)

first permanent molars were decayed, missing, or to 4 (high need). The percentages of adolescents who

filled (24). A study in Michigan showed that migrant had moderate or serious gingival problems (or were

children 5- to 14-years-old had consistently higher not scored) were generally higher among nonwhite

DMFS scores than other nonmigrant children (104). than among white adolescents.
Chapter 8—Dental and Oral Health Problems: Prevention and Services . //-239

Data from the Indian Health Service study show

that by the end of adolescence, two out of five young

American Indian patients have destructive periodontal disease with bone loss (90). Six out of ten

American Indian children ages 19 and under have

gum disease.

Data from NIDR suggest that only a small

percentage of U.S. children receive orthodontic care

(95). In 1979-80, about 25 percent of 17-year-olds

had ever received any orthodontic treatment but

black adolescents were far less likely to have

received it (4 percent of black adolescents had ever

received orthodontic treatment) than white adolescent (27 percent had ever received orthodontic

treatment) (95). Although it appears that malocclusion occurs consistently across races (see table 8-2),

the treatment of orthodontic problems does not seem

to reflect the distribution of this problem.

In 1987, restricted-activity days due to acute

dental conditions averaged 1.5 days per 100 persons

per year for U.S. children 5 to 17 years of age (88).

In 1987, black children under age 18 had slightly

more restricted-activity days than whites of the same

age (6.9 days per 100 persons for black children v,

5.6 days per 100 persons for white children).

Black children under age 18 in this country suffer

more bed-disability days due to acute dental conditions than whites, In 1987, black children under age

18 had 4.3 bed-disability days per 100 persons per

year due to acute dental conditions, while white

children under age 18 had only 1.4 bed-disability

days (88).

Black children ages 5 to 17 in this country

experience almost four times as many school days

lost due to acute dental conditions as whites do, In

1987, black children ages 5 to 17 lost 3.9 school days

per 100 persons per year due to acute dental

conditions, while white children lost 1.0 school day

per 100 persons per year (88). The impact of acute

dental conditions as compared to other acute conditions on school performance or work is not known,

Table 8-2—Malocclusion Among U.S. Adolescents

Ages 12 to 17, by Race and Gender, 1970

Orthodontic Treatment

Priority Index (TPl) scorea

White Black

Age (years) Male Female Male Female

12 . . . . . . . . . . . . . . . . . . . . 5.2 5.6 4.1 4.9

13 . . . . . . . . . . . . . . . . . . . . 5.2 5.0 4.2 5.6

14 . . . . . . . . . . . . . . . . . . . . 5.1 4.7 4.8 6.1

15 ...............,.. . . 5.5 4.8 5.0 4.9

16 . . . . . . . . . . . . . . . . . . . . 4.9 4.6 5.3 5.0

17 . . . . . . . . . . . . . . . . . . . . 5.4 4.8 4.5 3.9

For group . . . . . . . . . . . . . 5.2 4.9 4.6 5.1

aThe orthodontic Treatment Priority Index (TPI) score is a Score raflglng

from O (normal occlusion) to 10 (very severe malocclusion with treatment

mandatory); a TPI score of 4-6 is considered a definite malocclusion, but

treatment is elective,

SOURCE: U.S. Department of Health, Education, and Welfare, Public

Heatth Service, National Center for Health Statistics, An Assessment of the Ckxlusion of the Teeth of Youths 12-17 Years,

DHEW Pub, No, (H RA)77-1 644 (Washington, DC: U.S. Government Printing Office, February 1977).

Data from the National Health Examination

Survey of the late 1960s suggest that white U.S.

adolescents ages 12 through 17 tend to have slightly

better oral hygiene as measured by the Simplified

Oral Hygiene Index than black adolescents (see table

8-4), 20 although both blacks’ and whites’ scores

were representative of relatively good oral hygiene.

The racial differences may reflect personal oral

hygiene behaviors which may be related to access to

care, patient education, or other factors.

Adolescents With Disabilities21

A reliable picture of the dental health of U.S.

adolescents with disabilities is unavailable. Adolescents with disabilities (and disabled people of other

ages) have not been well-evaluated for dental caries.

Most studies of dental caries among disabled people

have been small in scale and have used a variety of

indices. The lack of data, variety of indices, and

inadequate control of variables in many studies

make conclusions about the extent to which dental

caries affects disabled adolescents difficult to draw.

The discussion that follows draws on the few good

studies that are available.

20~e Slmpllfledoral Hygiene Index, ~ noted in ~x 8-A, is a m~sure of oral c]~lincss and plaque control. A low score indicates good oral hygiene.

‘lAs discussed inch. 6, ‘ ‘Chronic Physical Illness: prevention and Services,“ in this volume, the term disabled is used in many ways. In 1982, OTA

distinguished between a disabi/iry (i.e., a limited ability or inability to perform one or more basic life functions-at a level considered “typical”) and

a handicap (i. e., an imbility to perform one or more life functions~.g., working-at a ‘‘typical’ level beeause of the interaction of the individual’s

disability with the physical and social environments) (77). The terms handicapped and disabled have not been used consistently in studies of dental

disease, and the national dental surveys described eadier did not break down the study samples into disabled and nondisabled. The discussion here uses

the term disabled as the general term for both disabled and handicapped adolescents.
11-240. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 8-3—Distribution of Malocclusion Among U.S. Adolescents Ages 12 to 17, by Race and Gender, 1970

Percent with orthodontic Treatment

Priority Index score

White and black White Black

TPI score Both Male Female Both Male Female Both Male Female

0 = normal occlusion . . . . . . . . . . . . . . . 11.0 10,8 11.2 10.5 10.2 10.7 14.7 15.0 14.3

1-3 = minor malocclusion . . . . . . . . . . . 34.8 34.0 35.8 34.5 33.6 35.7 36.9 36.4 37.3

4-6 = definite malocclusion . . . . . . . . . 25.2 25.7 24.6 25.8 26.0 25.5 21.0 23.3 18.8

7-9 = severe malocclusion . . . . . . . . . . 13.0 12.8 13.0 13.0

10 = very severe malocclusion . . . . . . 16.0

12.7 13.2 12.2 13.5 11.0

16.7 15.4 16.7 17.5 14.9 15.2 11.8 18.6

SOURCE: U.S. Department of Health, Education, and Welfare, Public Health Service, National Center for Health Statistics, An Assessrnentof the @c/usion

of the Teeth of Youfhs 12-17 Years, Dt-EW Pub. No. (HRA)77-1644 (Washington, DC: U.S. Government Printing Office, February 1977).

Using data drawn from more than 20,000 disabled

patients in 1984, Nowak demonstrated a mean

DMFT score among 13- to 17-year-old disabled

adolescents of 6.0; this compared to a DMFT score

of 6.3 for an analogous age cohort in the general

population (58). The breakdown of the DMFT score

for 11- to 15-year-old disabled adolescents (1.18

(D), 2.48 (M), and 2.09 (F)) suggests that disabled

adolescents are receiving treatment for dental caries

but continue to have dental caries that progress to

tooth loss.

A review of the literature by Tesini shows that

periodontal conditions are a significantly greater

concern for disabled adolescents than is caries (75).

The probable reason is that the prevention of

periodontal diseases involves good oral hygiene

practices which may be given low priority by those

caring for disabled persons or require a dexterity

some disabled persons may not have.

Disabled adolescents who are unable to engage in

a major activity (i.e., attend school) tend to visit the

dentist at a rate similar to the rate among other

underserved groups (87). In 1986, only 54.4 percent

of seriously disabled adolescents between the ages

of 12 and 17 had at least an annual dental visit (87).

Disabled adolescents with less disability or limitation did only slightly better. In 1986,62.2 percent of

less seriously disabled adolescents between the ages

of 12 and 17 had at least an annual dental visit (87).

Disabled adolescents’ infrequent dental visits may

be related to a variety of factors, including preoccupation with their disabling condition (26), inability

to find a dentist (70), or financing22 (33).

Adolescents in Juvenile Justice Facilities

Small studies have shown that adolescents ages

13 through 16 who are in juvenile justice facilities

had more dental decay (as well as poorer nutritional

status, and more vision and hearing impairments)

than adolescents from similar communities who had

never been in juvenile justice facilities (64). It is not

clear, however, what the dental status of these

adolescents was prior to entering juvenile justice

facilities .23

Adolescents With Certain Behaviors or Conditions

A variety of behaviors and conditions affect

adolescents’ oral health-behaviors that include

ignoring personal dental hygiene practices, using

alcohol and other substances, using oral contraceptives, using smokeless tobacco or smoking cigarettes, participating in athletics (and experiencing

related injuries), and conditions that include bulimia

nervosa,

24 pregnancy, and sexually transmitted diseases (see table 8-5). Some of these behaviors and

conditions occur infrequently but result in long-term

damage to oral structures when they occur. Others

occur more frequently but have minor or reversible

effects.

Prevention of Adolescents’ Dental

and Oral Health Problems

The major dental and oral health problems faced

by adolescents in the United States—i.e., dental

ZZFor tier discussion offmc~g issues ti den~ care, see: the discussion below; ch. 16, “Fklilllcti Access tO Health Services, ’ in VO1. ~,~d

U.S. Congress Oftlce of ‘Ikchnology Assessment, Children’s Dental Services Under the Medicaid Program (78).

~For fifier discussion of tie health needs of adolescents in juvenile justice facilities, see ch. 13, ‘‘Delinquency: Prevention and Services,” in this

volume.

~Bulimia nen,osa is a severe eating disorder c~cte~ed by a cornp~sion to binge md then purge the MY t)y self-induced Vornitklg or Use Of

laxatives. For a further discussion see ch. 7, “Nutrition and Fitness Problems: Prevention and Semices,’ in this volume.
Chapter 8-Dental and Oral Health Problems: Prevention and Services . //-241

Box 8-B—Federal Sources of Data on Adolescents’ Dental and Oral Health

Several components of the Public Health Service within the U.S. Department of Health and Human Services

collect data on adolescents’ dental and oral health:

National Institute of Dental Research (NIDR), National Institutes of Health

—National Dental Caries Prevalence Survey, 1979-80: data on DMFS and DMFT, specific dental treatment

needs, by age and race (white and nonwhite), and gingival health assessment of U.S. school children.

—National Survey of Dental Caries in U.S. School Children: 1986-87: data on DMFS and DMFT, by age, race

(white and nonwhite), and geographic location, and gingival health assessment of U.S. school children.

National Center for Health Statistics, Centers for Disease Control

—National Health Interview Survey (NHIS), annual: data on utilization of dental services by age, income, and

residence; acute dental conditions and associated restricted-activity days, bed-disability days, lost school

days by age and gender, and race and family income. Usually, these questions are asked of adults about their

children. The 1982 survey included a Preventive Care Supplement, which included data on the first dental

visit. The 1985 survey included a special Health Promotion and Disease Prevention Questionnaire, with a

dental component.

—National Health and Nutrition Examination Survey (NHANES) III, 1988-94: data collected from

questionaires as well as from physical and oral examinations. Data collection will span from 1988 through

1994 and will include persons 2 months old and older. The dental component will include an assessment

of caries, periodontal status, tooth loss, soft-tissue lesions, malocclusion, and tooth trauma.

National Center for Health Services Research (now Agency for Health Care Policy and Research)

—National Medical Care Expenditure Survey (NMCES), 1977, and National Medical Expenditure Survey

(NMES), 1987: data on dental expenditures and utilization of services, by age, race, and family income.

Several authors involved in dental epidemiology and research, as well as dental public health, have noted that

Federal data collection programs may not provide accurate projections of dental and oral health need within

special populations (22,35,90). For example, the NIDR surveys of U.S. school children differentiate only between

white and nonwhite children and include only those children who attend school. This approach to data collection

may yield information about aggregate trends but is likely to mask the disease status and treatment needs of certain

populations.

SOURCE: CMce of Rdmology Assessment, 1991.

caries, periodontal disease, and malocclusion-are ● by reducing or interfering with the cariesoften preventable conditions. Effective preventive

measures involve water fluoridation and other preventive efforts at the community level, the services

of dental professionals, and personal dental hygiene

practices.

Preventive Interventions for Major

Dental Health Problems

Prevention of Dental Caries

Dental caries, the major dental infectious disease

problem for adolescents, can be prevented in the

following ways:

. by increasing the resistance of the teeth via the

use of fluoride and dental (occlusal) sealants,25

producing microorganisms in contact with the

teeth through the use of fluoride and oral

hygiene procedures, and

● by altering a person’s oral environment through

dietary interventions (36).

Fluoride--Fluoride has been key in the overall

reductions in dental caries among adolescents.

According to the American Academy of Pediatric

Dentistry, adolescents can benefit from fluoride

throughout their teenage years and into early adulthood (la). The benefit of incorporating fluoride into

the developing enamel of permanent teeth ends

around age 14 (or at the time of the eruption of the

second permanent molars) (36), but the benefits of

remineralization and the antimicrobial activity of

fluoride continue beyond that age (la). These

25Denta/ ~eafanf~ me ~~ ~~at~g~ of pl~ti~ ~teri~p~~d on tie OC-clus~ (che~g)surfa@s of posterior teeth to prevent the accumulation Of food

debris and bacteria in the pits and fissures of these teeth and subsequent dental decay (36).
//-242 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 8-5—GingivaI Treatment Needs of White and

Nonwhite U.S. Adolescents Ages 10 to 17, 1979-80

Percent of

individuals

with score

W NW W NW W NW W NW W NW W NW W NW W NW

1 00%

75%

50%

25%

o% 10 11 12 13 14 15

—

16 17

Age

Scores

~ O-1 = 2 _ 3-4 or not scored

NOTE: W - White; NW . Nonwhite

scoring Criteria: O - free of disease; 1 or 2 = needs minor treatment;

3 = moderate probiem; 4- disease wiii not respond to self-care.

SOURCE: U.S. Department of Heaith and Human Services, Public Heaith

Service, Nationai institutes of Heaith, Nationai institute of Dentai

Research, Dental Treatment Needs of United States Children

1979-80, NiH Pub. No. 83-2246 (Washington, DC: U.S. Government Printing Office, December 1982).

benefits can be obtained through water fluoridation,26 through fluoride that is topically applied by a

dental professional, or through the use of fluoride

rinses or fluoride-containing toothpaste (la).

Water fluoridation programs have been demonstrated effective in reducing caries in several studies,

resulting in a 20- to 40-percent reduction in caries

(9,13,14,23,25,47,50,58 ).27 As of 1988, nearly twothirds (61 percent) of the U.S. population served by

public water supplies had access to fluoridated

. . drinking water (84a). The Federal Government has

provided assistance for water fluoridation programs

through grants to States and also through technical

assistance, health education, and other methods. The

Dental Disease Prevention Activity of the Centers

for Disease Control in the Public Health Service of

DHHS has been responsible for the Federal Government’s water fluoridation effort since 1978 (22).

Table 8-4-Oral Hygiene Among U.S. Adolescents

Ages 12 to 17 as Measured by the Simplified

Oral Hygiene Index (OH I-S), 1966-1970

Age (Years) OHI-S scorea

12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.94

13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.92

14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.90

15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.87

16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.86

17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.82

White Black

12-17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.82 1.34

~The simplified oralHygiene index (OHi-S) is a measure of orai deaniiness

and plaque controi. A high score indicates poor orai hygiene.

SOURCE: U.S. Department of Health, Education, and Welfare, Pubiic

Heaith Service, National Center for Heaith Statistics, Ch/

Hygiene Amen.q Youths 12-17 Years, DHEW Pub. No. (HRA)76-

1653 (Washin~on, DC: U.S. Government Printing Office, 1976).

In 70 clinical trials of professionally applied

topical fluoride, caries was reduced by an average of

30 percent (66). A recent OTA study that sampled

seven State Medicaid programs found that professionally applied topical fluoride was a covered

dental benefit for adolescents in six of’ seven

programs (78).28 Limitations in State reporting

requirements to the Federal Government preclude a

determination of how many Medicaid-eligible adolescents actually had fluoride topically applied by a

dental professional. The American Dental Association has suggested the inclusion of professionally

applied topical fluoride in a model dental health

insurance benefit (3).

Nonprofessionally applied topical fluoride, such

as that contained in fluoride toothpastes or mouth

rinses, is also effective in reducing dental caries.

School fluoride rinse programs have been shown to

reduce the prevalence of dental caries among participating school children from 16 to 56 percent (17),

although there is some evidence that those children

in nonfluoridated communities may experience greater

benefit (67a). Approximately 10 percent of U.S.

school children ages 5 to 17 have access to school

fluoride rinse programs (87).

Dental Sealants--According to the Sealant Task

Force of the Massachusetts Public Health Depart-

~R~enfly, concerns have been r~s~ahut the carcinogenicity of sodium fluoride (the fluoride compound commonly supplemented in cornmtity

water supplies). In 1990, the National Toxicology Program at the National Institutes of Health issued preliminary results of a study on the carcinogenicity

of sod’urn fluoride in rats and mice that showed only equivocal evidence of carcinogenicity in male rats (98). After considering the weight of the evidence

on sodium fluoride, the Public Health Semice’s stated policy is to continue appropriate support for the use of fluorides for the prevention of dental decay

(98).

27~e low-end c~es reduction found ~ some studies my ~flect the f~t tit con~ol subjects were exposed to fluoride in forms other b in drin k

water (e.g., fluoride toothpaste).

2SS& tie following section for details of the Medicaid program and dental s~ices.
Chapter 8—Dental and Oral Health Problems: Prevention and Services ● II-243

Table 8-5-Behaviors and Conditions With Potential Effects on Adolescents’

Dental and Oral Health

Behavior/condition Potential effects on dental and oral health

Behaviors:

Cigarette smoking . . . . . . . . . . . . . .Short-term uses causes mucosal changes, staining of teeth.

Long-term use results in increased oral cancer risk, periodontal

disease.

Smokeless tobacco use . . . . . . . . .Same as for cigarette smoking.

Alcohol and drug use . . . . . . . . . . .Short-term use complicates drug administration by dentists and can

cause unusual off ice behaviors, dental neglect in addicted patients.

Lng-term use is related to oral cancer.

Participation in athletics . . . . . . . . .Traumatic injuries to teeth and jaws.

Oral contraceptive use . . . . . . . . . .Periodontal disease from hormonal change; increased risk of dry

socket after tooth extraction.

Conditions:

Bulimia . . . . . . . . . . . . . . . . . . . . . . . .Periodontal problems and acid destruction of teeth from vomiting.

Pregnancy . . . . . . . . . . . . . . . . . . . . .Gingival inflammation.

Sexually transmitted disease . . . .Oral infections.

HIV infection . . . . . . . . . . . . . . . . . . .Periodontal disease; access to care maybe restricted.

Stress . . . . . . . . . . . . . . . . . . . . . . . . .Oral infection.

SOURCE: P.S. Casamassimo, S.L. Bronstein, J. Christensen, et al., “Periodontal Disease and Temporomandibular

Joint Disorders,” Pediatrk Dentistry, infancy Through Adolescence, J.R. Pinkham, P.S. Casamassimo, H.

Fields, et al. (eds.) (Philadelphia, PA: W.B. Saunders Co., 1988). Reprinted by permission,

ment, a combination of fluoride and dental sealants

is the most effective preventive approach to reducing

dental caries (13,56). The National Preventive Dentistry Demonstration Program29 similarly found that

a program combining fluoride, sealants, and dental

health education30 had greater benefit than did

programs with fewer preventive techniques both in

communities with fluoridated water and communities without it (10).

In 1983, the National Institutes of Health held a

consensus conference on dental sealants, and the

consensus development group recommended the use

of sealants for the prevention of dental caries (91).

Despite such recommendations, in 1986, fewer

than 10 percent of U.S. adolescents had dental

sealants (101). Various factors, including practitioner attitudes, low public awareness, low priority

for dental health, and cost, have limited the availability of sealants to adolescents (100).

The Bureau of Maternal and Child Health and

Resources Development within the Health Resources and Services Administration of DHHS has

funded dental sealant programs through competitively awarded funding for its special projects of

regional and national significance (SPRANS) (8).

State agencies are utilizing Federal funds to initiate

sealant programs in various parts of the country (71).

The National Institutes of Health and the Center for

Disease Control’s Dental Disease Prevention Activity effort to encourage the use of sealants continues

in this regard with grants to States and public

awareness programs (21). On the other hand, the

American Dental Association reported in 1988 that

only 22 State Medicaid programs (including the

District of Columbia) covered dental sealants, and at

least one State recently discontinued sealants from

its program (2).31

Personal Oral Hygiene--Some studies show

that meticulous oral hygiene (i.e., including prophylaxis (cleaning) by a dental professional) can virtually eliminate dental caries (5,6,7). To OTA’s

knowledge, however, there are no clinical trials that

show what effects toothbrushing without fluoride

toothpaste or flossing has on dental caries (36).

Other Dietary Measures---Restricting sugary

foods in the diet has significantly reduced dental

me National Preventive Dentistry Demonstration Program was conducted jointly by the American Fund for Dental Health and the RAND Corp.

and was funded by the Robert Wood Johnson Foundation. The program spanned 4 years and included school childnm from 10 communities around the

country (67a).

~Den~ he~~ education is ~s~ssed in a Scpwate SeCtiOn hlow.

311t should & noted tit some M~ic~d dent~ ~al~t ~nefi~are limited in .$Cope, allowing ordy limited application Of Sd~tS (e.g., OIM3 Se@t

per tooth per lifetime) or allowing sealants only on limited teeth (e.g., only bicuspids and molars within 3 years of eruption), for limited ages (e.g., only

for children ages 12 and under), or for limited populations (e.g., for developmentally disabled children only) (78).
II-244 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

caries in clinical trials (41,42). This approach has

less pronounced effects on dental caries when

sugar-restricted diets are not carefully controlled

(68,96).

Prevention of Periodontal Disease

The prevention of periodontal disease requires

good personal oral hygiene habits, including brushing and flossing, to remove plaque from all teeth

surfaces (43,52,73). Personal oral hygiene is also

important because gingivitis can be reversed

through personal plaque control. Periodontitis is a

much more severe disease state and usually requires

professional treatment to prevent progression, but

personal oral hygiene must be practiced as well (76).

In addition to personal hygiene measures, prophylaxis (cleaning) by a dental professional at least once

a year is generally recommended to prevent periodontal diseases (37). The American Dental Association has suggested the inclusion of prophylaxis by a

dental professional in a model dental health insurance benefit (3).

Most of the seven State Medicaid programs

sampled in a recent OTA study covered dental

prophylaxis for adolescents at least annually (one

program limited the benefit to children under age 12)

(78).

Prevention of Malocclusion

The genetic basis of much of malocclusion in

adolescents makes it unpreventable (la). As noted

earlier, however, malocclusion is sometimes caused

by the premature loss of primary teeth due to dental

caries. The timely use of space-maintainin g appliances effectively prevents the shift of teeth that

results from the premature loss of primary teeth (37).

The American Dental Association has recommended

the inclusion of space maintainers as part of a model

dental health insurance benefit (3).

In its study of seven State Medicaid programs

mentioned previously, OTA found that all seven

programs limit coverage of space maintainers for

adolescents (78).

Dental Health Education and Behaviors

Dental Health Education

The benefits of dental health education for adolescents are hard to assess. Although such education

may tend to increase knowledge (102), its lasting

effect on attitudes and behaviors appears less

significant (28). Recent data suggest that adolescents have positive attitudes toward dental health,

and that their attitudes improve with education and

result in better behaviors (102). There is some

indication that concerns about self-image and appearance can encourage good oral health behaviors

for adolescents (1,53,54).

A primary locus for receipt of dental health

education is during the dental visit (30), although the

effectiveness of education in this setting is unknown. This locus presents an obvious problem for

adolescents without frequent access to professional

dental care. Health care providers other than dentists

may have potential for either providing oral health

information or providing referrals to dental professionals.

School health education programs are another

locus for adolescents’ receipt of oral hygiene information, but health education programs are not

consistent across schools and generally provide little

emphasis on older adolescents, who are at higher

risk (30). Some evidence suggests the positive value

of these programs if both parents and children are

involved, but many programs have been found to be

inadequate because they fail to involve the parents

(59).

There is no central repository of oral health

educational materials (29), although such a repository might inject a consistent element into schoolbased programs and office- or clinic-based educational materials. Further, adequate evaluations of

educational programs and interactions are scarce,

specifically in relation to adolescents.

Adolescents’ Knowledge of and Attitudes Toward

Dental Health

Although there is no similar information for

adolescents, data from DHHS national surveys

suggest that young adults (ages 18 to 29) know as

much as or more than older adults about the benefits

of fluoride, the positive effects of brushing and

flossing on periodontal health, and the anticaries

benefit of sealants (83). Higher income and education levels of these young adults were associated

with a greater knowledge of these preventive benefits. Racial differences in young adults’ knowledge

are small (suggesting that many have been exposed

to preventive information), but nonwhites do appear

to know less about sealants than do whites.

—
Chapter 8—Dental and Oral Health Problems: Prevention and Services . //-245

A small study of adolescents in Minneapolis

found that almost 75 percent of the predominantly

white adolescents sampled had a regular dentist (54).

Ninety percent said they brushed their teeth daily,

and 80 percent felt tooth decay was a serious

problem. Eighty-four percent believed that caries

was preventable, though few knew much about

preventive methods. A study of inner-city, largely

black adolescents found that study participants were

good at assessing their overall oral health, but they

were not as good at assessing their gingival health

status when compared with a dentist’s assessment

(15).

Adolescents’ responsibilities in health careseeking change over the course of adolescence.

During the first part of adolescence, an adolescent

typically depends on a parent or legal guardian for

the initiation of health care visits; at the end of

adolescence, decisions about care-seeking are increasingly likely to be a personal decision. Utilization of dental care parallels this change; dental visits

drop off in the transition between adolescence and

young adulthood (83). Meanwhile, the acute manifestations of dental conditions consistently increase

in the early adult period (87).

Interventions and Services for the

Treatment of Adolescents’ Dental

and Oral Health Problems

Interventions for the Treatment of Adolescents’

Dental Health Problems

The usual therapies for dental caries include

fillngs (restorations), pulpal therapy, and, sometimes, removal of the affected tooth (see box 8-A).

Therapies for periodontal disease include plaque

removal, in the case of uncomplicated gingivitis, and

various surgical and nonsurgical treatments, in the

case of more serious periodontal disease. The

treatment of malocclusion depends on its severity.

Minor malocclusions can often be corrected by

space-maintaining appliances or minor orthodontic

treatment. Major malocclusions may require major

orthodontic treatment. Few, if any, efforts have been

made to trace the effects of specific interventions for

the treatment of dental health problems from adolescence into adulthood.

The Dental Service Delivery System

Access to services in the U.S. dental care service

delivery system is strongly influenced by the ability

of patients to pay for services. Family income is

directly associated with adolescents’ utilization of

dental care (39,87). Most oral health services are

provided in private practices, which represent 85

percent of dentists (45), and are provided to middleand upper-income patients (40). The likelihood that

an adolescent has had a dental visit within the last

year increases with family income (see figure 8-6).

The likelihood also increases with private dental

insurance. About four of five 12- to 17-year-olds

with private dental insurance make at least annual

visits to the dentist, while only about three of five

without private dental insurance make such visits

(87). The private dental insurance status of adolescents in various categories (gender, race/ethnicity,

family income, activity limitation) is shown in table

8-6. Many adolescents from low-income families

rely on public clinics or public insurance or both.

Many public dental programs are federally sponsored (see below), but State and local governments

are also active in providing dental health education

and services to adolescents from low-income families. 32 The size and scope of both State and local

dental programs vary considerably. Local dental

programs are more likely to provide clinical services

than State dental programs (46). In a recent survey

of local dental health agencies, 109 of 127 local

health agencies that provide for clinical services (80

percent of survey respondents) provided them to

adolescents (51). The clinical components were

generally limited to preventive, emergency, and

basic restorative services. Some local health agencies providing dental education programs targeted

junior high (52 of 125 agencies) or high school (34

of 125 agencies) students, but twice as many (104 of

125 agencies) targeted elementary school students.

Federal Programs Pertaining to

Adolescents’ Dental and Oral Health

DHHS is the primary locus of Federal dental and

oral health programs. Several DHHS agencies are

involved in dental and oral health programs:

. the Public Health Service, which includes the

National Institute of Dental Research (NIDR)

32 Funding for loc~ ~genclc~ ~omc~ from ~ “~e~ of ~owce~, including 1~~ t~es, Sbte ~~~,Fede~ gran~, revenue shtig, dir@3 payIIlen~ ~d

third-party reimbursement (including Medicaid).
II-246 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 8-6-Percentage of U.S. Adolescents

Ages 12 to 17 With a Dental Visit in the Past Year,

by Family Income,a 1986

Percent with dental visit In last year

100%

80%

60%

40%

20%

o%

$10,000 $10,000 to $20,000 to $35,000

$19,999 $34,999 and above

Family income.

aFarnily in~rne was adjusted for family size.

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, Centers for Disease Control, National Centerfor Health

Statistics, Use of Dental Sem”ces and Dental Health, 1986,

DHHS Pub. No. (PHS)88-1593 (Washington, DC: U.S. Government Printing Office, October 1988).

of the National Institutes of Health; the Health

Resources and Services Administration, which

provides dental care through its National

Health Service Corps; the Indian Health Service; and various other Public Health Service

agencies (e.g., Centers for Disease Control);

and

. the Health Care

which administers

programs.

In fiscal year 1988, as

Financing Administration,

the Medicare and Medicaid

shown in figure 8-7, these

DHHS agencies spent nearly $580 million on oral

and dental health (32). Almost 4, percent of total

Medicaid expenditures for adolescents ages 10 to 18

was spent on dental services in fiscal year 1988

(82a).

An Interim Study Group on Dental Activities

appointed by DHHS in 1987 found that a focus for

dental and oral health activities within DHHS was

lacking (45). That study group suggested that a

central focus for oral health activities should be

located within the Public Health Service at the

Office of the Assistant Secretary for Health and

should be advised by a formally chartered committee

(45).

Table 8-6-Private Dental Insurance Status of

U.S. Adolescents Ages 12 to 17, by Various

Demographic Categories, 1986a

Percent Percent

with ‘without

private private

dental dental

Demographic categorv insurance insurance

Males . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Females . . . . . . . . . . . . . . . . . . . . . . . . . .

Whites . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Blacks . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . .

Mexican-American. . . . . . . . . . . . . . . . .

Other Hispanic . . . . . . . . . . . . . . . . . . . . .

Family income:

Under $10,000 . . . . . . . . . . . . . . . . . . . . .

$10,000-$ 19,999 . . . . . . . . . . . . . . . . . . .

$20,000-$34,999 . . . . . . . . . . . . . . . . . . .

$35,000 or more . . . . . . . . . . . . . . . . . . .

Unable to engage in major activity..

44.0%

42.2

45.6%

30.2

35.1

36.8

33.0

10.6%

28.3

50.5

63.1

26.0%

52.1%

53.3

50.3%

65.2

60.5

59.6

61.7

86.5%

67.9

46.6

33.8

74,0%

~otals do not equal 100 due to unknown coverage.

bDisabled.

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, Centers for Disease Control, National Centerfor Health

Statistics, Use of Dental Sew”ces and Dental Health, 1986,

DHHS Pub. No. (PHS)88-1 593 (Washington, DC: U.S. Government Printing Office, October 1988).

Public Health Service

The Public Health Service has many responsibilities for the Nation’s oral health, including research

on oral health problems, support of community

fluoridation efforts, and support for the direct

provision of services.

NIDR, one of the National Institutes of Health, is

the primary agency supporting Federal research on

oral health-the causes, prevention, diagnosis, and

treatment of oral and dental diseases and conditions.

The limitations of national surveys conducted by

NIDR were discussed previously.

The Federal Government’s water fluoridation

activities, as mentioned previously, are overseen by

the Centers for Disease Control’s Dental Disease

Prevention Activity. Water fluoridation programs

have been shown effective in reducing dental caries,

but almost one-third of the U.S. population served

by public water supplies lacks access to fluoridated

water (67a).

In September 1989, the Bureau of Maternal and

Child Health and Resources Development within the

Health Resources and Services Administration of

the Public Health Service sponsored a Workshop on

the Oral Health of Mothers and Children (72). A full
Chapter 8—Dental and Oral Health Problems: Prevention and Services . //-247 —.

Figure 8-7—Dental and Oral Health Expenditures by

the U.S. Department of Health and Human Services,

Fiscal Year 1988

HCFA 54%

$312.4

Star

10.9

HRSA

$68

Other

$

t 2%

$47.9

($ in millions)

ABBREVIATIONS: HCFA - Health Care Financ/ng Admmistratlon, HRSA -

Health Resources and Services Administration, IHS =

Indian Health Service, NIH - National Institutes of

Health, PHS = Publlc Health Service,

aThe National Institutes of Health includes the National Institute of Dental

Research.

SOURCE: S, Ginsburg and R,E, %hmldt, An /nventory of Resources and

Acbvities Devoted to Dental and Oral Health in the Department

of Health and Human Sem’ces (Bethesda, MD: Richard Schm Idt

Associates, Ltd., April 1989).

report containing the workshop participants’ recommendations should be issued soon on issues that

include oral health policy, integration and collaboration, advocacy, resources for oral health, oral health

education and promotion, oral health status, contributing factors, oral health standards, documentation

and evaluation, and research.

Direct dental services are provided through approximately 300 community health centers and

migrant health programs that receive Federal grants

under section 330 of the Public Health Service Act.

Section 330 grants go to public and private nonprofit

organizations that provide primary health care to

populations or areas that are “medically undererved.’ Almost all Public Health Service National

Health Service Corps personnel are assigned to

community health centers and migrant health programs. At least 121,000 adolescents received dental

care in these centers in 1989 (55).

Another direct dental service program in the

purview of the Public Health Service is the Indian

Health Service, which has the responsibility for

providing care to American Indians and Alaska

Natives.

Health Care Financing Administration

Though the Public Health Service supports various dental and oral health activities, the Medicaid

program administered at the Federal level by the

Health Care Financing Administration is the largest

source of public expenditures for oral health services

for children and adolescents.

While Medicaid provides public health insurance

for low-income people of all ages, its Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

program is specifically intended to serve children

under age 18 (or age 21) and is the program through

which most children under Medicaid receive dental

care.

33 Further, Medicaid eligibility does not translate into utilization of services. In 1988, 46 States

and the District of Columbia reported that of over 9

million Medicaid recipients under age 18 who where

eligible for dental services, only 26 percent had a

dental service of some kind performed (2). In New

Jersey, for example, only about one-third of 15- to

20-year-olds who were covered by Medicaid received dental services in fiscal year 1988.

As part of a separate study, OTA recently

surveyed the Medicaid/EPSDT dental programs in

seven States regarding their coverage of selected

preventive and therapeutic services (78). The survey

found that some of the seven State programs did not

provide a minimal dental benefit package, choosing

not to cover certain procedures, such as sealants,

despite the Health Care Financing Administration’s

instructions to the contrary. The study also identified

several barriers within the Medicaid program that

block access to services, including structural aspects

of the program, low provider participation, low fees

and other reimbursement issues, and burdensome

paperwork.

Conclusions and Policy Implications

In general, available national data on the U.S.

adolescent school population from NIDR show a

remarkable decline in the prevalence of dental caries

since 1979-80. Unfortunately, the data from these

surveys do not provide much information about

specific subgroups of adolescents. They do show,

however, that white adolescents have far fewer

33 For a discussion of Medicaid and its EPSDT program, s~ ch. 16, ‘‘Financial Access to Health Services, ’ in Vol. III,
//-248 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

decayed teeth than nonwhite adolescents, fewer

missing teeth due to decay, and more restored

(previously decayed but treated) teeth. Other smaller

studies confirm this observation within specific

groups of adolescents, including the children of

migrant workers and American Indians. Also, there

is some evidence to suggest that adolescents with

disabilities and adolescents in juvenile justice facilities have poorer dental health than the adolescent

population as a whole. Other adolescents not represented in the data are those who do not attend school,

since the national surveys are school-based. Oversampling of specific populations in national surveys

or conducting occasional special surveys may rectify this gap in information,

Another limitation of the national data on dental

caries is that they do not provide information on

possible confounding factors. Such factors might

especially include income level and insurance status,

but adolescents’ perceived need of dental care, past

history of dental disease, oral hygiene behaviors,

and diet may also be relevant. More information on

whether these factors may confound data on the

prevalence of dental caries among racial or ethnic

minority groups is necessary to further define the

apparent differences between national white and

nonwhite prevalence rates and to design appropriate

interventions.

The most recent data on periodontal disease in

adolescents (1986-87) from NIDR do not suggest

severe periodontal problems in most adolescents,

but rather, fairly widespread mild gingival conditions. Nonwhite adolescents tended to experience

more gingival and periodontal problems than white

adolescents.

Malocclusion, another dental problem for some

adolescents, has not been studied or analyzed

recently. Old data (1970) suggest that malocclusion

is a problem that requires treatment for nearly 30

percent of adolescents. In 1979-80, about 25 percent

of 17-year-olds had ever received any orthodontic

treatment, but black adolescents were far less likely

to have received it (96 percent of black adolescents

had never received orthodontic treatment) than

white adolescents (73 percent had never received

orthodontic treatment), though there do not appear to

be great differences in the occurrence of severe

malocclusion conditions (81). An additional complication, besides the lack of recent data, is that the

measurement tool used to assess the severity of

malocclusion is subjective, rendering absolute conclusions based on the available data questionable.

Conclusions about the prevalence of these dental

problems are limited by the data, but it is clear that

there are discrepancies in the occurrence of these

dental problems among groups of adolescents.

Interestingly, there are also discrepancies among

adolescents in their access to dental services; dental

insurance and income are primary factors influencing an adolescent’s dental visit within the past year.

Adolescents from low-income families are the least

likely to have private dental insurance and are also

the least likely to have visited a dentist within the

last year. Similarly, white adolescents are more

likely than nonwhite adolescents to have private

dental insurance and are more likely than black

adolescents to have had a dental visit. There is no

direct evidence to suggest that adolescents who

suffer the worst dental problems have the least

access to dental services, but the possibility that this

may be the case would seem to warrant further

studies of certain groups of adolescents.

Publicly funded dental programs may not be

accessible to all low-income adolescents; of over 9

million Medicaid recipients under age 18 who were

eligible for dental services, only 26 percent had a

dental service of some kind performed. One way

publicly funded dental programs could become more

accessible is if more dentists would treat lowincome adolescents—reimbursement rates, program

administration, and program structure appear to be

barriers to dentists’ participation in the Medicaid

program.

Since the visit to a dentist is a primary locus for

dental health education, low-income adolescents

may have less access to dental health education than

other adolescents. It is at least conceivable that increasing low-income adolescents’ oral health awareness might spur their dental care-seeking behaviors,

thereby improving their effective access to dental

services.

Topical fluoride, sealants, prophylaxis (teeth cleaning by dental professionals), restorations, and space

maintenance are the primary preventive or therapeutic treatments for most adolescents’ dental problems

(not including extraction). Unfortunately, not all

publicly funded dental programs offer these primary

services or the services are offered on a limited basis.

Thus, many low-income adolescents lack access to
Chapter 8—Dental and Oral Health Problems: Prevention and Services . II-249

certain dental treatments that could reduce or

prevent their dental diseases.

Besides professional services, personal oral hygiene plays a significant role in dental health (e.g.,

personal plaque control can reverse gingivitis and

self-application of fluoride can help prevent caries).

Adolescents are held responsible for their personal

hygiene behaviors, but it is not clear that they are

provided with adequate information. The effectiveness of health education programs can be measured

in terms of changes in attitudes or behaviors or,

preferably, in terms of changes in the rate of disease.

Schools and dental offices and clinics are primary

sites for dental health education. A central repository

of dental health education materials<. g., within

the Public Health Service-could improve the

likelihood of consistent information and improve the

chances for coordinated educational activities.

Dentists should also be included in dental educational activities. To treat adolescents effectively,

dentists probably could benefit from materials

intended to make them more aware of adolescentspecific dental conditions (e.g., localized juvenile

periodontitis) and adolescent-specific needs (e.g.,

for information on the effects of behaviors such as

smokeless tobacco).

Chapter 8 References

1.

la.

2.

3.

4.

5.

6,

7.

8.

9.

Albino, J. E.N., and Lawrence, S. D., “promoting Oral Health in

Adolescents,“ in S.G. Millsteti A.C, Peterseu and E,O. Nightingale (eds.), Health Promotion for Adolescents, in preparation.

American Academy of Pediatric Dentistry, “Guidelines for Dental

Health of the Adolescent, ” Chicago, IL, May 1986.

American Dental Association, Council on Dental Care Programs,

Dental Programs in Medicaid: 1988 Sun’ey (Chicago, LL: 1988).

American Dental Association, Council on Dental Care Programs,

Policies on Dental Care Programs (Chicago, IL: 1989).

Applewhite, H.L., “Total Dental Care for the Adolescent,” New

York State Dental Journal 40(2):83-87, 1974.

Axelsson, P., and Lindhe, J., ‘‘Effect of Fluoride on Gingivitis and

Dental Caries in a Preventive Program Based on Plaque Control,’

Community Dentistry and Oral Epidemiology 3:156-160, 1975.

Axelssom P., and Lindhe, J., “The Effect of a Preventive

Programme on Dental Plaque Gingivitis and Caries in School

Children: Results After One and Two Years,’ Journal of Clinical

Periodontology 1 :126-138, 1974.

Axelsson, P., Lindhe, J., and Waseby, J., “The Effect of WOUS

Plaque Control Measures on Gingivitis and Caries in School

Childreni” Community Dentistry and Oral Epidemiology 4:232-

239, 1976.

Beck, R. W., “An Overview of Maternal and Chitd Health Dental

Activities and the Dental Head Start Program,’ Journal of Public

Health Dentistry 45(4):232-233, 1985.

Bell, R. M., Kleiw S. P., Bohannan, H. M., et al., Results of Baseline

Dental Exams in the National Preventive Dentistry Demonstration

Program (Santa Monica, CA: RAND Corp., 1982).

]~ly !4 1!) ~11 1 -. ‘1 ( [. {

10.

11.

12.

13.

14.

15.

16.

17.

18.

18a.

19.

20.

21.

22.

23.

24.

25.

26.

27,

28.

29.

Bell, R.M., Klein, S.P., Bohannon, H. M., et al., Treattnenr Eflects

in the National Preventive Denn”stry Demonstration Program

(Santa Monica, CA: RAND Corp., 1984).

Bhat, M., “Periodontal Attachment Loss in 14- to 17-Year-Old

U.S. School Childreq’ Program and Abstracts, American Association for Public Health Dentistry, Richmond, VA, 1989.

Bhat, M., and Brunelle, J., “Gingival Status of 14- to 17-Year-Old

U.S. School Childrem JournaZ of Dental Research 68:955, June

1989.

Bohannoq H. M., Stamm, J.W., Graves, K.C., et al., “Fluoride

Mouthrinse programs in Fluoridated Communities, ” Journal of

the American Dental Association 11 1(5):783-798, 1985.

Brunelle, J. A., Miller, A.J., and Smith, J.I., “DMFS in U.S.

Children With and Without Lifelong Exposure to Water Fluoridation,” Journal of Dental Research 62:203, 1983.

Brunswiclq A.F., and Nikias, M., “Dentists’ Rating and Adolescents’ Perception of Oral Healt&’ Journal of Dental Research

54(4):83&843, 1975.

Call, R.L., Entwistle, B., and SwansoQ T., “Dental Caries in

Pe rmanent lketh in Children of Migrant Farm Workers, ’ Amen”-

can Journal of Public Health 77(8):1002-1003, 1987.

Carlos, J.P., ‘‘Fluoride Mouthrinses,’ Clinical Uses of Fluon”des,

S.H,Y. Wei (cd.) (Philadelphia PA: Lea& Febiger, 1985).

Casamassimo, P., and Castaldi, C., “Considerations in the Dental

Management of the Adolescent” Pediam”c Clinics of North

America 29(3):631-651, 1982.

Casamassimo, P. S., Bronste@ S.L., Christensen J., et al.,

“Periodontal Disease and ‘r’emporomandibular Joint Disorders,”

Pediatric Dentistry, Infancy Through Adolescence, J.R.PP.s. Casamas sirno, H. Fields, et al. (eds.) (Philadelphia, PA: W.B.

Saunders Co., 1988).

Casamassimo, P., Christens% J., and Fields, H., “Examination%

Diagnosis, and Treatment Plarming for General and Orthodontic

Problems, ’ Pediatn”c Dentis+nfancy Through Adolescence,

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PREVENTION AND SERVICES

RELATED TO SEXUALLY

TRANSMITTED DISEASES

AND PREGNANCY
Chapter 9

AIDS AND OTHER SEXUALLY

TRANSMITTED DISEASES:

PREVENTION AND SERVICES

Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

Background on AIDS and Other STDs.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

Trends in the Prevalence and Incidence of HIV Infection and AIDS . . . . . . . . . . . . . . . . . . . . . . . 261

Prevalence and Incidence of AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261

Prevalence and Incidence of HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

Trends in the Prevalence and Incidence of STDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

Prevalence and Incidence of Chlamydia Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268

Prevalence and Incidence of Gonorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268

Prevalence and Incidence of Condyloma Acuminatum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269

Prevalence and Incidence of Herpes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269

Prevalence and Incidence of Syphilis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269

Prevalence and Incidence of Chancroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270

Prevalence and Incidence of Pelvic Inflammatory Disease (PAD) . . . . . . . . . . . . . . . . . . . . . . . . 270

Factors Associated With HIV and STDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

Sexual and Drug-Using Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

Lack of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272

Other Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275

Prevention of AIDS/HIV Infection and Other STDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

Problems in Evaluating the Effectiveness of AIDS and STD Prevention programs . . . . . . . . . . 278

Education-Based AIDS and STD Prevention Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

Education-Based Prevention Efforts That Involve Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

Education-Based Prevention Efforts in Schools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280

Education-Based Prevention Efforts in Community Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

AIDS and STD Prevention Efforts Other Than Those That Are Education-Based . . . . . . . . . . . 288

Condom Distribution Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Needle Exchange and Bleach Distribution Programs for Adolescents Using IV Drugs . . . . . 293

Early Diagnosis of Adolescents With HIV Infection and Sods . . . . . . . . . . . . . . . . . . . . . . . . . 293

Services and Interventions for the Treatment of AIDS and Other Sods . . . . . . . . . . . . . . . . . . . . . . 295
Major Federal programs Related to HIV Infection, AIDS, and Other STDs . . . . . . . . . . . . . . . . . . . 298

Federal Programs Related to AIDS and STD Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298

Federal Programs Related to AIDS and STD Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306

Prevention of HIV Infection, AIDS, and Other STDs in Adolescents . . . . . . . . . . . . . . . . . . . . . . 307

Treatment of AIDS and STDs in Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

Federal Agencies’ Role in prevention and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

Chapter preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311

Box

Box Page

9-A. Limitations of Federal Data on the Prevalence and Incidence of

HIV Infection, AIDS, and Other STDs Among U.S. Adolescents. . . . . . . . . . . . . . . . . . . . . . . 258

Figures

Figure Page

9-1. Male-to-Female Ratio for Reported AIDS Cases in the United States, by Age of

Diagnosis . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

9-2. AIDS Cases Among U.S. Adolescents Ages 13 to 19, by Race and Exposure

Category, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

9-3. Gonorrhea Incidence Rates Among U.S. Adolescents, 1977-89 . . . . . . . . . . . . . . . . . . . . . . . . . 269

9-4. Syphilis Incidence Rates Among U.S. Adolescents 1977-89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270

Tables

Table Page

9-l. State Reporting Requirements for Selected Communicable Diseases . . . . . . . . . . . . . . . . . . . . 259

9-2. Cumulative AIDS Cases Among Adolescents and Young Adults in the United States,

by Exposure Category, 1981-90 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

9-3. Cumulative AIDS Cases in the United States, by Age and Race/Ethnicity, 1981-90 . . . . . . 263

9-4. Selected Studies of Human Immunodeficiency Virus (HIV) Seroprevalence

Involving Adolescent Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264

9-5. Overview of Selected Sexually Transmitted Diseases and Syndromes . . . . . . . . . . . . . . . . . . 265

9-6. Selected Studies Demonstrating Prevalence Rates of Sexually Transmitted Diseases (STDs)

Among U.S. Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266

9-7. Eighth and Tenth Grade Students’ Knowledge Regarding STDs, by Grade and Sex, 1987. 273

9-8. Percentage of Correct Responses Among U.S. High School Students for Questions

Related to HIV Transmission Routes, by Selected States and Cities, 1989 . . . . . . . . . . . . . . . 276

9-9. Studies Evaluating Education-Based AIDS and STD Prevention Efforts in Schools . . . . . . 281

9-10. Studies Evaluating Selected Condom Distribution Programs for the prevention of

HIV Infection and Other STDs Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

9-11. Steps in AIDS Drug Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

9-12. Sex, Race, and Ethnicity of the 47 Patients Ages 12 to 211nvolvedin Federally Sponsored

AIDS Clinical Trials, October 5,1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

9-13. U.S. Department of Health and Human Services HIV/AIDS-and STD-Related Projects

and Grants That Include or Target Adolescents, 1989-90 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Chapter 9

AIDS AND OTHER SEXUALLY TRANSMITTED DISEASES:

PREVENTION AND SERVICES

Introduction

Within the past decade, acquired immunodeficiency syndrome (AIDS) has emerged as a major

national health problem. Although human immunodeficiency virus (HIV)--the virus associated with

AIDS-is transmitted from an infected individual to

another individual through methods that include the

sharing of intravenous (IV) drug needles, one of the

primary routes is through sexual intercourse. For this

reason, AIDS is often characterized as a sexually

transmitted disease (STD) (242).1 Individuals with

some of the more traditional STDs (i.e., chancroid,

herpes, and syphilis) may be especially vulnerable to

HIV infection (52,106,164,165,234); and for that

and other reasons, there has been an increasing

awareness of STDs as problems in themselves.

Adolescents who engage in sexual intercourse or

use IV drugs are at risk of infection with HIV or an

STD. 2 Although through August 1990, cases of

AIDS among adolescents ages 13 to 193 represented

under 1 percent (568 cases) of all AIDS cases in the

United States (237a), AIDS was the sixth leading

cause of death4 for 15- to 24-year-olds (110). Given

the estimated 10-year incubation period between

HIV infection and the onset of AIDS, it is probable

that many of the young adults who currently have

AIDS acquired HIV infection during adolescence.

Limitations in STD reporting requirements mean

that the number of U.S. adolescents with some STDs

is unknown, but STDs other than AIDS have been

characterized as being among the most pervasive

and costly communicable diseases threatening adolescents today (121 ,227,261). Until recently, however, efforts to control HIV infection and STDs have

not focused on adolescents (209).

.

The physical, emotional, and psychological complications of HIV infection or STDs can be severe.

There is still no cure for HIV infection, and

HIV-related illnesses are eventually fatal. Unlike

AIDS, many STDs can be cured (e.g., the bacterial

STD syphilis) or their symptoms can be substantially controlled (e.g., the viral STD herpes); if left

untreated, though, STDs other than AIDS can have

extremely serious consequences, including infertility, ectopic pregnancy,5 gonococcal arthritis, and

sometimes death. Because of their common predominantly sexual origin, this chapter explores AIDS

and STDs in the adolescent population together,

focusing on the extent of the problem, prevention

efforts, and services and interventions for treatment.

The chapter concludes by considering major Federal

policies and programs directed toward adolescents.

Background on AIDS and Other STDs

Accurate reporting of cases of HIV infection,

AIDS, and other STDs is important for determining

the extent of infection among a particular population, for planning, implementing, and evaluating

prevention and control activities, and for distributing Federal and other funds for HIV/AIDS and STD

programs and treatment (28,41,229).

For reasons including those described in box 9-A,

the precise number of adolescents with HIV infection and with many STDs is not known. The

authority to require the reporting of communicable

diseases by health professionals rests with the

States, and State requirements with respect to the

reporting by health care professionals of communiIA ,Yflualfy /ran.ymirreddi$f eaSe, fomer]y c~]ed venereal disease (36), is an infectious disease transmitted chiefly tiughsexu~ intercoms or geni~

contact. 2A~~ording t. prelfi~w data from a 198$) survey by the Centers for Disease Control within the U.S. Department of He~th and Human SerViCeS~

53 percent of the Nation’s high school students have had intercourse (72a). For further discussion see ch. 10, ‘‘Pregnancy and Parenting: Prevention and

Services” and ch. 12, ‘‘Alcohol, Tobacco and Drug Abuse: Prevention and Services, ’ in this volume.

3~e focus of this OTA repo~ for Ieasom noted in Vo], I, and ch, 2 in this volume, is on 10. ~rough l&year-olds, Some of the data presented in

this chapter are for other age groupings, because data for 10- through 18-year-olds are not readily available. For information about Federal agencies’

data collection activities related to adolescents, see ch. 19, “The Role of Federal Agencies in Adolescent Health, ” in Vol. III.

4’rhis rating is bm~ on 1987 data for ADS d~~s and 1986 data for deaths due to other causes.

5A ~croplc ~regnuncv is a pre~mcy that occurs somewhere in the WY otier than in tie uterus.

-II-257-
11-258. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 9-A—Limitations of Federal Data on the Prevalence and Incidence of HIV Infection, AIDS, and

Other STDs Among U.S. Adolescents

Various Federal sources publish data on the prevalence and incidence of reported cases of HIV infection, AIDS,

and other STDs. 1 The Centers for Disease Control (CDC) within the U.S. Department of Health and Human Services

(DHHS), for example, publishes such data in its Morbidity andMortality Weekly Report (e.g., 235), its “HIV/AIDS

Surveillance” report (236,237), and in its Sexually Transmitted Disease Statistics report (241). Some of the data

published by CDC are compilations of reported AIDS and STD cases from the States.

States have the authority to require health care professionals to report infectious diseases and to specify the

conditions under which they are to be reported (e.g., the time for reporting, person responsible for reporting, and

agencies to receive the reports) (5,41). Although CDC recommends that States report particular STDs (47), it does

not have the authority to require States to report them (64,229). In the absence of a national reporting requirement,

there is no uniformity in State reporting requirements for STDs. Currently, for example, all 50 States and the District

of Columbia do require that health care professionals report AIDS cases to State health departments; but as of April

1990, only 32 States required that health care professionals report cases of HIV infection (65) (in July 1989 there

were only 29 such States).2 Similarly, while all 50 States do require that health care professionals report gonorrhea

and syphilis, only 33 States require the reporting of chlamydial infections (41,229).

Even in those States that do require the reporting of certain communicable diseases reported in CDC’s

publications, data on STDs have several additional limitations. These are caused by incomplete reporting, by

differences in reporting by public and private health sources, and by limitations in the specificity of diagnostic tests

(17,125). In a number of States, including those with a high prevalence of HIV infection, there is evidence to suggest

that AIDS cases may be underreported by as much as 20 percent (48,228). Reasons for undercounting of AIDS and

other STDs are varied. One reason is that some individuals with STDs experience no symptoms and therefore do

not seek a health evaluation or diagnosis (65). Other reasons include the lack of symptoms for some STDs, the use

of differing criteria in diagnosing STDs, and the stigma associated with having an STD (133). Another problem is

that because public health clinics tend to report STDs more completely than do private practitioners, biases are

created by individuals attending public clinics (35).

In addition to providing compilations of reported AIDS and STD cases from the States, the Federal

Government supports ongoing HIV seroprevalence surveys among national samples, such as the National Health

and Nutrition Examination Survey, to monitor the spread of HIV infection and STDs (106,233). HIV seroprevalence

surveys supported by the Federal Government focus on groups of individuals at risk of infection (e.g., homosexual

and bisexual men, intravenous drug users), women in clinical settings and of childbearing age, college students,

migrant and seasonal farmworkers, blood donors, military recruits, Job Corps entrants, and selected “sentinel”

hospital patients (233). To avoid self-selection bias, some of the HIV seroprevalence surveys are conducted as

anonymous surveys that cannot link individuals to HIV test results; other surveys interview survey participants to

evaluate risk factors for HIV infection. Findings from HIV seroprevalence surveys supported by the Federal

Government are generally not representative of the adolescent population. Some of these surveys (e.g., surveys from

Job Corps residential entrants) probably overestimate the extent of HIV infection among adolescents, and others

(e.g., surveys among military recruits) may underestimate the extent of such infection.

lzncj&~e is a measure of the number of new cases of a disease or other condition occuming iu a population during a given period of time.

Prevalence is a measure of the number of individuals in a given population who have a spec~lc disease or other condition at a designated time

(or during a particular period).

2Eigh&n s~te~ q~e tit peql~ witb ~v~ reported by ~eo ~n of ~~S@tes, however, do ~OW for anonymous teS@ hlCC@Xl

circumstances (229).

cable diseases vary by disease and by State (see table professionals report cases of HIV infection (65), and

9-l). All 50 States and the District of Columbia do as of March 1, 1989, only 33 States required the

require that health care professionals report AIDS reporting of chlamydial infections (41,229). Evicases to State health departments, and all 50 States dence from selected samples suggest that certain

require reporting of gonorrhea and syphilis; as of segments of the adolescent population may be at

April 1990, only 32 States required that health care particular risk of HIV infection and STDs.
Chapter 9-AIDS and Other Sexually Transmitted Diseases: Prevention and Services . II-259

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VI
Table 9-l—State Reporting Requirements for selected Communicable Diseases-Continued

Sexually transmitted diseases (STDs)n

Human Acquired Pelvic

immunodeficiency immunodeficiency Chlamydial Gonococcal Herpes Nonspecific inflammatory

State virus (HIV)b

syndrome (AIDS)b

Chancroid infections disease simplex urethritis disease Unspecified Syphilis

Washington . . . . . . . . . . . . — x x x x X9 J x )@ x

West Virginia . . . . . . . . . . —

.

x x x

Wisconsin . . . . . . . . . . . . . Xc

— — — — — x

x x x x XJ x x x

Wyoming . . . . . . . . . . . . . . XC

—

x x x x

xl — — — x

KEY: X = reporting required.

— = no reporting required.

%Wrrent as of Mar. 1, 1989. jReporting required for primary e@@ of herpes simplex inf=tion and for genital herpes Simplex infection.

bcurrent as of July 1989. kMeningoemephal itis<

cRe~rting required with names. Iscromboid. dReW~ing required WithOUt n~es. mReWding rwuir~ for number (C)r age and number) only.

eReporting required for genital chlamydial infeCtiOn. ‘Optional.

fRep@ing required for females. ‘Unspecified.

9Congenital and newborn reporting required. PGonococca 1.

h~~ratow cmnfirmed cases required to be reported. qAcute or newiy diagnosed.

i Reporting r~uired for genital herpes Simplex.

SOURCE: mice of Technology Assessment, 1991, w on the following sour-s:~v and AIDS data: Us. Department of Health and Human se~as, pu~ic Heaith Service, CeflterS fOr Disease

@ntrd, “HIV Reporting-United States,” hforbi~ty~~ofi~ify We~/yR~R38(28):4~.4~, July 21,1 g8g; (for~jo) B. Kni, Assistant with the STD Unit, ~io Department Of Health,

Columbus, OH, personal communication, May 31, 1990. STD data: T.L. Chor&, R.L. Berkelman, SK. Sdford, et al., tcMan&toY RePfling of Inf=tious Diseases by CliniUaflS,” JOf.Mrla/

of the Amw”can Medical Association 262(21):301 8-3026, 1989.

●

:

. .
Chapter 9--AIDS and Other Sexually Transmitted Diseases: Prevention and Services .11-261

Trends in the Prevalence and Incidence of

HIV Infection and AIDS

HIV, the virus associated with AIDS, is transmitted chiefly from an infected person to another person

through anal, vaginal, or oral sexual intercourse,6 the

sharing of IV needles, infected blood or blood

products, and from an infected mother to her infant

(233,235). The best estimate of the median interval

between HIV infection and the onset of AIDS, which

is characterized by a deficiency in the immune

system, is approximately 10 years (233); the incubation period may vary depending on the route of HIV

infection (90) and may be different for adolescents

than for older individuals (81).

Prevalence and Incidence of AIDS

As noted earlier, AIDS is the sixth leading cause

of death for U.S. adolescents and young adults

between the ages of 15 and 24 (1 10),7 and there are

grounds for believing that it will remain in this

position in the future (51). In order to have an

accurate description of the extent to which and the

method by which adolescents with AIDS have

acquired HIV infection, it is important to examine

the Center for Disease Control’s (CDC) monthly

‘‘HIV/AIDS Surveillance" reports for data on 20- to

24-year-olds with AIDS and on 13- to 19-year-olds

with AIDS. As of August 31, 1990, these data

showed that adolescents ages 13 to 19 represented

under 1 percent (568 cases) of all AIDS cases; when

young adults ages 20 to 24 were included in the

calculation, however, the number of AIDS cases

rose to 6,740, or 4.6 percent of all AIDS cases (237a).

The method by which infected individuals transmit HIV to uninfected adolescents has relevance for

the design, implementation, and targeting of appropriate services and behavioral interventions to adolescents (88). It is also important to consider the

relevance of changing patterns in HIV transmission

for future adolescents. In general, adolescents who

currently have AIDS are less likely than adults ages

20 to 24 or adults over age 25 to have acquired HIV

through male homosexual/bisexual contact or IV

drug use; adolescents with AIDS are more likely

than other individuals to have acquired HIV through

the transfusion of contaminated blood and blood

products for the treatment of hemophilia (see table

9-2). However, most observers expect that, with

improvements in the safety of blood products used

by hemophilia patients, adolescent males with

hemophilia will no longer represent a large percentage of the adolescent male AIDS cases (90,267).

Patterns such as those seen in New York City, where

nonhemophilia cases predominate, are believed to

be a better “crystal ball” for the Nation (90).

Still, among adolescents with AIDS, the transmission of HIV through sexual intercourse is an

important route. For individuals ages 13 to 19, male

homosexual/bisexual contact is the second most

common route of HIV transmission (237). Furthermore, the percentage of 13- to 19-year-olds who

have become infected with HIV through heterosexual intercourse (12 percent) exceeds the percentage

of older adults who have become infected with HIV

through heterosexual intercourse (5 percent) (234,

237,267). Transmission through heterosexual intercourse is particularly important as a route of HIV

transmission for adolescent females. Forty-five percent of 13- to 18-year-old females with AIDS

acquired HIV through heterosexual intercourse (255).

In New York, where many adolescents with AIDS

live, close to half of the adolescent female AIDS

cases can be attributed to heterosexual spread, which

is twice the adult female rate (88,267,290).

Another indication of the importance of heterosexual HIV transmission among adolescents is the

male-to-female ratio of reported AIDS cases. For

example, compared with the 10: 1 male-to-female

ratio for adults in the United States over age 25, the

adolescent male-to-female ratio of 4: 1 more closely

resembles the 1:1 adult ratio in Africa, where the

primary route of HIV transmission is through

heterosexual intercourse (see figure 9-1) (165,237).

Given the number of adolescents who engage in

sexual intercourse, the higher proportion of heterosexual cases and the lower adolescent male-tofemale ratio illustrate the need to include a variety of

efforts for the prevention of HIV infection.

Most adolescent AIDS cases reported to date have

occurred in urban areas (227). However, AIDS cases

in rural and noncoastal areas are becoming increasingly common (77). Fifty-five percent of adolescent

me risk of HIV infection is greatest for individuals engaging in unprotected (i.e., without a condom) reeeptive anal intercourse with an infected

partnec the risk is lower for those engaging in oral intercourse and for those engaging in vaginal and insertive anal intercourse (142).

7~1S r~lng is based on 1987 data for ~Sdea~~ and 1986 data for death due to other CallSeS. Rankings for other age groups are as follows:

27th for children under age 1, 9th for 1- to 4-year-olds, and 12th for 5- to 14-year-olds (1 10).
II-262 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 9-2—Cumulative AIDS Cases Among Adolescents and Young Adults in the United States,

by Exposure Category, 1981-90a

Cumulative AIDS cases by age

13 to 19 20 to 24 225 Totalb

Exposure category No. !40 No. 0/0 No. Y“ No. “h

Male homosexual/bisexual contact . . . . . . . . . . . . . . . . . . . 145 (28%)

Intravenous (IV) drug use (female and heterosexual

male) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 (12)

Male homosexual/bisexual contact and IV drug use . . . . 23 (4)

Hemophilia/coagulation disorder . . . . . . . . . . . . . . . . . . . . . . 157 (31)

Heterosexual contactc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 (12)

Receipt of blood transfusion, blood components,

or tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 (7)

Other/undetermined d

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 (6)

Totalf

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .513 (1 OOYO)

3,254 (57$/0) 74,813 (60%) 78,212 (60°/0)

(16)

(9)

(3)

(9)

(21)

(7)

(1)

(5)

27,842

8,948

1,171

6,532

(21)

(7)

(1)

(5)

903

534

148

503

26,880

8,391

866

5,967

(2)

(3)

(99%)

(2)

(3)

(1 OOYO)

86

242

5,670

(2)

(4)

(1 OOYO)

2,995

4,1 57”

124,069

3,119

4,428

130,252

%urrent as of Apr. 30, 1990.

blncludes three patients infected with HIV type 2.

~his exposure category includes those individuals who have had sex with an IV drug user, a bisexual male, a person with hemophilia, an HIV-infected

transfusion recipient, or an H! V-infected person whose risk is not determined. In addition, the category includes individuals who are recorded as heterosexual

cases because they were born in areas of central, eastern, and southern Africa, which have distinctive patterns of transmission (i.e., most cases of AIDS occur

in heterosexuals and the male-to-female ratio is approximately 1:1).

%ther refers to two health care workers over age 25 who developed AIDS through ocapational exposure to HIV. Undetermined cases include those

individuals whose mode of HIV transmission is not known (i.e., individuals whose exposure category is being investigated, those whose category remains

undetermined after investigation, and those who either died, refused to be interviewed, or were not followed up).

~his figure includes two health care workers who developed AIDS after occupational exposure to HIV.

fBecause of rounding, percentages may not tOhl 100 percent.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Infectious Diseases, Division of

HIV/AIDS, “HIV/AIDS Surveillance,” Atlanta, GA, May 1990.

Figure 9-l—Male-to-Female Ratio for Reported AIDS

Cases in the United States, by Age of Diagnosisa

,~ , Ratio

In fact, blacks makeup a greater proportion of AIDS

cases among adolescents than do blacks in other age

groups (see table 9-3). Among adolescents, as

, “. , among young and older adults. blacks make up a I m larger proportion of female AIDS cases than of male 4A 4- I *: I

12: 1

1 o: 1

8:1

6:1

4:1

2:1

0:1

13-19 20-24

cases. Fifty-eight percent of the adolescent female

AIDS cases are black, and 30 percent of adolescent

male AIDS cases are black (237). The majority of

AIDS cases among both black and Hispanic adolescents are transmitted through IV drugs or homosexual or heterosexual contact. For white adolescents,

the primary mode of the transmission of AIDS is

through blood product exposure (see figure 9-2)

(253a).

25-29 30-39 40-4950 & over Prevalence and Incidence of HIV Infection

Age

%urrent as of Apr. 30, 1990.

SOURCE: U.S. Department of Health and Human Services, Public Heait h

Service, Centers for Disease Control, Center for infectious

Diseases, Division of IW/AIDS, “HiV/AIDS Surveillance,”

Atlanta, GA, May 1990.

AIDS cases have been reported from New York,

California, Florida, New Jersey, Texas, and Puerto

Rico (227).

Finally, black and Hispanic adolescents represent

a disproportionate share of adolescent AIDS cases in

relation to their numbers in the population (206,237).

The prevalence of HIV infection may give a more

accurate indication of the potential AIDS problem

within the adolescent population than does the count

of reported AIDS cases. Most seroprevalence studies

have relied on samples of convenience (see table

9-4), and few have included adolescents (91). Thus

far, the largest samples have come from active duty

military personnel, military recruits, and Job Corps

entrants, groups which are not representative of the

adolescent population. Data from the military indicate that adolescents ages 17 to 19 have relatively

low rates of HIV infection (31,224,225), but data
Chapter 9--AIDS and Other Sexually Transmitted Diseases: Prevention and Services ● //-263

Table 9-3—Cumulative AIDS Cases in the United States, by Age and Race/Ethnicity, 1981-908

Cumulative AIDS cases by age at diagnosis

13 to 19 20 to 24 25 to 29 >30 Total

Race/ethnicity No. 0/0 No. 0/0 No. 0/0 No. “A No. “/0

White, not Hispanic . . . . . . . . . . . . . . 246 (43°/0) 2,952 (480/.) 12,433 (53%) 64,943 (57%) 80,574 (560/.)

Black, not Hispanic . . . . . . . . . . . . . . . 206 (36) 2,001 (32) 6,731 (29) 30,923 (27) 39,861 (28)

Hispanic . . . . . . . . . . . . . . . . . . . . . . . . 102 (18) 1,159 (19) 4,066 (17) 17,005 (1:; 22,332 (16)

Asian/Pacific Islander . . . . . . . . . . . . . 7 (1) 30 (0.5) 118 (0.5) 731 886 (1)

American Indian/Alaskan Native. . . 6 (1) (0.2) 42 (0.2) 142 (0.1) 205 (0.1)

Totalb . . . . . . . . . . . . . . . . . . . . . . . . . 568 (l OOO

/.) 6,1~; (lOOO/o) 23,437 (1 OOYO) 114,044 (l OOO/.) 144,221 (I OO”LO)

Wurrent as of Aug. 30, 1990.

blncludes 363 persons whose race/ethnicit y is unknown.

SOURCE: U.S. Department of Health and Human Services. Public Health Service. Centers for Disease Control. Center for Infectious Diseases. Division of

HIV/AID’S, “HIV/AIDS Surveillance, ” Atlanta, GA; September 1990.

Figure 9-2—AIDS Cases Among U.S. Adolescents

Ages 13 to 19, by Race and Exposure Category, 1988

Race/ ethnic it y

American Indian i

Unknown 1, . . 1..1.

0 20 40 6’0 80 10012014016018 0

Number of cases

= Blood ...; Drugs

~-----

L

I Heterosexual [ Homosexual

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, Health Resources and Serwces Administration, Bureau of Maternal and Child Healt h and Resources Development,

Off Ice of Maternal and Child Health, Chi/d Hea/th Day USA, ’89,

DHHS Pub, No.HRS-MCH8915 (Rockville, MD: October 1989),

from Job Corps entrants (who are primarily economically disadvantaged 16- to 21-year-olds) suggest

that these adolescents and young adults have a

greater risk of HIV infection, though still a relatively

low risk (228). Among military recruits ages 17 and

18, the male-to-female HIV prevalence ratio is 0.9:1

(31).

Data from smaller samples suggest that certain

groups of adolescents, including runaway and homeless adolescents attending STD clinics, may have an

appreciable risk of HIV infection (30,164,192,192a,

224,225,233,267 ).8 Among runaway and homeless

adolescents age 18 staying at the Covenant House in

New York, for example, 3.4 percent tested positive

for HIV (192a).9 Survey data from anonymously

screened patients at Baltimore STD clinics show that

HIV seroprevalence rates for adolescents ages 15 to

19 were relatively high and nearly equal for males

and females (2,5 and 2 percent, respectively) (165).

HIV prevalence rates among adolescents vary by

race, and blacks bear a disproportionate share of HIV

cases. Even among male military recruits, who

appear to have a relatively low risk of infection,

black male recruits ages 17 and 18 were more than

four times as likely to be HIV infected as white male

recruits (31). Additionally, data from the Job Corps

show that black adolescents ages 16 to 18 have a

male-to-female ratio for HIV infection of approximately 1: 1, suggesting an important role for heterosexual transmission among economically disadvantaged black adolescents (190).

For adolescents of all races combined, HIV

seroprevalence rates are higher in the Northeast and

South than in other regions of the country (190). For

white adolescents, however, rates are highest in the

West (190). Screening data from 1985-87 military

recruits, 82 percent of whom were under age 25,

suggest that HIV is increasingly spreading to low

prevalence areas, particularly among young black

males (77).

Trends in the Prevalence and Incidence of STDs

Sexually active adolescents are at risk for contracting all types of STDS (see table 9-5), but

because of variable State reporting (see table 9-1)

8For ~ general discussion of the healti problems of runaway and homeless adolescents. see ch. 14? “Hopelessness: Prevention and Services, ” in

this volume.

~uring the period October 1987 to December 1989, about 2 percent of 15-to 16-year-olds, about 3 percent of 17-year-olds, and 7.4 percent of 19-

to 20-ywr-olds tested positive for HIV in this sample (192a).
II-264 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 9-4-Selected Studies of Human Immunodeficiency Virus (HIV) Seroprevalence Involving

Adolescent Groups

Date of data Age Percent HIV Number

Group collected (years) positive tested

Active duty military personnel . . . . . . . . . . . . . . . . . . . . . . . 1/87-4/88 17-19 0.0170 322,506

20-24 0.12 568,920

25-29 0.21 366,156

Civilian applicants for military service . . . . . . . . . . . . . . . 10/15/85-3/31/89 <20 0.03’?40 1,141,164

17-18 males 0.02 763.872

17-18 females 0.03 112;604

<20 black 0.10 215,869

<20 white 0.02 837,544

<20 Hispanic 0.03 55,630

Job’ Corps residential entrants . . . . . . . . . . . . . . . . . . . . . . 3/87-5/89 16-21 0.4170 84,08 9

College studentsa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA College age 0.20/0 12,00 0

Mothers of newborns screened in New York . . . . . . . . . 11/30/87-1 1/30/88 <20 upstate New York 0.13Y0 12,34 4

20-29 upstate New York 0.17 83,055

<20 New York City 0.72 17,871

20-29 New York City 1.3 67,818

Incarcerated youth in Los Angeles County . . . . . . . . . . . 2187-8187 16-17 0.2”/0 1,878

Runaway and homeless youth in Covenant

House, New York City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10/87-1 2/89 15-16 2.2Y0 312

17 2.9 340

18 3.4 591

19-20 7.4 1,403

Sexually transmitted disease (STD) clinic

patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212187-4130187 15-19 females 2.5?4. 434

15-19 males 2.0 509

20-24 females 3.4 385

20-24 males 3.8 840

25-29 females 2.9 239

25-29 males 6.9 598

Adolescents in an adolescent clinic in

Washington, DC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10/87-1/89 13-18 o.37°/ob 3,520

13-15 0.11

15-18 0.69

KEY: NA = not available.

aMajority of cases come from males.

~his represents only 46 percent of all positive adolescents seen during the 15-month study interval.

SOURCE: Office of Technology Assessment, 1991, based on the following sources: Active-duty military personnel: U.S. Department of Health and Human

Services, Pubiic Health Service, Centers for Disease Controi, “Prevalence of Human immunodeficiency WusAntibocty in U.S. Active Duty-Military

Personnei, Aprii 1988,” A-fofbldityarrcfh formality Week/y RePof’t37(30):461 -463, Aug. 5, 1988. Civilian applicants: D.S. Burke, J.F. Bruncfage, M.

Goldenbaum, et ai., “Human Immunodefidency Virus infections in Teenagers: Seroprevalence Among Applicants for U.S. Military Service,” Journal

of the American Medica/Association 263(1 5):2074-2077, 1990. Job Corps, college students, Incarcerated youth: U.S. Department of Health

and Human Services, Pubiic Health Service, Centers for Disease Control, Center for infectious Diseases, “AIDS and Human immunodeficiency

Virus Infection in the Unitad States: 1988 Update,” Morbidity and Morla/ity Week/y RePoti38(S-4):1 -38, May 12,1989. Mothers of newborns: L.F.

Novick, D. Berns, R. Stricof, et ai., “HiV Seroprevaience in Newborns in New York State,” Journal of the American Meckad Association

261(12):1745-1750, 1989. Runaway and homeless youth: R. Stricof, J. Kennedy, T.C. Nattell, et al., “HiV Seroprevaience of Adolescents in a

Faciiity for Runaway and Homeiess Adolescents,” American Journal of Pub/ic Health 81( Supplement) :50-53, 1991. STD clinic patients: T.C.

Quinn, D. Giasser, R.O. Cannon, et al., “Human immunodeficiency Virus Infection Among Patients Attending Clinics for Sexuaiiy Transmitted

Diseases,” New ErtgkwdJouma/ of Medicine 318(4):197-203, 1988. Adolescent clinic patients: L. D’Angelo, P. Getson, N. Luban, et ai., “HIV

Infection in Adolescents: Can We Predict Who Is at Risk,r’ poster presentation at the Fifth international Conference on AIDS, “The Scientific and

Sodal Challenge,” Montreal, Quebec, Canada, June 4-9, 1989.

and the reticence of private physicians to report HIV seroprevalence studies in that they are typically

STDs,10 it is impossible to estimate national inci- based on small samples of convenience (see table

dence and prevalence rates for STDs other than 9-6). Still, the available data indicate that chlamydia

gonorrhea and syphilis. STD surveys are similar to infection and other STDs are much more common in

1~~~ ~20 ~~cent of SD repom come fmm Pfivate physicians; approximately 80 percent come from public Smclinics (82). Two-~ds of

gonorrhea cases are reported from public health clinics (241). Younger adolescents ages 10 to 14 of both sexes and older fernale adolescents ages 15

to 19 have approximately the same ratio of case reporting from public and private facilities.
Chapter 9-AIDS and Other Sexually Transmitted Diseases: Prevention and Services ● (1-265

Table 9-5—Overview of Selected Sexually Transmitted Diseases and Syndromes

Typical presenting signs and Examples of

Agent Disease or syndrome symptoms potential complications/

sequelae

Bacterial Agents:

Neisseria gonorrhoeae . . . . . .,

Gardnerella vaginalis . . . . . . . . .

Ch/arnydia frachomatis . . . . . . .

Treponema pallidum. . . . . . . . . .

Hemophilusducreyi . . . . . . . . . .

Shigella sp. . . . . . . . . . . . . . . . .

Virai Agents:

Herpes simpiex virus

(HSV) 1 .......,..,,,.....,

Herpes simpiex virus

(HSV) 2 . . . . . . . . . . . . . . . . . . .

Human papillomavirus(HPV) . .

Hepatitis B virus. . . . . . . . . . . . . .

Cytomegaiovirus . . . . . . . . . . . . .

Human immunodeficiency

virus (HIV) . . . . . . . . . . . . . . . . .

Mycopiasmai Agents:

Urea@asma urealyticum . . . . . .

Protozoa:

Trichomonas vaginalis . . . . . . . .

Fungi:

Candida albicans . . . . . . . . . . . . .

Gonorrhea

Nonspecific vaginitis

Chlamydiai infections:

Nongonococcai urethritis

Mucopuruient cervicitis

Primary syphiiis

Secondary syphilis

Chancroid

Shigeiiosis

Nongenitai herpes

Genital herpes

Condyloma acuminatum

Hepatitis

Heterophil negative

mononucleosis

HiV infection

Acquired immunodeficiency

syndrome (A iDS)

Nongonococcal urethritis

Trichomoniasis

Genital candid iasis

Abnormal vaginai or penile

discharge, abdominai pain;

may be asymptomatic

Vaginal inflammation, abnormal

discharge; may be

asymptomatic

Dysuria, urinary frequency,

abnormal penile discharge;

may be asymptomat ic

Abnormal endocervicai

discharge; may be

asymptomatic

Chancre

Skin rash, mucous patches,

Iymphadenopathy,

condyioma iata

Genitai ulceration, often painfui,

accompanied byadenopat hy

Diarrhea, tenesmus, abdominai

cramping

Blisters on eyes or other faciai

regions

Blisters, genitai uicers,

stomatitis, and orai iesions

Warty lesions in genital or anal

area

Maiaise, jaundice, vomiting; may

be asymptomatic

Malaise, Iymphadenopathy

Generalized Iymphadenopathy,

weight loss, night sweats,

intermittent fever, malaise,

diarrhea; may initiaily be

asymptomatic

Symptoms of opportunistic

infections such as

pneumocystic pneumonia,

or kaposi’s sarcoma

Dysuria, urinary frequency,

abnormal peniie discharge;

may be asymptomatic

Vaginai inflammation, abnormai

discharge, nongonococcal

urethritis; may be

asymptomatic

Vaginal inflammation, abnormai

discharge, vulval

inflammation; may be

asymptomatic

Disseminated gonococcai

infection (e.g., septicemia),

PID, infertility, epididymitis

Recurrent infection

Urethrai stricture, prostatitis,

epididymitis

Endometritis, salpingitis,

infertility, adverse obstetric

outcomes

Late (tertiary) syphilis and

sequeiae, neurosyphiiis

Secondary infections of iesions,

phimosis

Rectai prolapse, dysentery

Aseptic meningitis, recurrent HSV

infection

Disseminated infection,

recurrent HSV infection

Genital dyspiasia, carcinoma

Cirrhosis, iiver failure, arthritis,

death

Congenital cytomegaiic

inclusion disease

Full-blown AIDS

Death

Urethrai stricture, prostatitis,

epididymit is

Secondary excoriations,

recurrent candidiasis

SOURCE: Office of Technoloav Assessment. 1991, based on U.S. Department of Health and Human Services, Pubiic Health Service, Centers for Disease

Control, “Sexually-~ransmi tted Disease Summary: 1990,’’’Atianta, GA, June 1990.
Table 9-6-Selected Studies Demonstrating Prevalence Rates of Sexually Transmitted Diseases (STDs) Among U.S. Adolescents

study’ Population Age Location tested gonorrhoeae) tradromatis) vaginalis) Other STD

Alexander-Rodriguez New York City, NY 4.8%

and Vermund, 1987

STD and percent of study group infected

Gonorrhea Chlamydia Trichomaniasis

Number (Neisseria (Chlamydia (Trichomonas

Bell, Farrow, Stamm, et

al., 1985

Chacko and Lovchik,

1984

D’Angelo, Mohla, Sneed,

et al., 1987

Eager, Bead-r,

Davidson, et al., 1985

Fraser, Rettig, and

Kaplan, 1983

Hardy, Hardy, Nell, et

al., 1984

Jaffe, Siqueria,

Diamond, et al., 1986

Johnson, Nahmias,

Magder, et al., 1989

Martinez, Smith,

Farmer,

et al., 1988

Adolescent male and

female entrants into the

New York City Juvenile

Detention Center

Female detainees in a

juvenile detention

center

Urban sexually active

young males and

females

Adolescents seen in the

Adolescent and Young

Adult Clinic of the

Children’s National

Medical Center

Sexually active females

attending three

ethnically diverse urban

Department of Health

and Hospitals

adolescent clinicsb

Indigent girls

Low-income pregnant,

predominantly black,

females receiving

Prenatal care in the Johns

Hopkins Adolescent

Pregnancy Program

Low-income sexually

active black and

Hispanic females

attending the

Adolescent Health

Center of Mount Sinai

Hospital

Participants in the

National Health and

Nutrition Examination

Survey

Sexually active

adolescent females, who

are primarily black and

from low-income

communities, attending

an adolescent clinic of

the University of

Maryland Hospital

9-18

12-18

—

12-18

13-17

14-20

1-74

13-19

Seattle, WA

Baltimore, MD

Washington, DC

Denver, CO

Oklahoma City, OK

Baltimore, MD

New York City, NY

United States

Baltimore, MD

2,521

100

280

567

396

125

115

95

4,201

89

(males: 3.O%;

femalas: 18.3%)

18%

3%

18.5%

7 %

(blacks:16% ;

Hispanics: 4%;

whites: 2%)

3.8%

1 0.40/’

8.4%

—

—

— — Syphilis (Treponema

Pallidum): 0.83% males:

0.63%; females: 2.5%)

20% 48% Bacterial vaginosisd

:

25%.

22% 16% —

— — —

21% 6% —

(blacks: 28%; (blacks: 20%;

Hispanics 23%; Hispanics: 2%;

whites: 14%) whites: 1 %)

15.3 % —

370/0 34%

26.30/0

(blacks: 28.6%; —

Hispanics:

24.1%)

—

—

—

—

Candidiasis (Candida

albicans): 38?/.;

Mycoplasma

hominis: 70%;

Ureaplasma

urealyticum: 90%

—

Herpes (Herpes

simplex virus type 2):

<1% under age 14

Condyloma

acuminatum (Human

papillomavirus): 13%
Table 9-6—Selected Studies Demonstrating Prevalence Rates of Sexually Transmitted Diseases (STDs) Among U.S. Adolescents-Continued

STD and percent of study group infected

Gonorrhea Chlamydia Trichomaniasis

Number (Neisseria (Chlamydia (Trichomonas

study’ Population Age Location tested gonorrhoeae) trachomatis) vaginalis) Other STD

Neinsteln and

Rabinovitz, 1988

Oh, Feinstein, Soileau,

et al., 1989

Saltz, Linnemann,

Brookman, et al., 1981

Shafer, Beck Blain, et

al., 1984

Shafer, Schachter,

Moscicki, et al., 1989

All adolescents having 12-21

a chlamydia culture at

the Teenage Health

Center at Children’s

Hospital

Inner-city low-income 12-18

adolescent females

seeking contraceptive

counseling at the Teen

Accent Clinic

Low- and middle- —

income sexually active

adolescent females from

urban areas attending

the Adolescent Clinic of

the Children’s Hospital

Medical Center

Sexually active 13-21

adolescent females from

working class and

impoverished inner-city

families attending the

University Hospital Teen

Clinic or the San

Francisco General Teen

Family Planning Clinic

Sexually active 13-19

asymptomatic

adolescent males

attending teen and

detention clinicsc

Los Angeles, CA

Birmingham, AL

Cincinnati. OH

San Francisco, CA

San Francisco, CA

184

376

100

366

948

6.5%

6.8%

30/0

3.80/0

(blacks: 7.6%;

Hispanics:1.4%;

whites: 2.1%)

9%

20.1 % — —

1 9.4% — Trichomoniasis

(Trichomonas

vaginalis): 13.6%;

Herpes (Herpes

simplex virus): 1.1%

220/0

1 5.3%

(blacks: 23.3%;

whites:10.3%)

16% Candidiasis (Candida

albicans); 26%; Group

B streptococci: 60%

8% —

(blacks:1 3.6%;

Hispanics 2.9%.;

whites:8.O%)

KEY: — - no data provided;s - significant difference.

aFull a’tations are listed at the end of this chapter.

bTwo of the Clini= served Pfimady low-in~me bl~k andHispanic adolescents The third clinic served primafily white adolescents from IOW- to middle-income familieS.

~een clinics included a university and health maintenance organization-based adolescent clinic. The detention clinic was a general clinic for incarcerated adolescents. Excluded from the study were

adolescent males who had symptoms of urethritis, had taken antibiotics within the past 3 weeks, had a systemic disease, or identified themselves as homosexual.

d~is includes multipie organisms.

SOURCE: Office of Technology Assessment, 1991.
II-268 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

the adolescent population than HIV infection is. In

fact, if the number of sexually active adolescents is

used as the denominator in calculating rates instead

of the entire adolescent population, overall STD

prevalence rates are even higher (88).

In general, STD rates appear to vary by sex and

race, there being more STDs reported among adolescent females than males and more among nonwhites

than among whites (86,194,201,240). The overrepresentation of females may be explained in part

by the fact that sexually active females seeking

family planning services are frequently screened for

common sexually transmitted infections regardless

of the presence or absence of symptoms (10).

Sexually active male adolescents have no such

formal access to reproductive health care. The high

reported STD rates among black and Hispanic

adolescents may reflect the tendency of these

adolescents, who are disproportionately of low

socioeconomic status, to use public health clinics,

which report STDs more completely than do private

practitioners (17,125,287). An additional reason

may be the higher rate of sexual intercourse among

black adolescents (145).11

Prevalence and Incidence of Chlamydia Infection

The bacterium Chlamydia trachomatis is the

agent that causes chlamydia infection, the most

common type of STD infection among adolescents

(9,55,176,180,182,201). Infected individuals, especially females, often experience no symptoms or

signs of chlamydia infection (240). It is important to

note, however, that chlamydia infection can lead to

pelvic inflammatory disease (PID) in females and

epididymitis 12 in males (36), both of which may

result in involuntary infertility.

Although national surveillance of chlamydia infection is based on pilot projects (35), data from

selected studies of adolescent females attending

various types of clinics (i.e., STD clinics, juvenile

detention clinics, and adolescent clinics) suggest

that chlamydia infection appears to be highly

prevalent among certain subgroups of sexually

active adolescents, particularly among black innercity adolescents from low socioeconomic backgrounds (see table 9-6) (15,67, 103,151,176,180,181,

182,240). This observation may reflect the fact that

many STD clinics are located in large metropolitan

areas.

13 Chlamydia infection rates vary from 3 to 37

percent depending on the surveyed population. One

study of ethnically diverse sexually active females

ages 12 to 18 attending three urban adolescent health

clinics in Denver found significant differences

among black (28 percent), Hispanic (23 percent),

and white (14 percent) adolescents’ rates of chlamydia infection (67).

Prevalence and Incidence of Gonorrhea

The bacterium Neisseria gonorrhoeae is the agent

that causes gonorrhea, the second most common

STD among adolescents (55). As table 9-6 shows,

female adolescents who attend health clinics and

juvenile detention centers and are from racial or

ethnic minority groups may be at particular risk of

Neisseria gonorrhoeae infection, with prevalence

rates ranging from 3 to 18 percent (4,15,39,54,67,73,

103,129,149,151,176,180,1 81). Black adolescent females ages 13 to 21 who attended a teen and family

planning clinic in San Francisco were more likely to

test positive for Neisseria gonorrhoeae (7.8 percent)

than either their white (2. 1 percent) or Hispanic (1.4

percent) peers (85,180).

Because reporting of gonorrhea cases is required

in all 50 States (see table 9-l), a more reliable

indicator of the extent to which Neisseria gonorrhoeae has occurred in the adolescent population

may be the number of reported gonorrhea cases

among adolescents (239) (see figure 9-3).

In 1989, the most recent year for which data on

gonorrhea rates are available, the incidence of

gonorrhea in adolescents ages 10 to 14 was 69.7

cases per 100,000 (equal to 11,820 cases) and the

incidence rate in adolescents ages 15 to 19 was

1,145.4 cases per 100,000 (204,023 cases) (13a).

Adolescents ages 10 to 19 accounted for 29.4

percent of newly reported gonorrhea cases in 1989

(13a). Although various factors may make year-byyear comparisons unreliable, it is disturbing to note

that the incidence rate of gonorrhea jumped 63

percent among 10- to 14-year-olds between 1987

and 1989. Gonorrhea incidence rates have hovered

around 1,200 cases per 100,000 adolescents for

1 lAdo1e5mnt5* sexu~ activity rates are diSCUS.d in ch. 10, “Pregnancy and Parenting: Prevention and Services, ” in this volume.

~zpelvlc inflammtoV disease is tie ~a.mmation of any female pelvic organ. Epididymitis is the ~ammation of the epididymis.

13~ some ~a5e5, ~divid~s from StiIm comm~ties attend these clinics because they pWXiVe them aS Offering b@ler services ~d grater

confidentiality (122).
Chapter 9--AIDS and Other Sexually Transmitted Diseases: Prevention and Services . II-269

Figure 9-3--Gonorrhea Incidence

Incidence rate (cases per 100,000 population)

1,400

1,200 :

L

~.M

1,000

800

600

400

200

0 ET –T—..7 -r—r –- ---

.—— - T ——

77 78 79 80 81 82 83 84 85 86 87 88 89

Year

— 10- to 14-year-olds -

15- to 19-year-olds

Gonorrhea Incidence Rates for 10- to 19-Year-Olds, 1977-89

Rates Among U.S. Adolescents, 1977-89

Incidence rate (cases per 100,000 population)

1,600 I 1

1,400

1,200

1,000

800

600

400

200

0 h

77 78 79 80 81 82 83 84 85 86 87

Year

_ Males (10-14 yrs) ~

~ Males (15-19 yrs) m

Gonorrhea Incidence Rates for 10- to

Females (10-14 yrs)

Females (15-19 yrs)

19-Year-Olds by Sex,

1977-87’

aNOte inciden~ rates by sex were not available for 1988 and 1989 as this report was being written

SOURCES: F. Barnes, Education Specialist, Center for Prevention Services, Centers for Disease Control, personal communication, Atlanta, GA, Feb. 28,

1991. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Prevention Services,

Division of Sexually Transmitted Diseases, Sexua//y Trarrsmitfed Disease Statkfics: 1987, Issue No. 146 (Atlanta, GA: October 1988); and U.S.

Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Prevention Services, Ditision of

Sexually Transmitted Diseases, Sexua/ly Transmitted Disease Statistics: 1985, Issue No. 145 (Atlanta, GA: August 1987).

15- to 19-year-olds. There are marked differences in

rates of reported cases by sex. The reported gonorrhea incidence rate is higher in adolescent females

than in adolescent males. For females ages 10 to 14,

the rate in 1989 was over three times that of males,

and for females ages 15 to 19, the rate was

approximately 1.5 times that of males (see figure

9-3). 14 It is important to note that, if the proportion

of sexually active adolescents were to be used as the

denominator, the gonorrhea rates would be higher

(90). The proportion of sexually active 10-to

14-year-olds is unknown.

Prevalence and Incidence of Condyloma

Acuminatum

Human papillomavirus (HPV), which often results in condyloma acuminatum (exophytic warty

lesions) has also been associated with cervical and

anal cancer. As shown for other STD agents, the

prevalence of HPV may be high within certain

adolescent subgroups. For example, data from a small,

selected sample of predominantly black adolescent

females attending a Baltimore adolescent clinic indicate that 13 percent were infected with HPV (129).

Prevalence and Incidence of Herpes

Herpes simplex virus (HSV) causes herpes, usually producing small, sometimes painful blisters on

the skin or mucous areas of the body. HSV 1

infections are usually nongenital (e.g., herpes labialis); HSV 2 infections are usually limited to the

genital region (e.g., herpes genitalia). Few adolescents have tested positive for HSV infection. According to results from the National Health and

Nutrition Examination Survey conducted between

1976 and 1980 (NHANES II), for example, less than

1 percent of adolescents under age 15 were infected

with HSV 2 (106). Because of the large number of

subclinical infections and because symptoms occur

in less than 40 percent of HSV infections detected

serologically (106), however, these rates may underestimate the extent of infection within the adolescent

population.

Prevalence and Incidence of Syphilis

Syphilis is caused by the bacterial organism

Treponema pallidum. The first two stages of the

infection, primary and secondary syphilis, are followed by a period of latency. Without treatment,

some individuals may eventually develop tertiary

syphilis. Because tertiary syphilis usually takes

many years to develop, individuals between the ages

of 10 and 18 are not likely to develop this stage of

infection during adolescence.

14~e &m Provided by CDC are not broken down by race ~d age.
11-270. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 9-4-Syphilis Incidence Rates Among U.S. Adolescents, 1977-89

Incidence rate (cases per 100,000 population) 30

25

20

15

10

5

0 , 1 1 1 1 1 1 1 I , I

Incidence rate (cases per 100,000 Population) 30 ] I

15

10

5

0

77 78 79 80 81 82

1

83 84 85 86 87

IL

Year

= Males (10-14 yrs) = Females (10-14 yrs)

77 78 79 80 81 82 83 84 85 86 87 88 89 U Males (15-19 yrs) = Females (15-19 yrs)

Year

— 10- to 14-year-olds ‘+– 15- to 19-year-olds

Primary and Secondary Syphilis Incidence Rates for Primary and Secondary Syphilis Incidence Rates for

10- to 19-Year-Olds, 1977-89 10- to 19-Year-Olds by Sex, 1977-87a

aNote incidence rates by sex were not available for 1988 and 1989 as this Report was being Written.

SOURCES: F. Barnes, Education Specialist, Center for Prevention Services, Centers for Disease Control, personaI communication, Atlanta, GA, Feb. 28,

1991. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Prevention Services,

Division of Sexually Transmittal Diseases, Sexua//y Transmitted Disease Statistics.’ 198Z Issue No. 146 (Atlanta, GA: October 1988); and U.S.

Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Prevention Services, Division

of Sexually Transmitted Diseases, Sexually Transmitted Disease Statistics: 1985, Issue No. 145 (Atlanta, GA: August 1987).

primary and secondary syphilis incidence rates

among adolescents ages 15 to 19 in the 50 States

have increased substantially since 1977 (see figure

9-4).15 For all age groups (including adolescents),

the increases appear to be largely among heterosexuals and among individuals living in California,

Florida, and New York City (220).16 For 10- to

14-year-olds, the 1987 syphilis prevalence rate of

1.4 cases per 100,000 population was the highest

reported in over 30 years and represents a 75-percent

increase from 1977; the 1989 rate was 1.27 per

100,000 (13a). For 15- to 19-year-olds, the 1987 rate

(23.7 per 100,000) was the highest since 1965

(220,240); the 1989 rate was 24.74 per 100,000.

Most of the increase in syphilis morbidity is

accounted for by the large increase in the reported

rate among female adolescents. Between 1977 and

1987, the incidence rate for adolescent females ages

10 to 14 and 15 to 19 increased approximately 120

percent, while the syphilis prevalence rate for 10- to

14-year-old males stayed almost constant, and the

rate for 15- to 19-year-old males increased 33

percent (see figure 9-4) (240).

Prevalence and Incidence of Chancroid

Chancroid is a highly contagious, local ulcer

caused by infection with the bacterium Haemophilus

ducreyi. Internationally, chancroid is more common

than syphilis (for all ages combined) (42). With just

under 5,000 cases reported in 1987, chancroid is

currently uncommon in the United States (125,240).

Cases have been reported in 23 States with the

highest rates reported in New York, Florida, and

Georgia (240). The proportion of adolescents currently infected with chancroid is not known, and

accurate reports are difficult to obtain (179).

Prevalence and Incidence of Pelvic Inflammatory

Disease (PID)

PID is caused by Neisseria gonorrhea,

Chlamydia trachomatis,17 and other organisms and

is the most common consequence of STD infection

for women (29,221,240,270,276). Forty-three percent of women hospitalized with PID are under age

25 (240). Between 1975 and 1981 approximately 16

percent of over 260,000 women ages 15 to 44

experiencing an episode of PID were between the

15~e CDC dab me not broken down by race and age. Among Native Americans of W ages (including adol~wnts) in eight reseNtldOn Shtm, tie

primary and secondary syphilis rate was 26.5 per 100,000 in 1985, more than three times the overall rate (7.1 per 100,000) for those States. The U.S.

incidence rate for primaxy and secondary syphilis was 11.4 per 100,000 (101).

16~e cities ~fihe ~@est ~tes tieA~@ w,wp% Memp~, Wastigtom ~, md New York City (241).

ITAppm~ately 40 ~rmnt of all pm cxes in the United States are caused by c~~my~”a fiacho~tis (2~).
Chapter 9-AIDS and Other Sexually Transmitted Diseases: Prevention and Services ● II-271

ages of 15 and 19 (271). In general, black adolescent

females are reported to have received treatment for

PID more frequently than are whites (240,271). The

reason for this is unclear. It may be that socioeconomic status accounts for the difference in incidence

and thus treatment episodes; for example, white

females, or middle-class females in general, could be

misdiagnosed or given a different diagnosis because

of the social stigma attending an STD (90).

Factors Associated With HIV and STDs

All STD agents and HIV can be transmitted from

an infected person to another partner through sexual

intercourse-- oral, anal, or vaginal (149,175,211,

223). 18 Increasingly, HIV infections have been

linked with the sharing of contaminated needles

used to inject illicit drugs and intercourse between

infected IV drug users and their sexual partners

(233,235,242). The use of crack cocaine, because of

its association with increased levels of sexual

intercourse, is thought to have contributed to enhanced HIV and STD levels in a number of States,

such as New York, New Jersey, and Georgia (154).

The adolescent population is heterogeneous, and

the risk of HIV infection and STDs varies for

different groups of adolescents (89). For adolescents

who have not had sexual intercourse at all or who

have had few partners, and who do not use IV drugs,

the risk of HIV or STD infection is low. At higher

risk are adolescents who do one or more of the

following:

●

●

●

●

●

●

●

engage in sexual intercourse at early ages (136,

153);

engage in unprotected anal intercourse;

engage in male-to-male sexual relations (167);

have several sexual partners (234);

have sex with IV drug users;

do not use condoms during sexual intercourse

(222,234);

use drugs that can be administered intravenously, such as cocaine, amphetamines, steroids, and heroin (88,144,168,212,214,227).

Statistically, members of racial and ethnic minority

groups with low socioeconomic status may be at

particular risk of both HIV infection and STDs

(234).

Sexual and Drug-Using Behaviors19

Some adolescents engage in sexual or drug-using

behaviors that put them at risk for HIV infection or

STDs.

Sexual Behavior—By age 18, 47 percent of

adolescent females and 65 percent of adolescent

males have engaged in sexual intercourse (127);

furthermore, data from California, Michigan, and

San Francisco suggest that between 16 and 35

percent of adolescents in those areas have had

intercourse before age 15 (33,226). Black adolescents are more likely than whites and Hispanics to

report having had sexual intercourse (96,127,

139,140,185,284). This holds true at every age,

Although some adolescents do not have sexual

intercourse until after age 18, some adolescents

engage in risky sexual behaviors that increase their

chances of infection. Data on particularly risky

sexual behaviors, such as anal intercourse, are very

sparse for adolescents. Two studies with very small

samples, however, do suggest reason for concern.

One study, by Goodman and Cohall, found that 8

percent of sexually active racial and ethnic minority

adolescents attending a comprehensive clinic in a

New York City public high school reported participation in anal intercourse (83). It is not clear from this

study whether condoms were used during anal

intercourse. Jaffe and colleagues reported that 26

percent of adolescent females in a clinic population

had had anal intercourse (102).

The most effective way to prevent the transmission of HIV and other STD agents is to abstain from

sexual intercourse. For individuals who do engage in

sexual intercourse, however, the most effective way

to prevent transmission is to prevent the exchange of

blood, semen, or vaginal fluid. Various studies

among adults found that the use of latex condoms

lubricated with nonoxynol-9 is effective in lowering,

but not eliminating, the risk of STD and HIV

infection (46,69,74,107,172,222,234). The actual

effectiveness of condoms in preventing transmission

of HIV infection and STDs among adolescents is not

known (273), because most data collected on adolescent condom use are from studies that have investi18~n ~ddltlon, ~V ad most SD ~gen~ Ca & passed pe~t~]y from mother to child (233,234,235).

l~or a discussion of adolescents’ sexual practices, see ch. 10, “Pregnancy and Parenting: Prevention and Semices. ’ For a discussion of the use of

drugs by adolescents, see ch. 12, “Alcohol, Tobacco, and Drug Abuse: Prevention and Services, ” also in this volume.
II-272 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

gated condom use as a method of contraception and

not as a method of protection from STDs.20

Most adolescents do not use any method of

contraception at first intercourse (45,195,288), and

they often delay contraceptive use up to a year after

they have become sexually active (285,288). Among

adolescents who do use contraception at first intercourse, however, condoms are one of the most

commonly used methods of contraception (161,185,

195,285,288). 21 For adolescents who use condoms,

there appear to be important racial, ethnic, and age

differences. One study found that white adolescent

females are more likely than either black or Hispanic

adolescent females to have intercourse with partners

who use condoms (195). Another study among a

small, selected sample of sexually active inner-city

black and Hispanic adolescent females found that

some of these adolescents were less likely to use

condoms during anal intercourse than during vaginal

intercourse, although anal intercourse is believed to

be more risky than either oral or vaginal intercourse

in transmitting HIV (102). A study in Minnesota

found that 9th graders were significantly less likely

than 12th graders to use condoms (138).

Drug Use--As a group, adolescents are less

likely to engage in drug-using behaviors that put

them at risk for HIV and STDs than they are to

engage in sexual behaviors that put them at risk. In

recent statewide surveys in Massachusetts, for

example, only 0.1 percent of adolescents reported

engaging in IV drug use (95). Nevertheless, there are

some adolescents who do use IV drugs and probably

share IV needles, who exchange sex for drugs, or

engage in sexual intercourse without condoms

because of drug- or alcohol-induced disinhibitions

and loss of judgment. Adolescents at highest risk

may be adolescents who have been abused,22 adolescents who are homeless or runaways,23 adolescents

who have engaged in prostitution, and adolescents

who have been locked up in a juvenile detention

facility 24 (4,57,152,167,192,250). One Texas study

found that 7 percent of 213 runaways ages 11 to 16

reported injecting illicit drugs (98). However, surveys of high school students by CDC have found

considerable geographic variation in IV drug use

(226,231).

Although the use of drugs such as heroin among

adolescents is not widespread, the use of alcohol and

some other drugs is more prevalent and may, in fact,

encourage risky sexual behavior that results in the

transmission of HIV and STDs (35).25

Lack of Information

In general, American adolescents have a fairly

high level of factual knowledge regarding HIV

transmission and methods of preventing its transmission (226). Data from the 1987 National Adolescent Student Health Survey suggest, however, that

many American adolescents lack information or are

misinformed about many aspects of transmission,

prevention, and treatment of other STDs (see table

9-7).26 Approximately 30 percent of a nationally

representative sample of 8th and 10th graders did not

know that most STDs are acquired through sexual

intercourse, and a substantial minority did not know

or were unsure that a sore on the sex organs (33

percent) and discharge of pus from a sex organ (44

percent) were signs of STD infection. Those adolescents who were female or older had more accurate

information.

Although the National Adolescent Student Health

Survey found that students, particularly 10th graders, seem to know more about HIV transmission and

prevention than about STDs, a large minority of

students continued to be misinformed about specific

sexual behaviors that put them at risk of HIV

infection (7). While over 90 percent of the students,

both 8th and 10th graders, knew that HIV could be

transmitted through sexual intercourse, for example,

~~e u5e of condoms to prevent pregnancy among adolescents is discussed inch. 10, “Pregnancy and Parenting: Prevention and Services,’ in this

volume.

211n 1988,47 Pwcent of U.S. fem~e5 ages 15 to 1$) used a condom at f~st ~tercourse (72a). Twenty percent of sexdy active feIIUdeS ageS 15 tO

19 reported current use of condoms as a method of contraception (140a).

22For a d&u55ion of adole5cent5 who ~ve been m~treated, see ch. 3, “parents ~d F~ies’ Muence on Adolesunt Heal@” hl I.hiS VOhlIlle.

~For a discussion of homeless and runaway adolescents, see ch. 14, “Homelessness: Prevention and Sewices, ” in this volume.

~For a discussion of tie he~~ of adolescents in juvenile detention facilities, Seed. 13, “Delinquency: Prevention and Services, ” in this volume.

~For a discussion of tie use of ~cohol ad o~er ~gs by adolescents, sw Ch. 12 ‘ ‘Alcohol, ‘roba~o ad Drug Abuse: Prevention ~d Services, ”

in this volume.

261t is fipo~t t. note tittie Natio~ Adolescent Student He~~ survey did not hclude out-of-school yOU@ a grOUp thiit mily be at p~CUhN

risk for contracting STDS.
Chapter 9--AIDS and Other Sexually Transmitted Diseases: Prevention and Services .11-273

Table 9-7—Eighth and Tenth Grade Students’ Knowledge Regarding STDs,

by Grade and Sex, 1987

Grade Sex

Total 8th 10th Male Female

Transmission of STDs:

How do most people get STDs?

Objects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5%

Kissing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5

● Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69.6

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.4

Method of preventing STDs:

Not having sex:

● Very effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57.5

Somewhat effective . . . . . . . . . . . . . . . . . . . . . . . . . . 14.1

SIightly effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.6

Noneffective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1

Don’t know...........,.. . . . . . . . . . . . . . . . . . . . . 10.7

Going to the bathroom after having sex:

Very effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3

Somewhat effective . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6

● Slightly effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.5

● Noneffective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.3

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34.3

Taking birth control pills:

Very effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.0

Somewhat effective . . . . . . . . . . . . . . . . . . . . . . . . . . 11.8

Slightfly effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.2

● Non effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.5

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.6

Washing after sex:

Very effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.6

Somewhat effective . . . . . . . . . . . . . . . . . . . . . . . . . . 13.0

Slightly effective.......,.. . . . . . . . . . . . . . . . . . . . 18.7

● Non effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32,7

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29.0

Having sex with steady partner

● Very effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.6

‘Somewhat effective . . . . . . . . . . . . . . . . . . . . . . . . . 28.9

Slightly effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.7

Noneffective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.7

Don’t know.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.1

Using condoms:

● Very effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.7

*Somewhat effective . . . . . . . . . . . . . . . . . . . . . . . . . 24.5

Slightly effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.9

Noneffective, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.7

Signs of STDs:

Lower abdominal pain in females:

● ls a sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44.9

Is not a sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48.0

Nausea and vomiting:

Is a sign,......,...,...,.. . . . . . . . . . . . . . . . . . . . 27.8

*Is not a sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.6

Don’ t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57.6

Discharge of pus from sex organs:

● ls a sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56.4

Is not align . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.7

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39.8

Sore on sex organs:

● ls a sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67.0

Is not a sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.8

5.5%

4.0

58.9

31.6

48.6

14.7

7.5

14.1

15.2

3.9

9.6

12.0

33.2

41.2

8.9

13.3

11.4

34.1

32.3

7.0

12.3

14.6

29,5

36.6

19.2

23.7

16.5

16.3

24.3

38.2

21.8

8.1

12.2

19.7

39.3

7.7

52.9

25.0

13.1

61.8

44.8

4.6

50.6

56.4

3.1

40.4

3.5%

3.1

79.2

14.1

65.8

13.4

5.8

8.3

6.6

2.7

7.6

12.9

48.8

28.0

5.3

10.4

9.0

55.8

19.5

6.3

13.7

22.4

35.6

22.0

27.6

33.6

13.1

13.2

12.5

48.8

27.0

5.8

10.1

8.2

49.9

6.6

43.5

30.3

15.9

53.7

67.1

2.9

30.0

76.6

1.3

22.1

4.5%

4.2

68.6

22.7

56.8

14.3

7.9

10.8

10.2

4.0

9.7

13.4

39.3

33.6

7.4

11.6

10.0

44.0

27.0

7.1

16.5

19.4

30.5

26.6

26.8

29.9

12.4

14.0

16,9

47.8

23.4

5.6

11.2

12.1

40.5

6.7

52.8

26.3

15.0

58.7

53.4

4.0

42.6

64.1

2.8

33.1

4.5 %

2.8

70.6

22.2

58.4

13.8

5.2

11.3

11.2

2.5

7.4

11.6

43.4

35.1

6.5

12.0

10.3

47.1

24.1

6.2

9.5

18.0

35.0

31.4

20.2

27.8

17.1

15.5

19.3

39.5

25.7

8.3

11.0

15.4

49.4

7.7

42.9

29,4

14.1

56.4

59.7

3.4

36.9

70.1

1.5

28.5

Continued on next page
II-274 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 9-7—Eighth and Tenth Grade Students’ Knowledge Regarding STDs,

by Grade and Sex, 1987—Continued

Grade Sex

Total 8th 10th Male Female

Pain when going to the bathroom:

● ls a sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59.3

Is not a sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5

Don’t know........................................,.......,.......,...,., 36.2

Appropriate responses to possible STD:

Wait to see if signs go away:

Helpful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3

● Harmful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56.6

No effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.9

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.1

Take leftover medicine for similar problem:

Helpful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6

● Harmful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59.9

No effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.9

Get tested for STD:

“Helpful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88.2

Harmful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.6

No effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.6

Do not have sex:

● Helpful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67.2

Harmful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.0

No effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.7

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.1

Tell sex partner:

● Helpful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76.5

Harmful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3

No effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.9

Take medicine only until signs go away:

Helpful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.4

● Harmful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.8

No effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.8

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.9

Treatment for STDs:

Public health department informs parents of

STDs in minors:

True . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40.1

● False . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.3

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.7

Most clinics require parental permission for

treatment of minors:

True . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.8

● False . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.1

Don’t know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.1

49.2

5.3

45.4

11.5

47.8

13.6

27.1

9.8

56.2

8.1

25.9

84.6

0.7

2.2

12.5

63.4

3.2

13.4

20.0

68.7

3.5

9.2

18.7

24.3

26.5

10.2

39.0

47.1

16.4

36.5

50.7

15.0

34.3

68.5

3.7

27.8

5.5

64.6

12,3

17.6

7.4

63.3

9.0

20.3

91.5

0.5

1.0

6.9

70,6

2.8

13.9

12,6

83.6

1,3

5.5

9,6

24.6

36.7

9,4

29.3

33.7

31.4

34.9

37.6

26.7

35.8

56.6

4.8

38.6

9.1

51.1

15.4

24.4

10.1

54.5

8.5

27.0

84.8

0.8

2.2

12.2

64.7

3.4

13.9

18.0

74.1

3.1

7.5

15.3

28.1

27.3

10.9

33.8

39.7

25.6

34.7

45.1

21.9

33.0

62.2

4.1

33.7

7.5

62.4

10.3

19.7

7.0

65.6

8.8

18.7

91.8

0.4

1.0

6.8

69.8

2.6

13.4

14.2

79.0

1.5

7.0

12.5

20.6

36.6

8.7

34.1

40.4

22.9

36.7

42.4

20.4

37.2

KEY: ● - Correct response. In some cases, more than one response was considered correct.

SOURCE: American School Health Assodation, Association for the Advancement of Health Education, and the Society

for Public Health Education, Inc., The Natbna/Adokwcerrt Student Health Survey: A Report on the Health

of Amen’cds Youth, a cooperative project of the National Institute on Drug Abuse, Alcohol, Drug Abuse, and

Mental Health Administration; the Centers for Disease Control; and the Office of Disease Prevention and

Health Promotion, Public Health Service, U.S. Department of Health and Human Services (Oakland, CA:

Third Party Publishing Co., 1989).

close to 20 percent of the students were not aware getting HIV infection (7). Data from State and local

that having multiple sexual partners, a male having surveys confirm that students are also misinformed

sexual intercourse with another male, or having about factors that do not increase risk, but which

sexual intercourse with someone who has had raise fear and have public policy implications, such

several partners increased an individual’s chances of as donating blood (see table 9-8).
Chapter 9-AIDS and Other Sexually Transmitted Diseases: Prevention and Services . II-275

Misperceptions about effective STD and HIV

prevention methods persist, The National Adolescent Student Health Survey found that the majority

of students were not aware that taking birth control

pills (55 percent) or washing after sex (67 percent)

were ineffective methods of protection from STDs

(see table 9-7). Almost a quarter of the national

student sample did not know that abstaining from

sexual intercourse lowered their risk of infection and

20 percent did not know that not using a needle27

while taking drugs lowered the risk (7). One local

sample reported that 19 percent of 657 Connecticut

junior and senior high school students believed that

not kissing an HIV-infected person on the cheek was

an effective method of prevention (92). Although

most of the students surveyed in the National

Adolescent Student Health Survey (86 percent

overall) knew that the use of condoms during sexual

intercourse decreases their risk of getting HIV

infection (7), earlier data from 14- to 18-year-old

San Francisco students suggest that there may be

significant racial differences in this knowledge,

whites (71.7 percent) having more knowledge than

blacks (59.9 percent) and Latinos (58.3 percent)

(62).

Other Concerns

To change behaviors that put them at risk for HIV

infection or STDs or to maintain safe behaviors,

adolescents must perceive that they could become

infected (104). For AIDS prevention efforts, this

poses a particular problem. Given the estimated

10-year latency period between HIV infection and

diagnosis with AIDS, it is unlikely that most

adolescents now know or encounter another adolescent who has AIDS.28 29

Furthermore, even though adolescents are developing the cognitive abilities to perceive risks accurately, 30 some observers believe that adolescents

often do not weigh relevant risks in making decisions (131,137). In not weighing relevant risks,

adolescents may be no different from adults (70,197).31

Even though many adolescents worry about getting

infected (83,138), they, like adults, may be more

concerned about satisfying needs (e.g., peer acceptance, having a sexual relationship, being attractive

to members of the opposite sex) than about preventing possible HIV or STD infection. As a result, they

may try to prevent HIV infection through inappropriate or ineffective means (87). In addition, however, STD prevention during adolescence may be

constrained by ambiguities in the social status of

American adolescents.32 While adolescents are bombarded with messages from commercial media that

are likely to encourage them to engage in sexual

intercourse, their level of realistic information about

effective means to prevent HIV infection and STDs

may be limited by external forces (e.g., school

boards) (147,147a, 204). As discussed throughout

this Report, there are many barriers that restrict

adolescents’ access to health care, including barriers

to obtaining information. Even when information

about treatment is available, there may be legal

barriers (e.g., requirements for parental consent),33

financial barriers,34 and a scarcity of appropriately

trained health care professionals.35 Thus, in considering strategies for reducing the burden of HIV

infection and STDs on adolescents, it is important

not to “blame the victims” of these health conditions (91 b). General strategies for reducing barriers

to care, and for establishing a more effective

approach to health promotion and disease prevention for adolescents are discussed in Vol. I of this

Report (205a). A critique of existing prevention and

27~e Nati~~ Adolescent s~d~~t H~~~ Smey did not exp~cifly mention s-gN n~dl~ but &d students if not taking i~egal drugs with

a needle lowered their chance of getting AIDS.

2S~s ob~emation my not hold me, however, for ~olescen~ ~ ~~wh~e ~olescents me likely to ~ve sex aly; adolescents ~th older, hlf~kd

partners; or adolescents who use IV drugs early.

mere are virtually no data on the number of adolescents who know someone with AIDS. The National Health Interview Suxvey conducted by the

National Center for Health Statistics in the Depmtrmmt of Hdth and Human Sefices asks individuals over age 18 whether they know someone with

AIDS, but it does not collect comparable data on adolescents.

~MolwWnts~ co~tive development is discussed in ch. 2! “What Is Adolescent Health?” in this volume.

glFor a discussion of several studies of the decisionmakm“ g abilities of adolescents, see ch. 17, “Consent and Cotildentiality in Adolescent Health

Care Decisionmaking, ” in Vol. III.

32s& Ch. 2, “mt h Adolescent Health?” in this volume.

33s= ~h. 17, * ~Consent ~d co~ldent~ity in Adolescent He~~ &re Decisionrnaking, ” in VO1. ~.

MS= ch. 16, ‘‘F~cial Access to Health Services, ” in VOI. ~.

35s& ~h. 15, ~ ‘MajorIssuesp~~figt.meDelivery of -~d Comprehensive H~t.h Semices to Adolescents, ’ in VO1. ~.
II-276 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 9-8-Percentage of Correct Responses Among U.S. High School Students

for Questions Related to HIV Transmission Routes, by Selected States

and Cities, 1989

Percentage of correct responses concerning

HIV transmission routes

Using

Student Donating Insect public Having a

Sample response blood does bites do toilets blood test

Site sizearate (%) not not does not does not

state

Alabamab . . . . . . . . . 6,702

Arkansas b . . . . . . . . . 303

Californiab c . . . . . . . 1,858

Coloradoc d. . . . . . . . 1,908

Delawaree 

. . . . . . . . . 2,414

District of

Columbiae f . . . . . 1,077

Georgia d . . . . . . . . . . 421

Hawaiie . . . . . . . . . . . 4,908

Idahod. . . . . . . . . . . . . 1,008

Iowae . . . . . . . . . . . . . 1,463

Kansasd . . . . . . . . . . 1,101

Kentuckye . . . . . . . . . 1,458

Louisiana b . . . . . . . . 6,013

Massachusetts c e . . 2,043

Michiganb . . . . . . . . . 873

Missouri b . . . . . . . . . . 1,201

New Jerseyc d . . . . . 2,153

New Mexicod . . . . . . 770

New Yorkc d . . . . . . . 3,026

North Carolinad . . . .10,279

North Dakotad . . . . . 2,924

Ohiod . . . . . . . . . . . . . 4,341

Oklahoma d

. . . . . . . . 2,521

Oregonb

. . . . . . . . . . 2,895

Pennsylvania c e. . . . 4,548

Rhode lslandb . . . . . 7,076

South Dakotae 

. . . . 

. 1,392

Tennessee d . . . . . . . 2,098

Utahd

. . . . . . . . . . . . . 4,174

Washingtonc d . . . . . 1,176

city

Chicaga b . . . . . . . . . . 1,171

Dallase . . . . . . . . . . . . 3,483

Fort Lauderdaled 

. . . 861

Jersey Citye . . . . . . . 493

Los Angelesd . . . . . . 3,030

Miamie . . . . . . . . . . . . 1,192

New York Cityd . . . . 1,135

San Diegod . . . . . . . . 317

San Franciscod . . . . 793

Seattleb . . . . . . . . . . . 1,374

90

86

41

NA

NA

66

68

78

NA

90

83

84

70

81

90

NA

88

NA

NA

NA

NA

NA

43

74

82

77

87

NA

NA

NA

90

87

90

70

90

83

NA

61

NA

67

61.1

63.3

55.6

52.0

71.6

49.0

57.0

51.7

54.3

60.9

64.7

62.3

58.2

66.5

66.1

63.3

61.4

55.9

56.0

52.8

63.7

64.1

60.2

68.6

71.9

69.9

60.9

65.3

54.7

74.5

39.9

54.1

49.0

32.4

37.9

42.1

33.6

61.8

47.7

56.4

43.2

44.0

42.3

45.6

49.6

44.2

45.3

64.0

43.3

45.3

58.0

54.8

50.1

54.3

48.0

44.2

50.6

50.7

58.4

57.6

57.6

50.2

55.6

47.5

54.8

63.9

48.4

43.2

48.8

66.5

41.9

55.5

45.2

43.9

29.0

45.6

52.9

58.7

41.7

48.5

67.5

68,9

72.2

82.6

69.1

70.9

73.0

82.5

75.5

79.2

80.1

71.0

66.8

76.6

72.1

73.9

73.2

75.2

81.3

75.7

84.2

75.1

76.1

72.4

76.4

NA

80.1

66.6

70.1

84.3

70.5

76.4

66.7

59.0

52.1

70.3

71.0

84.9

68.8

75.7

76.9

72.5

70.8

69.8

77.2

68.3

68.5

72.5

67.4

74.2

72.8

74.6

71.2

76.3

76.4

73.4

73.1

72.0

74.6

75.3

80.3

73.8

75.5

75.8

77.7

80.3

72.1

74.6

69.1

82.4

64.8

74.1

67.7

63.2

58.5

68.6

64.2

79.4

63.4

70.7

KEY: NA - not available.

a~hools and studetis were not randomly assigned.

bprobability sample, unweighed data.

csurveys Cfkj not include students from the largest Cities.

dNonprobabitity sample, unweighed data.

eprobability sample, weighted *ta.

fThe District of Columbia is categorized as a State for CDC funding purposes.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control,

“HIV-Related Beliefs, Knowtedge, and Behaviors Among High School Students,” Morbidity and Mortality

Weekly Report 39(23) :3S5-397, June 15, 1990.
Chapter 9-AIDS and Other Sexually Transmitted Diseases: Prevention and Services . //-277

treatment systems, and specific strategies related to

HIV infection and STDs, are included below.

Prevention of AIDS/HIV Infection

and Other STDs

In the absence of a cure, preventing initial

infection is the best method for controlling the

spread of some STDs and is the only way to

effectively control the spread of HIV (234). As

suggested by the recent rise in syphilis rates among

adolescents, prevention efforts directed at changing

risky sexual and drug-using behaviors will continue

to be necessary even if a cure for certain STDs and

HIV infection is found (24). Given that adolescents

have differing levels of risk for infection, prevention

efforts can take many forms. For low-risk individuals, for example, efforts can be limited to education

and counseling to prevent initial STD and HIV

infection. For those at higher risk, prevention efforts

may include the detection of infection among

asymptomatic and symptomatic adolescents and

their sex partners and the effective treatment of those

who are already infected (234).

An alternative goal may be the modification,

rather than the elimination, of risky sexual and

drug-using behaviors. As noted by the National

Academy of Sciences, it is often easier to modify an

existing behavior than to eliminate it (143). For

adolescents who engage in sexual intercourse, modifications may include using condoms, avoiding

multiple partners, and knowing the sexual and drug

history of sexual partners and acting on that information. For adolescents who have been using drugs,

modifications may include using sterile needles to

inject drugs, not sharing needles, or using bleach to

clean injection equipment.36

Until recently, HIV prevention efforts have not

been focused on adolescents (209). Currently, however a wide range of educationally based preventive

interventions target adolescents of varying ages

within and outside schools, including school-linked

health centers, and community-based youth services

agencies (e.g., The Door in New York City, Bridge

Over Troubled Waters in Boston, and El Puente in

Brooklyn) .37 It is important to note that preventive

interventions are not—and should not be-limited

only to didactic presentations to adolescents. They

include teen theater, television and radio campaigns,

‘‘rap contests, poster contests, street outreach

workers, peer counselors, role-playing activities,

interactive computer-based information dissemination systems, and STD and AIDS hot lines, but they

also include services that may require more intensive efforts on the part of the clinical services

system, such as condom distribution programs,

needle exchange and bleach programs, and testing

for HIV and STDs.

Systematic evaluation of the effectiveness of

preventive interventions is rare (26), particularly in

the case of interventions targeting adolescents at

increased risk of infection (e.g., minority adolescents, gay adolescents, runaways, and homeless

adolescents) (201 ,209). Furthermore, many preventive interventions are not based on a clear theoretical

framework (72). Thus, little is currently known

about what interventions are successful in preventing the spread of HIV or STD infections among

adolescents.

The need for effective HIV and STD preventive

interventions for adolescents at higher risk is clear.

Although most recent data suggest that some adolescents have taken steps to reduce their risk of HIV

infection (83,95,155), many adolescents are not

consistently adopting safer sex practices. In a 1988

Massachusetts telephone survey, for example, only

19 percent of the sexually active adolescents ages 16

to 19 reported adopting condom use because of

AIDS (95). Low proportions of condom users were

also observed among a group of adolescent males

with hemophilia (31 percent; N = 26) and a New

York City minority adolescent population (39 percent; N = 196) (83,155). In the Massachusetts

survey, only half of those reporting condom use used

condoms all the time (95). In a study in New York

City, 32 percent of the sexually active minority

adolescents reported engaging in intercourse without condoms during their last sexual encounter (83).

~OTA did not review the effects of using bleach as preVentiOn against infectiOn.

s7’Hav~g aaess t. a school-llnked he~~ center may help adolescents reduce tie time &tween expos~e to STD infecticm ~d Seekhg IIlt5dCd LXW3

(35). For a discussion of school-linked health centers, see ch. 15, “Major Issues Pertaining to the Delivery of primary and Comprehensive Care to

Adolescents, ” in Vol. III.
II-278 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Problems in Evaluating the Effectiveness of

AIDS and STD Prevention Programs

Over the past several years, various approaches

have been developed for the prevention of HIV

infection and other STDS. The preventive programs

undoubtedly vary in quality, but their effectiveness

has been difficult to assess.38

Numerous obstacles impede evaluations of the

effectiveness of AIDS and STD prevention programs--

limited funds or time, the need for technical expertise, and certain methodological difficulties (e.g.,

separating the effects of the environment from the

intervention, ethical issues of using control groups,

parental concern about particular behavior-related

questions) (1 17,256).

Limited funds, time, or other factors often force

evaluators to choose between process evaluation and

outcome evaluation (1 17).39 The most accurate

evaluation of a program’s success involves both

process and outcome evaluations (1 17). Unfortunately, however, many interventions for the prevention of HIV infection and STDs among adolescents

have undergone process evaluation alone (203).

Evaluation of an intervention’s effectiveness is

difficult when no definite link has been established

between the process and desired outcomes.

Adolescents are not a homogeneous group, so

preventive interventions should have differing goals

depending on the subgroup being targeted--e. g., the

subgroup of adolescents who are not sexually active

and do not use drugs (especially younger adolescents) v. subgroups of adolescents who engage in

sexual intercourse or use drugs. Unfortunately,

many HIV and STD prevention efforts do not have

clear goals. Most programs are probably seeking to

reduce the rates of HIV and STD infection among

adolescents, but measuring infection rates is difficult

because of the asymptomatic nature of many STDs,

the hesitancy of adolescents to seek treatment, and

many adolescents’ concerns about confidentiality

(144), and the cost and intrusiveness of populationbased testing. Furthermore, the initial base rates of

HIV infection and STDs are low, so determining the

effectiveness of a preventive program is difficult if

success is measured in terms of decreasing infection

rates.

For these and other reasons, most evaluators use

outcomes other than HIV or STD infection rates to

determin e a preventive intervention’s success. Such

measures typically include cognitive outcomes (beliefs, attitudes, behavioral intentions) or selfreported behavioral outcomes that bear directly on

the transmission of HIV infection and STDs (144).

Some AIDS and STD prevention programs seek

to increase adolescents’ factual knowledge and to

change their attitudes related to HIV and STD

prevention, although increases in individuals’ factual knowledge and changes in attitude do not

necessarily lead to changes in behavior (95,109,155).

Other prevention programs attempt to influence

behaviors that eliminate or reduce an individuals’

risk of infection or protect against infection. Many

AIDS and STD prevention programs do not measure

the outcomes they seek to maintain or modify,

however, so no information about the impact of the

preventive intervention is developed.

Another problem in evaluating the effectiveness

of HIV and STD prevention efforts is that few

prevention programs use experimental designs (63,

144,203). Subjects are often volunteers in convenient settings without regard to an appropriate control

group. Also, parents may exempt their adolescent

children from participating in HIV/AIDS and STD

educational activities in the schools (147). Only

rarely are subjects assigned randomly to an intervention, and many preventive interventions use ‘‘before

and after’ evaluation designs40 with virtually no

long-term followup, making it impossible to see if

program effects are maintained. The length of time

subjects spend in an intervention and the period

between completion of an intervention and posttest

are not standardized.

Education-Based AIDS and STD

Prevention Efforts

OTA and the U.S. General Accounting Office

(GAO) have each identified elements of health

education models that theoretically should be rele38cen~~ tO my twof ev~uation of S’rD/~S~temention is the ~CuraCy of self-report data on sex~ and drug behaviors and attitudes. These

concerns are addressed in ch. 12, ‘‘Alcohol, Tobacco, and Drug Abuse: Prevention and Services, ’ in this volume.

39proceSS ~vafua~on ~volves the ev~mtion of a~ects of aproWm’s implementation ~d operation (e.g., nurnkr of pamphlets distributed); OUtCO~

evaluation measures an intervention’s results (e.g., increased knowledge, changed behavior).

~Before ~d titer ~ompfisom of ~ evaluation my ~ ~fomative when no change ~curs ~d might be useful in future program designs (144).
Chapter 9--AIDS and Other Sexually Transmitted Diseases: Prevention and Services . II-279

vant to designing education-based AIDS and STD

prevention interventions that are effective in changing risky behaviors (199,203). Taken together, these

elements include the following:

●

●

●

●

●

●

using a credible source to reach an intended

audience by acknowledging the audience’s

beliefs and values;

making individuals understand that they may

be at risk of infection so that they will be

motivated to change risky behaviors;

developing skills among individuals to overcome physical and psychological barriers to

behavioral change;

stressing positive aspects of an intervention,

but still acknowledging the negative aspects, so

as to increase individuals’ belief in the credibility of the source;

gaining the approval of friends and the community to increase individuals’ intentions to

change; and

using role models (e.g., opinion leaders and

peer counselors) to change risky behavior,

Some education-based AIDS and STD prevention

efforts target all adolescents, including adolescents

who experiment with risky sexual and drug-using

behaviors, by seeking to increase their knowledge

about modes of HIV and STD transmission and ways

to avoid HIV and STD infection. Other educationbased AIDS and STD prevention activities seek to

build adolescents’ decisionmaking skills and strategies to resist real and perceived peer pressure. Other

education-based prevention efforts, which include

traditional sex education, and drug education programs, are discussed in other chapters of this

Report.41

Education-based AIDS and STD prevention efforts that focus specifically on adolescents are

discussed below. Some of these education-based

prevention efforts involve families, some take place

in schools, and some take place in community

settings.

Photo credit: Office of Technology Assessment

Posters such as this one in a high school offer an

opportunity to remind adolescents of the dangers of AIDS.

It is unclear whether this kind of education effort is enough

to change adolescents’ behavior, however.

Education-Based Prevention Efforts That

Involve Families

Generally, individuals are more likely to act on

information if the person or agency providing the

information is credible (203). Many, if not most,

adolescents have been found to perceive physicians,

peers, and parents as credible sources of information

(45,95,155,274). Adolescents from racial or ethnic

minority groups who view the extended family as an

important social support system (13,126,210) may

see members of the extended family as credible

deliverers of health information.42

Family interventions may have paticular promise

in helping adolescents delay sexual intercourse and

avoid drug use, because most adolescents live at

home. Often, however, parents do not discuss

sexuality-related topics, including homosexuality

and prostitution, with their adolescent children

(95,204,248); and many adolescents report having a

difficult time discussing such topics with their

parents (45,174,204). For illustration, although adolescents were not specifically targeted to receive

CDC’s brochure “Understanding AIDS,”43 CDC

hoped they would be reached by promoting discus41 Sex education is discuss~ in ch. 10, ‘‘Pregnancy and Parenting: Prevention and Semices, ” and drug education is discussed in ch. 12, “Alcohol,

Tobacco, and Drug Abuse: Prevention and Services,” both in this volume.

AzFor a dis~ssion of parent~ influences on adolescent decisionmtiing, s~ ch. s, “Parents and Families’ Influence on Adolescent Health, ” in this

volume. For a discussion of issues in the delivery of services to racial and ethnic minority adolescents, see ch. 18, “Issues in the Delivery of Services

to Selected Groups of Adolescents, ’ in Vol. III.

43~e brmhwe, which des~~s tie modes of ~v ~~mlsslonand me~ods of prevention,was mail~ tO all households and residential pOSt OffiCe

boxes in [he United States between May 26 and June 30, 1988 (223).
II-280 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

sions of AIDS within families (223). Provisional

data from the 1988 National Health Interview

Survey conducted by the National Center for Health

Statistics in the U.S. Department of Health and

Human Services (DHHS) showed that while 35

percent of the parents reported discussing the

brochure with their 10- to 17-year-olds, the remainder (over 60 percent) did not discuss it (244,245).

The quality of the discussions among those who did

discuss the brochure is not known.44

Currently, few of the adolescent HIV or STD

prevention efforts that are being carefully evaluated

target families. The Office of Minority Health within

DHHS, under its Minority HIV Education/

Prevention Grant Program, is funding a project in

Salt Lake City, Utah, that provides HIV education

and prevention in the homes of Mexican American

adolescents who are engaging or may engage in

risky behaviors associated with HIV transmission.45

Social service workers try to foster family communication, strengthen family relationships, and build

skills to support less risky behaviors (22).

One major drawback of family interventions is

that family interventions are unable to reach runaway, throwaway, homeless, and incarcerated adolescents who may engage in behaviors that place them

at increased risk of infection.% Prevention efforts

other than those that are family-based are necessary

to reach these populations.

Education-Based Prevention Efforts in Schools

The vast majority of American adolescents, particularly younger adolescents, attend school (206).

For that reason, some observers have suggested that

culturally sensitive and age-appropriate prevention

programs in schools maybe one of the most practical

ways to influence the spread of HIV infection and

STDs (63,82,209,280). In fact, most students report

wanting to learn about AIDS and, presumably,

STDs, at school (92). Studies of education-based

AIDS and STD prevention efforts in schools are

summarized in table 9-9.

Even though most States encourage STD or AIDS

education in schools, many students, particularly

younger adolescents, are apparently not receiving

any STD or AIDS education (3,7). Among the public

secondary schools that reported providing sex education, 95 percent reported offering at least one class

on STDs (3). Nevertheless, 68 percent of the

students surveyed in the National Adolescent Student Health Survey in 1987 reported either not

knowing whether they had had STD instruction or

never receiving such instruction (7).47 Additionally,

65 percent of the students surveyed reported either

not having or not knowing if they had had AIDS

education, with relatively no difference between

older and younger students (7). This information is

confined by the National Association of State

Boards of Education, which reported in 1989 that

only 28 States and the District of Columbia required

HIV/AIDS education (147).48

The Federal Government supports AIDS and STD

education primarily through monetary support and

technical assistance to States. The scope and content

of the AIDS and STD educational messages developed with Federal assistance are determined at either

the State or local level. CDC had cooperative

agreements with State and local education agencies

totaling over $19 million in program years 1989-

1990, to support developmentally appropriate HIV/

AIDS education in the schools (118,227). In addition, CDC has been working with State education

departments to develop a method for monitoring

changes in students’ knowledge, attitudes, and

behaviors (118,147,226). According to CDC, AIDS

and STD education may be most effective within a

comprehensive school health education program

(232,238). Only 19 States, however, require that

HIV/AIDS education be taught within either a

44~c$~ Nati~~~S~o-tionad ~ucation ~owm’s~ysis of cross-~b~ations of howledge questions with those adults who said they

had children between 10 and 17 years of age (183) may provide some information about whether parents gave their children accurate information,

dsFOr a discussion Of issu~ pe rtaining to the delivery of services to adolescents from Hispanic and other rackl or ethnic minority groups, see ch. 18,

“lSSUCS in the Delivery of Services to Selected Groups of Adolescents,” in vol. III.

~FOr a discussion Of the problems of runaway, throwaway, and homeless adolescents, see Ch. 14, ‘‘Hopelessness: Prevention and Services,’ in this

volume. Incarcerated adolescents are discussed in ch. 13, ‘‘Delinquency: Prevention and Services, ” in this volume.

470~y 18 ~rwnt of the sth waders reported r=iving ins~ction on S~S as comp~d with 44 percent of the loth graders (7).

4S~e ’28 S~te5 we ~ab-, conn~ticu~ Delawme, Florid% Georg~ I~ois, ~di~ IOW& ~m,KeKItucky, Marytid, M.iChigUl, ~O@

Nevadaj New Mexico, New York North Carolina, Oklahoma, Orego% Pennsylvania Rhode Island, South Dakota, ‘lknnessee, Utah, Vermont, Wrgir@

WashingtorL and West Virginia (147).

4~e s~te ofww~~on ~u~e5 tit~v/~s ~u~tion bC add~ to theMD requirement (147).
--n.

=

-. Table 9-9—Studies Evaluating Education-Based AIDS and STD Prevention Efforts in Schools

. .

Study population,

Intervention(s) and sample size, and year

Study’ Goal(s) outcome measure(s) Research design data collected Results

Brown, Fritz,

and Barone,

1989

DiClemente,

Pies, Stoner, et

al., 1989

Hernandez and

Smith, 1990

Improve knowledge,

attitudes toward future

behaviors and tolerance

for people with AIDS, and

coping strategies

Improve AIDS

knowledge, decrease

misconceptions, and

Increase tolerance

toward individuals with

AIDS

Compare the effects of

three primary prevention

education programs with

differing philosophies:

abstinence, condom use,

delaying sex, and

considering alternatives

Intervention:

Two 45-minute classes on

AIDS taught by health

teachers. About half of

each session was a film

presentation and the

remaining time was an

open class discussion.

Outcome measure:

Performance on

knowledge, attitude, and

coping survey

Interventiom

Three class period AIDS

prevention curricula

presented on

consecutive days

Outcome measure:

Performance on

knowledge questionnaire

/intervention:

One-hour multimedia

presentation

Outcome measure:

Performance on

attitudes, intentions, and

behavior questionnaire.

Pretest/posttest design, no Study population:

comparison group Predominantly white,

suburban, middle class

Rhode Island 7th and 10th

graders

Sample size:

7th grade: 174

10th grade: 139

Year data collected:

NA

Pretest/posttest control Study population:

group design Middle and high school

students in the San

Francisco Unified School

District

Sample size:

High school: 254

Middle school: 385

Year data collected:

1986 or 1987

Pretest/posttest design Study population:

with control group Students ages 18 to 21

from two Southeastern

State universities

Sample size:

388 students completed

both a pretest

questionnaire and

posttest questionnaire 6

weeks later.

Year data collected:

1988

Knowledge test scores increased significantly

for both grades. Students in both grades

reported a greater likelihood to engage in safer

behaviors. 7th graders changed their attitudes

for risk behaviors and tolerance for people with

AIDS. Only the former changed significantly for

10th graders. 7th grade males and 10th grade

females reported being more tolerant. 7th

graders reported endorsing wishful thinking and

self-criticism coping strategies less frequently,

and 10th graders reported endorsing social

withdrawal Iess frequently and problem-solvingcoping strategies more frequently.

Intervention group showed statistically

significant knowledge gains and fewer

misconceptions. Middle school students

demonstrated more knowledge gain (mean of

4.8) than high school students (mean of 3.5),

and both groups had more knowledge than the

nonintervention group. Students in the

intervention group showed less fear about

having a student with AIDS in the classroom.

No significant effects of programs on any

cognitive (e.g., sexual motivation, intended

condom use) or behavioral items (e.g., condom

use, number of sex partners). The abstinence

program did not lead to an increase in

abstinence, nor did explicit condom use

information lead to condom use. However,

those in the decisionmaking group which

stressed condom use were significantly more

likely to use condoms after the program than

were those in the group which stressed all

alternatives including delaying sex.

Continued on next page
Table 9-9-Studies Evaluating Education-Based AIDS and STD Prevention Efforts in Schools--continued

Study population,

Intervention(s) and sample size, and year

study’ Goal(s) outcome measure(s) Research design data collected Results

Huszti, Increase AIDS Intervention:

Clopton, and knowledge and improve 45-minute AIDS

Mason, 1989 attitudes toward people educational program using

with AIDS and increase either a lecture or film

practice of preventive

behaviors Outcome measure:

Performance on

knowledge and attitude

questionnaire

Miller and Improve AIDS knowledge Intervention:

Downer, 1987 and attitudes 50-minute multimedia,

AIDS program

Outcome measure:

Performance on

knowledge and attitude

survey

Sroka, 1986 Improve knowledge and Intervention:

modify attitudes and 5 days of STD education

behavioral intentions Outcome measure:

Performance on

knowledge, attitudes, and

behavioral intentions

survey

Pretest/posttest/l month

followup design.

Volunteer subjects were

randomly assigned to 1 of

3 conditions: lecture, film,

or no program.

Pretest/posttest design, no

comparison group

Pretest (1 week before)/

posttest (1 week after)

design, involving a

control group. Teachers

were also asked to

evaluate what they

perceive to be significant

gains in students’

knowledge, attitudes, and

behavioral intentions.

Study population:

10th grade students ages

14 to 17 attending 2

suburban Oklahoma City

area public schools

Sample size:

448 students completed

pretest, posttest, and

followup

Year data collected:

NA

Study population:

Seattle high school

students

Sample size:

114 students completed

pretest 1 month prior to

and 1 week after

educational program. 53

students completed a

posttest 8 weeks later

Years data collected:

1986-87

Study population:

9th grade students in an

urban inner-city area

Sample size:

Intervention group: 67

(completed pretest and

posttests

Control group: 87

(completed pretest and

posttests)

Year data collected:

1986

Intervention groups’ knowledge scores

increased significantly from pretest to posttest

and decreased significantly at 1 -month followup

although scores were still higher than at pretest.

Students hearing the lecture had significantly

higher knowledge scores than either film or no

program groups at both posttest and followup.

Students watching the film had significantly

higher scores than the no program group. In

addition, intervention groups had significantly

more positive attitudes toward people with AIDS

and preventive behaviors than the no program

group. However, these attitudes decreased

significantly 1 month later. Students’ attitudes

toward preventive behaviors were not

significantly different than at pretest. Females

had significantly higher levels of knowledge and

more positive attitudes toward people with AIDS

at all measurement times and more positive

attitudes toward preventive behaviors than males

at posttest and followup.

Remark:

Students’ initialty high positive attitudes toward

preventive behaviors may have created a

ceiling effect.

Students’ knowledge test scores increased

from 78% to 90%. The percentage who thought

they might get AIDS did not decrease

significantly. The 8-week posttest showed

retention of knowledge.

Knowledge, attitudes, and behavioral intentions improved in the intervention group

compared with the control group (although

significance was not determined). In general, a

large proportion of teachers felt that substantial

gains had been made in students’ knowledge

(98%), attitudes (81%), and behavioral

intentions (77%).

Remark:

Teachers surveyed were located in only 3

States. Results may not be generalizable to

other populations.
Table 9-9-Studies Evaluating Education-Based AIDS and STD Prevention Efforts in Schools-Continued

Study population,

Intervention(s) and sample size, and year

Study” Goal(s) outcome measure(s) Research design data collected Results

Stout and This study reviewed five lntervention:School-based

Rivara, 1989b earlier studies of junior sex education programs

and senior high schoolbased sex education

Outcome measure:

Sexual activity,

programs. contraceptive behavior,

and pregnancy

Yarber, 1986 Improve students’ Intervention:

knowledge and attitudes Five class periods (250

related to preventive minutes) of a CDCbehaviors related to STDs sponsored STD

curriculum, STD: A Guide

for Today’s Young Adults

Outcome measure:

Performance on

knowledge and attitude

survey.

Variety of research

designs. Three were crosssectional using national

survey data. One was a

longitudinal survey. The

final study was a casecontrol of exemplary sex

education programs.

Quasi-experimental

design involving

experimental (CDC

curriculum) and 2 control

groups (schools’

standard STD

educational program of 2

to 6 class sessions and

no STD instruction).

Pretest and posttests

immediately following

instruction and 6 weeks

later. Students were not

randomly assigned.

Study population: Age of

participants varied: 15-to

16-year-olds sampled in

the 1981 National Survey

of Children; 15- to 19yearold females; nationally

representative sample of

14- to22-yearddsin1979;

nationally representative

sample of 15- to 19-yearolds living in households;

and elementary through

high school students

Sample size:

Varied from 500 to 12,069

Years data collected:

Varied from mid-1970s to

mid-1980s

Study population:

Junior high and high

school students ranging

in age from 12 to 19 in 6

school districts (3

suburban, 2 urban, 1 rural)

in Eastern and Central

States

Sample size:

CDCSTD curriculum: 566

School STD curriculum:

161

No STD education: 387

Year data collected:

1985

Three studies found no effect on sexual activity.

One study showed lower prevalence rates for

those who had taken a class while the other

found a weak positive relationship. There

appeared to be little effect on use of effective

methods of birth control. No measurable impact

was found on pregnancy rates except in one

study where a lower rate among 15-to 17-yearold females was observed.

Remark:

Studies did not have control groups, and all

were retrospective. The quality of the programs

could not be determined.

CDC curriculum improved students’ STD

knowledge. However, increases in knowledge

decreased at 6-week followup. Intentions to

engage in healthy behaviors increased, but not

as much as beliefs and feelings about such

behaviors. Six weeks later, scores were not

significantly different than at pretest.

KEY: NA = not available.

aFull citations are listed at the end of this chapterb~is ~tu~ review~ the following five school sex ~ucation ~t~ies: Dawson, 1986; Fu@en~~g, 1985; ffirby, 1984; MarsigliO and kfdt, 1986; and Zelnick and Kim, 1982. Fuii citations

for these studies are listed at the end of this chapter.

SOURCE: Office of Technology Assessment, 1991. .
II-284 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

comprehensive health or family life education curriculum (147).49

Given the fact that risky sexual and drug-using

behaviors are directly related to the transmission of

HIV and STDs, the ultimate goal of education-based

AIDS and STD prevention efforts is to increase the

use of preventive behaviors (35,99). As the programs listed in table 9-9 illustrate, education-based

AIDS and STD prevention programs in schools

often attempt to influence students’ behavior by

increasing knowledge about AIDS and, to a lesser

extent, knowledge about STDs (including methods

of transmitting and preventing infection); by changing students’ attitudes; and by modifying their

behavioral intentions with respect to preventive

behaviors (3,27,63,99,1 12,135,147,187,280). There

is little evidence to suggest that increased knowledge alone will result in behavioral change ( 14,203).

Behavioral intentions are believed to be more

closely related to behavioral change (2). Very few

studies have evaluated how educational interventions affect risky behavior related to the transmission of STDs and HIV infection (203,280). Thus,

very little is known about the effectiveness of

education-based STD and AIDS prevention efforts

in schools. Only 11 States include an evaluation

component in their ~/AIDS education programs,

and most of those are insufficient to measure the

educational program’s effectiveness (147).

Some available evidence suggests that brief

educational instruction can significantly increase

adolescents’ knowledge about HIV and STD infection. A study evaluating the impact of a 3-hour AIDS

prevention curriculum taught in San Francisco

middle and high school classes (63), for example,

found that students receiving the curriculum (including knowledge that condoms could reduce the risk of

HIV transmission during sexual intercourse) showed

significantly more knowledge than students who

received no instruction. Because students’ knowledge was not assessed after a longer period of time,

however, it is possible that the increases in knowledge may not have remained strong. One study

demonstrated that students’ knowledge about STDs

increased significantly immediately following a

CDC-sponsored STD curriculum and then decreased

6 weeks later (280).

The method by which AIDS and STD information

is presented may be important in students’ ability to

retain knowledge they have gained, although the

evidence is unclear. Traditionally, STD education

classes have consisted of didactic biomedically

oriented lectures (35), although videotapes and films

are becoming more popular. By using a 50-minute

videotape, Miller and Downer demonstrated that

Seattle students retained their increase in knowledge

8 weeks later (135).50 In contrast, one study involving 10th grade Oklahoma City students found that a

lecture increased students’ knowledge more than

watching a film (99). Both the film and lecture were

more effective than having no program. A month

later, knowledge gains remained significantly greater

than at pretest (99).

Data from education programs for the prevention

51 and programs for the of adolescent pregnancy

prevention of smoking suggest that effective AIDS

and STD prevention efforts must go beyond the

transferring of knowledge to helping adolescents

deal with real and perceived peer pressures in

negotiating safer sex and drug use behaviors with

unwilling or ambivalent partners by building decisionmaking and communication skills (23,1 11,126,

178,199,203). So far, most education-based AIDS

and STD prevention programs have not gone beyond

disseminating knowledge and have not attempted to

provide adolescents an opportunity to build skills for

the prevention of HIV infection and STDS (27,63,99,

135,187,280). Changing behaviors without providing opportunities to build skills appears to be most

difficult (280).

Two currently popular educational programs being

used to teach students about the behavioral aspects

of STDs, including AIDS, provide information

about STD prevention and treatment and encourage

educators to teach skills, such as resisting peer

pressure, reducing risky behaviors, and negotiating

safer sex (188,189,280). Neither program measures

changes in students’ actual behaviors, however, so it

d~e Stite of wash~on requires that HIV/AIDS education be added to the STD requirement (147).

-e videotape was entitled ‘‘Sex, Drugs, and AIDS” (135). A recent study of 5S4 California college students demonstrated that videotapes differ

in their ability to improve knowledge. Students who viewed the “Sex, Drugs, and AIDS” videotape and those who viewed “AIDS: What Everyone

Needs to Know” evidenced significantly greater knowledge gains than did students who viewed ‘‘AIDS: Acquired Immune Deficiency Syndrome’ and

“Beyond Fear: The Virus” (170).

slFor a discussion of the prevention of adolescent p~gIltlllCy,s= ch. 10, “Pregnancy and Parenting: Prevention and Services, ” in this volume.
Chapter 9-AIDS and Other Sexually Transmitted Diseases: Prevention and Services . //-285

is not clear that students are using these skills

(189,280).

In a 1984 evaluation of 14 promising sex education programs, many of which provided STD information, Kirby concluded that most of the programs

had little impact on the number of times adolescents

reported intercourse or on adolescents’ use of birth

control (1 11).52 Stout and Rivara, on the basis of a

review of five studies that evaluated the effect of

junior and senior high school-based sex education

programs, confirmed Kirby’s findings that sex

education programs appear to have no effect on the

levels of adolescents’ sexual activity (191).

With Federal demonstration grant money provided by the DHHS Office of Population Affairs

under the Public Health Service Act Title XX

Adolescent Family Life (AFL) Program, the Arkansas Family Life Education Project has developed a

24-day abstinence curriculum for junior high and

high school students; this curriculum is aimed at

developing students’ skills in decisionmaking, peer

pressure reversal, and communication (281). In

various components of the high school curriculum,

for example, students discuss the advantages and

disadvantages of avoiding getting an STD and why

STDs receive no media attention. Classroom volunteers receive scripts of different life situations and

must try to persuade a peer ‘‘decisionmaker’ to

accept their perspective on life options. Preliminary

data indicate that junior high students who participated in the program report decreased intentions of

engaging in premarital intercourse (281). Data for

the high school program curriculum was field tested

during 1989-1990 in eight schools.

Education-based AIDS and STD prevention activities in schools can be expected to reach most

adolescents, but a major limitation of efforts that

occur in schools is that they overlook school

dropouts. In “Guidelines for Effective School

Health Education To Prevent the Spread of AIDS,’

CDC noted that the needs of hard-to-reach adolescents, such as out-of-school adolescents, non-Englishspeaking adolescents, physically impaired adolescents, and learning disabled adolescents, should be

addressed (11 8,232). A 1989 survey by the National

Association of State Boards of Education found,

however, that only Minnesota had addressed the

need to target hard-to-reach adolescents in its State

policy regarding HIV/AIDS education (147).

Another important limitation of AIDS and STD

prevention programs in schools is that they may fail

to target homosexual and bisexual adolescents—a

group that is at particular risk of HIV infection. One

promising program for homosexual and bisexual

adolescents is the University of Minnesota Youth

and AIDS project (169). This program uses school

personnel, social groups, and peer referrals to reach

homosexual and bisexual males ages 14 to 21 so that

they can receive individualized counseling on risk

reduction, peer education, or referrals for psychosocial and medical services, and regular followup

visits.

According to a 1990 evaluation of public school

HIV education programs, the U.S. General Accounting Office (GAO) concluded that "CDC-led nationwide education efforts are not yet commensurate

with the [HIV] epidemic’s potential for disaster’

(262a). GAO noted that, while two-thirds of the

Nation’s public school districts reported providing

some formalized HIV education for students in the

1988-89 school year, such education was not offered

at every grade level, ‘‘especially the upper grades,

where the probability of sexual activity is highest’

(262a). One of five HIV teachers surveyed by

GA053 received no training; the training that teachers did receive was judged by GAO to be “often

insufficient, that is, too brief and with limited

coverage of important topics (262a). GAO found

that CDC provided no guidance to districts on the

appropriate length of teacher training in HIV topics,

and that CDC-funded education departments did not

collect from students essential planning and monitoring information needed to set program priorities

and evaluate success (262a). Consistent with findings throughout this Report and elsewhere (e.g.,

147a), the scarcity of monitoring information was

held to be due to “a lack of staff and difficulty in

obtaining community support to collect sensitive

sexual and drug use data’ (262a).

52~ ~pomt ll~[atlon of Kfiby$s study was hat adolescents were not randomly assigned to sex education programs and con~ol grouPs (1 11). h

addition, results from the programs Kirby evaluated cannot be generalized to all sex education programs.

53~le reSpomc rate for GAO$S sumey of 9,g~ ~V teachers was 45 percent, wi~ tie highest respo~e rate coming fim nurses (262a). It is UllCle

whether non-nurse respondents receivai more training than nurse respondents; one would expect that nonrespondents would have received less training

and been less involved in HIV education than respondents.
II-286 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Education-Based Prevention Efforts in

Community Settings

Education-based AIDS and STD prevention efforts in community settings are more likely than

efforts in families or schools to reach adolescents

who are out of school or on the streets; furthermore,

efforts in community settings can support and

reinforce prevention messages introduced within the

schools (203).

A large number of education-based AIDS and

STD prevention efforts involving health care practitioners, peers, churches, national and local organizations, and the media have been undertaken by many

local communities throughout the country. Specific

activities include teen street theater, ‘‘rap’ and

poster contests, distribution of print material, STD

and AIDS hotlines, individual and group counseling,

and media campaigns. The Latin American Youth

Center in Washington, DC, distributed bumperstickers, had a poster contest, and enlisted adolescents to

talk to other adolescents on radio programs (130).

Several community-based AIDS education projects

that target students and street youth have received

Federal funds from the National Institute on Drug

Abuse and CDC (240).

Very few of the large number of education-based

AIDS and STD prevention activities in communities

have been systematically evaluated to identify

effective approaches and methods for preventing

HIV infection and STDs among adolescents. Teen

street theater (e.g., the Teen Teatro AIDS Prevention

Project of the East Los Angeles Rape Crisis Center,

El Teatro Juvenile De La Comunidad in McAllen,

Texas),

54 "rap "

contests, and comic books, for

example, are often viewed as useful approaches for

targeting racial and ethnic minority adolescents and

runaway and homeless youth (22,34,126,128,130,173).

Although these approaches may be especially effective because they involve adolescents as deliverers

of the prevention message, no systematic evaluations have been completed. Measures of the success

of these programs are limited to process measures

(e.g., the number of adolescents who participate).

It is possible to use community settings to deliver

intensive educational interventions. For example,

Rotheram-Borus and her colleagues engaged 63

Photo credit: Los Angeles Free Clinic

Approaches to AIDS education such as teen theater may

be particularly effective because they involve adolescents

as deliverers of the prevention message. However, there

have been no systematic evaluations of their effectiveness.

runaways and gay male adolescents in 4 New York

City community agencies in a 10-session educational program that was based on cognitivebehavioral theory (e.g., the sessions were participatory and focused on specific behaviors) (175a). The

intervention was more successful in increasing

self-reported condom use during anal, oral, and

vaginal intercourse than was the ‘‘state-of-the-art’

2-session intervention used as a comparison (175a).

The intervention was only effective in the short term

(i.e., 3 months) in reducing levels of sexual activity

(175a). A brief one-time AIDS-specific education

session with females in adolescent medical clinics

was effective in increasing knowledge, but generally

not effective in changing attitudes or increasing

condom acquisition, except among those females

who had already been using condoms and who were

exposed to a videotape on condom use as well as a

lecture by a health professional (17 la). In this study

condom acquisition was both encouraged and measured by providing participants with a coupon to

exchange for a free condom at a local pharmacy; it

did not measure actual condom use, but acquisition

of a condom is a necessary precursor to use (171a).

s4~ teen ~&@t ~mter ~r~uctiom, adolescent actors ~ic~ly present a play tit Musmtes a diffkd SOCial situation tht is overcome by US*

appropriate peer refusal and communication skills. Usually, the play is followed by a question-and-answer period between the audience and the actors.
Chapter 9-AIDS and Other Sexually Transmitted Diseases: Prevention and Services ● II-287

Because many adolescents learn about public

health problems such as drugs and AIDS through the

media (135,163) and because the media appear to

have played an integral part in changing people’s

behaviors in antismoking efforts, the reduction of

cardiovascular disease, and the control of syphilis

(203), many organizations have suggested that an

expanded use of the media might be an effective

approach in preventing HIV infection and STDs

among adolescents (142,162,203).

Since 1987, CDC’s National AIDS Information

and Education Program has been conducting a major

multimedia AIDS prevention effort, ‘‘America Responds to AIDS’ (219). This multimedia effort

targets the general population and various subgroups, including women at risk of AIDS and

sexually active adults with multiple partners (219).

One phase of CDC’s AIDS prevention campaign,

begun in May 1989, targets parents and adolescents

who are racially and ethnically diverse and are of

different age ranges (e.g., late-elementary and middleschool aged and junior- and senior-high-school

aged) (183,21 8). This phase aims to promote communication between adults (including parents) and

adolescents about HIV and AIDS, to encourage

adolescents to adopt and maintain less risky sexual

and drug use behaviors, and to make the public

aware that certain adolescents are at risk for contracting HIV (183,218). English and Spanish television, print, and radio public service announcements

were pretested on focus groups of parents and youth,

ages 10 to 20 years. Additionally, CDC has developed an “AIDS Prevention Guide’ to be distributed

to adults having contact with adolescents (2 17,218).

This guide provides facts about HIV and AIDS and

ways for parents and other adults to talk comfortably

with adolescents of all ages about HIV infection and

AIDS (217).

For several reasons, including the difficulty of

isolating the effects of any media campaign, the

impact of CDC AIDS prevention campaign on

adolescents and their parents is not clear. Evaluation

components include measuring the increase in the

number of phone calls to the National AIDS Hot

Line and the National AIDS Clearinghouse and

testing adults’ and students’ knowledge, attitudes,

and behaviors (134,183). As of May 28, 1990, over

1.1 million copies of the “AIDS Prevention Guide”

had been distributed, and over 1 million calls to the

AIDS hot line had been made (269). Unfortunately,

information specialists at the AIDS hot line and

clearinghouse are not permitted to ask callers’ ages

nor to ask whether callers have children (134,183,

269). 55 Furthermore, because the National Health

Interview Survey does not survey most adolescents

directly, it is not clear how many adolescents heard

or saw the public service announcements.

Not surprisingly, individuals who have analyzed

the effectiveness of mass media campaigns suggest

that changing people’s drug- and sex-related knowledge and attitudes is easier than changing risky

behaviors (71,268). In order to be effective, messages must be repetitive, consistent, understandable,

and supported by the community (71,268). In spring

1989, CDC’s National AIDS Information and Education program established the Applied Communication Research and Evaluation Branch to help

evaluate future phases of the CDC’s AIDS prevention campaign (134,183).

There are few mass media campaigns directly

targeting adolescents for the prevention of STDs, as

opposed to AIDS. Burroughs Wellcome Co., a

pharmaceutical company based in North Carolina, in

conjunction with several medical organizations,56

began an innovative multimedia advertising campaign in July 1989 targeting sexually active adults

(25,32). This campaign encourages sexually active

adults ages 18 to 49 to check for the signs and

symptoms of STDs (e.g., chlamydia, genital herpes,

gonorrhea, genital warts, and syphilis) using a

genital self-examination (25,32). Because the campaign was designed and tested to address the STD

epidemic among the adult population, however, it is

likely that a different program would be required to

55CDC considers the hot line and the Cl earinghouse as services to the general public, not as sources of research (134). Reeently, information specialists

have been completing passive report forms after speaking to a caller. For example, hot line operators fill out forms based on information volunteered

by the caller. In additio% operators may estimate various other types of informatiorL for example, the caller’s age (269). C!DC is in the plannin g stages

to get an Office of Management and Budget clearance [o ask callers general questions related to particular campaigns, for example, have you seen the

Public Service Announcements, and what part of the Public Service Announcements do you remember most? (269).

%~e m~lc~ org~zatiom me tie Americm Academy of Dermatology, the titi~ Academy of F~lY physic~,tie Ameficm College of

General Practitioners in Osteopathic Medicine and Surgery, and the American Osteopathic Association (32).
II-288 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Photo credit: Centro del Control de las Enfermedades

de Ios Estados Unidos

This poster is one of few efforts to focus on the prevention

of STDs overall, in addition to the prevention

of HIV transmission.

meet adolescents’ needs (25).57 Local media campaigns, such as Terrific, Inc. ’s Teen AIDS Prevention and Risk Reduction Program in the District of

Columbia, involve adolescents in community radio

broadcasts as a method to encourage other adolescents to change risky sexual and drug-using behaviors (22,195). These campaigns have not yet been

evaluated .58

One limitation in using television media for AIDS

and STD prevention is that while certain adolescents

identify television as their first and major source of

AIDS information (135,163,274), others, such as

runaway adolescents, homeless adolescents, dropouts, and hemophilia patients, either do not have

access to television or view information presented

on television as “biased and superficial” (155). For

these groups of adolescents, other approaches are

necessary.

AIDS and STD Prevention Efforts Other Than

Those That Are Education-Based

Education-based AIDS and STD prevention efforts alone are a fairly passive approach to prevention. Such efforts rely totally on the recipient of the

prevention message to initiate the suggested behavior change (e.g., abstinence, safer sex). Some

education-based efforts are more informative than

others, of course, but many are somewhat vague

about effective courses of action. Vagueness sometimes arises because of limitations in time and space

(e.g., on a poster), but sometimes prevention messages may be less than explicit in order to avoid

offending some perhaps unintended recipients of a

message (e.g., about specific safer sex practices).

This section describes several prevention interventions that are designed to provide selected means for

preventing AIDS or other STDs. These means

include condom distribution, needle exchanges, and

early diagnosis and treatment.

The prevention efforts described in this section

can also be distinguished from the adolescentspecific education-based AIDS and STD prevention

efforts described above in that they are directed at

those individuals who are already engaged in

activities that may put them at risk of HIV infection

or STDs. Thus, they can be considered secondary

prevention efforts.59

It is important to note that while prevention efforts

such as those described below are designed to

57A ~tere.fig fea~e of tie Buou@s Wellcome Campaign is me buying of commercial air the [o show a 30-swond geni@ self-examination

commercial during afternoon progr arnming in the 2 to 4 p.m. time slot and certain evening programs airing after 9:00 p.m. (25). In the past OTA

suggested that paying networks for air time may be an effective method for reaching a targeted audience for HIV prevention (203), However, because

the primary method of evaluating the campaign focuses on the total distribution of genital self-ex amination instruction booklets (25), it will be difficult

to determine if paid advertising is more effective in reaching an intended audience for HIV or STD prevention than public service announcements which

rely on networks’ volunteering air time.

58 Grm~a’5H~use, a div1510n of Terrific, ~c., is working Wlti a consulting firm to develop fu(ure ev~uation irlstrurnenw for its HIV prevention

efforts (196).

-lgsec.o~awprevenf lon ~tewentlom ~e hose tits~ivc [0 shorten tie Coume of ~i~ess or condition by early identification and rapid intervention,

Targets for secondary prevention interventions typically include populations at high risk of a particular problem.
Chapter 9--AIDS and Other Sexually Transmitted Diseases: Prevention and Services . II-289

provide the means to help individuals at risk avoid

contracting a disease or condition, targeted individuals still have to find out about the preventive

measure and be motivated to use it. Thus, educational efforts designed to improve knowledge and

change attitudes and behavior are a necessary

component of a full prevention effort.60

For adolescents who are not abstaining from

sexual intercourse or experimentation with drugs,

the goal of AIDS and STD prevention efforts maybe

the elimination of risky sexual and drug-using

behaviors. 61

Condom Distribution Programs

Although the most effective method for preventing the transmission of HIV and STDs is to abstain

from sexual intercourse, many U.S. adolescents do

not abstain from sexual intercourse. For adolescents

who cannot be persuaded to refrain from sexual

intercourse, the use of latex condoms lubricated with

nonoxynol-9 is the most effective method to lower

the risk of HIV and STD infection (46,74,107,

148,172,180,222,234). 62

In general, U.S. adolescents’ knowledge about the

effectiveness of condoms in preventing the transmission of HIV is substantial (7,83,95,155). Many

adolescents’ knowledge regarding the effectiveness

of condoms in preventing STD infection, however,

is minimal (see table 9-7).

Despite their high level of knowledge about the

efficacy of condoms in preventing the spread of

HIV, adolescents continue to be inconsistent condom users (94,95,109,155). The reasons include

both perceived and real barriers to the use of

condoms (38,43,94,95,17 1,265). Condom instructions written at high reading levels, for example,

pose particular problems for adolescents who cannot

read at those levels. Adolescents who do not

regularly carry condoms or who believe that condoms reduce pleasure or are embarrassing to buy or

use are highly likely to avoid using them (94,1 15).

Another possible barrier to use maybe adolescents’

belief that their friends are not as supportive of

condom use as they are themselves (7). Among 10th

grade students surveyed in the National Adolescent

Student Health Survey, for example, 94 percent

agreed that sexually active people should use

condoms. Somewhat fewer—8 1 percent—thought

that their peers would agree. A study conducted by

adolescents with the assistance of the Center for

Population Options in 1988 found that it was

difficult for adolescents, particularly females, to buy

condoms at drug stores located in the Washington,

DC area because of physical barriers (i.e., condoms

are in places not readily located in stores, such as

behind pharmacy counters) and unhelpful and judgmental store clerks (37). Because of these barriers

and the inconsistent use of condoms by adolescents

who are engaging in sexual intercourse, the actual

effectiveness of condoms in preventing transmission

of HIV and STDs may be lower than what is

theoretically possible (273).63

CDC recommends that condoms and spermicides

be available in any facility providing STD services,

but the CDC guidelines do not specifically address

the availability of condoms to adolescents (234).

Currently, free condoms are being distributed to

adolescents through various methods and at diverse

locations, including clinics, sports areas, emergency

rooms, bathrooms, bars, and service centers. In some

places, condoms are placed in easily accessible

locations so adolescents need not even ask for them

(e.g., at Three-for-Free program sites in Maryland,

Children of the Night in Hollywood, California, and

at Condom Sense in Atlanta) (12,87,1 13,264). Two

a~o~erbroad s~atev forpreventlon is ~~hea~thprorection. Hea/thprotection Strategies aretiterventions related to env~o~enW or m@lato~

measures that confer protection on large population groups. They do not require educational efforts to increase knowledge or change attitudes or

behaviors. For example, limiting the overall spread of a disease through public health efforts can be considered a health protection strategy for the

prevention of HIV infection and STDS among adolescents, This Report does not consider the effectiveness or potential effectiveness of strategies such

as these on the adolescent population.

61Dmg ~ea~ent programs for adolescents are discussed in ch. 12, ‘‘Alcohol, lbbacco and Drug Abuse: Prevention and Services. ” The effectiveness

of pregnancy- and drug-prevention efforts taking place in school-linked health centers (e.g., Lanier Clinic in JacksoU Mississippi), the community (e.g.,

The Door in New York City and Bridge Our Troubled Waters in Boston) and family plarming clinics are discussed inch. 10, “Pregnancy and Parenting:

Prevention and Services, “ in this volume and in ch. 15, ‘‘Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Services to

Adolescents,” in Vol. Ill.

62Da~ re~~g condom ~~e t. p~lm]w Sexua] practlc~ such as ~ ~d or~ sex me ve~ lifi[ed. Dab fmm a SM s~p]e Of seXu~J/ XliVe, IIWM

city black and Hispanic adolescent females attending an adolescent health center suggest that at least some adolescent females are less likely to use

condoms during anal intercourse than during vaginal intercourse (102).

SSFor a discussion of adolescen~’ use of various birth control methods, see ch. 10? “Pregnancy and Parenting: Prevention and Semices, ” in this

volume.
11-290. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Photo credit: Off&of Technology Assessment

There are a number of reasons why adolescents maybe

inconsistent or inefficient users of condoms, including lack

of knowledge about how to use condoms, rest, and

physical and social-psychological barriers to purchasing or

otherwise obtaining condoms. In 1988, only about half of

adolescent females ages 15 to 1.9 and their partners used

condoms at first intercourse, and only one in five reported

“current” use of condoms during sexual intercourse.

other efforts include a condom giveaway in the rock

magazine Spin and free mail-order condoms to a

small study sample of adolescent males ages 16 to 17

(80,1 13). Both of these programs were time-limited.

The number of high schools distributing condoms

through health services centers appears to be increasing, with distribution in selected school-linked

health centers in high schools reported in Cambridge

(Massachusetts), Los Angeles, and Miami (Florida)

(123a). Following an impassioned debate in the city

and among board of education members, New York

City’s public high schools are to begin distributing

condoms on request to students (13a,69a). Some

high schools in Canada have installed condom

machines on school premises (46a).64 In general,

however, the distribution of free condoms to adolescents, even to those who are sexually active, appears

to be the exception rather than the rule.65

Parents may be a more effective and appropriate

source of condom information and distribution than

schools, but it is not known how many parents

provide condoms or discuss the need for them with

their sexually active adolescent children.

To OTA’s knowledge, few studies have evaluated

the success of condom distribution programs. Very

little is known regarding the impact of condom

distribution programs on adolescents’ attitudes or

behavior. No evaluations of condom distribution

programs to date have used reductions in the

incidence of HIV infection and STDs as outcome

measures (see table 9-10). Many factors (e.g., media,

families, friends) may influence condom use, so

evaluating the effect of condom distribution programs is particularly difficult.

A fear that facilitating access to condoms may

encourage adolescents to have sex may make some

people reluctant to support condom distribution.

One recent study of 16- to 17-year-old males found

that a pamphlet discussing STDs and pregnancy and

the offer of free condoms did not increase adolescents’ levels of reported sexual activity (1 13). That

study also found that the offer of free condoms had

no apparent impact in terms of changing the

adolescents’ attitudes related to sexual behavior or

the use of condoms. It is important to note, however,

that the offer of free condoms was made through the

mail and through telephone followup. This seems a

~Apart from the ~ntroversy surrounding introducing condoms into the schools (13a#6a), anecdotal information from * CanadiaII ex~~e

suggests that making condoms available is not as simple an answer to STD and pregnancy prevention as it may seem at fwst. School offkials in Canada

debated about the tradeoffs in quality and cost of the condoms to be made available in the schools, and at least one student informed school officials

that she had become pregnant ostensibly beeause of a tom eondou raising concerns about liability in the minds of the officials, As discussed in ch.

10, “Pregnancy and Parenting: Prevention and Services,“ in this volume, adolescents typically experience contraceptive failure rates (in terms of

unintended pregnaney) higher than the theoretical failure rates expected among women who rely on contraception consistently and correctly during each

act of intercourse: for U.S. females under age 20 who participated in the 1982 National Survey of Family Grow@ the percentage who experienced an

unintended pregnancy in the fmt year of using condoms was 13.3 percent for whites and 22.3 percent for nonwhitca; this compares to a theoretical failure

rate for condoms among women who use them perfectly of only 2 pereent (see table 107 in ch. 10 in this volume). The failure rate of condoms in terms

of preventing STDS has not been calculated for adokmxmts. ‘l’he evidence on unintended pregnancies and the Canadian experience with condom

distribution suggests that education about condom use is esscdial to making condoms an effective contraceptive or STD-protection deviee. In New York

condoms are to be distributed in a‘ ‘health resource center’ containing information on HIV and AIDS, STDS, and other health issues (69a). The health

resouree site is to be staffed at least 10 periods each week at a variety of times during the school day (69a).

6SSyst_tic ~~ ~ -v~able. For e~pk, in its ~eys of sch~]-w c~cs, ~ c~~ for Poptitioxl O@OIIS wll~ts hlfOllIdOIl abOUt

the number of schools that dispense birth control methods, but the survey does not ask specflcally about dispensing condoms (see ch. 15, “Major Issues

Pertain@ to the Delivery of Primary and Comprehensive Health Services to Adolescents,” in Vol. III).
Table 9-10-Studies Evaluating Selected Condom Distribution Programs for the Prevention of HIV Infection and Other STDs

Among Adolescents

Intervention(s) and Research design and

study” Study population Outcome measure(s) year data collected Results

Arnold, 1973 NA Interventions:

Condoms were distributed in pool halls,

barber shops, a restaurant, and a

grocery store through a summer youth

program. More condoms were

distributed during the week than on the

weekends. Participants went to sites

near their homes.

Outcome measures:

Female fertility rates and number of

distributed condoms

Kirby, Harvey, Low-income 16- to 17-year- Intervention:

Claussenius, et al., old males A cover letter, pamphlet discussing STDs

1989band pregnancy and methods of birth

control, and an order coupon for free

condoms were mailed to adolescent

males throughout the country. Targeted

males could order free condoms.

Outcome measures:

Performance on knowledge, attitude,

and behavior telephone survey

Kirby, Was* and Students attending school- Intervention:

Zegler, 1989 based clinics at 1 of 6 School-based clinic available in the

sites around the country school

Outcome measures:

Use of condoms

Research design:

Descriptive. Male outreach workers in

North Carolina organized condom sites.

Fertility rates of target area and

nontarget areas were compared.

Condom use over the study year was

tracked.

Year data collected:

Late 1960s

Research design:

Experimental design. Males were

randomly assigned to an intervention (N

= 984) or control (N = 1,033) group.

1,000 males from both groups were

randomly selected to be contacted by

telephone 5 weeks after the

intervention; those who had ordered

condoms were telephoned again 7

months later. Adolescents from

Mountain and Pacific States were

underrepresented. Completion rate for

the interviews was 53 percent.

Research design:

Quasi-experimental involving

comparison groups for 4 schools and

pre-post surveys (before and 2 years

after clinic opening) for the remaining 2

clinics. Pre- and post-use of condoms

specifically compared in only one site.

Year data collected:

1989

FertiIity rate of black adolescent females

ages 10 to 19 declined 190/. compared with

no decrease in nontargeted areas. Site of

condom distribution did not appear to make

a difference.

Of those receiving the material, 9 out of 10

said they read the pamphlet, and half

discussed the pamphlet with their parents.

Knowledge score increases were small but

significantly higher for the intervention group

(83% compared with 80%). Pamphlet and

offer of free condoms appeared to have no

impact on changing attitudes related to

sexual behavior. The offer of free condoms

did not appear to increase levels of sexual

intercourse or increase the possibility of

using condoms.

Condom use increased from 26% to 48%.

Remark:

Numerous factors could have accounted for

the increase in condom use: location in a

city at high risk for HIV-infection, intensive

AIDS education programs in the school, use

of sports and health physicals to talk about

condom use, distribution coupons for free

condoms.

Continued on next page
Table 9-10-Studies Evaluating Selected Condom Distribution Programs for the Prevention of HIV Infection and Other STDs

Among Adolescents-Continued

Intervention(s) and Research design and

Studya Study population Outcome measure(s) year data collected Results

Kjoller, Hansen, 28 9th grade classes in Intervention:

and Segest, 1989 Copenhagen, Denmark None; students questioned about

desirability of condom distribution, and

about current condom use

Outcome measures:

Performance on a structured attitude

and behavior questionnaire

University of Sexually active general Intervention:

Maryland, no date population Over 170 sponsors distributed condoms

along with directions for proper use in

quantities of 3 to 15 in 371 sites.

Outcome measure

Number of condoms distributed

Research design: Classes were 34% of the students had had sexual

selected by means of a lottery. intercourse. 90% wanted to receive free

Year data collected: condoms, and half preferred getting

November-December 1987 condoms from the pharmacy, school, or

their own doctor. 40% of the students had

not used a condom during their last sexual

intercourse experience.

Research design: The Three-for-Free In 1988, approximately 1,870,000 condoms

program of the Division of Family were distributed around the State compared

Planning, Maryland State Department of with close to 386,000 in 1987 and 33,230 in

Health and Mental Hygiene is 1986.

sponsored by county health

departments, college and university

health centers, community clinics, the

Boys and Girls Club, and the Baltimore

City Health Department. Program

participants pick up condoms in an

anonymous fashion without being

questioned. Counseling or discussion

with a health educator was not required.

Year data collected:

1986-88

KEY: NA = not available.

aFull ~tatiom are listed at the end of this chapter.

he clinics are located in Gary, Indiana; Muskegon, Michigan; Jackson, Mississippi; Dallas, Texas; Quincy, Florida; and San Franasco, California.

SOURCE: Office of Technology Assessment, 1991.
Chapter 9-AIDS and Other Sexual/y Transmitted Diseases: Prevention and Services . II-293

rather indirect way to distribute condoms, although

the study and program designers did have the

advantage of being able to followup participants.

The results of a Danish study suggest that some

adolescents may need more than easy access to

condoms for them to use condoms (1 16). Kjoller and

her colleagues found that while students thought that

the availability of free condoms would increase use,

many wanted condoms available where they could

get advice and individual guidance (116). Given that

the mere availability of condoms may not increase

use, innovative educational programs may be needed

to address adolescents’ ultimate decision to use

condoms.

Programs seeking to increase condom use among

adolescents must address the barriers that adolescents perceive as sufficient to affect their decision to

use condoms. Networks will agree to air radio public

service announcements about the effectiveness of

condoms in preventing AIDS (143), but they have

been reluctant to allow commercial advertising of

condoms, particularly advertising targeted to adolescents (1 13). In countries other than the United

States, social marketing techniques have been used

to advertise condoms for STD prevention.66

Needle Exchange and Bleach Distribution Programs

for Adolescents Using IV Drugs67

Virtually nothing is known about whether adolescents who use IV drugs have changed their behavior

in response to AIDS. Several studies show that many

adult drug users modified aspects of their drug

behavior to avoid getting AIDS even prior to the

implementation of official AIDS prevention programs (60,203). In fact, adult IV drug users appear

to be changing their drug use behaviors more

frequently than they are changing risky sexual

behaviors (58,203).68 These data from adults, however, cannot be generalized to adolescent IV drug

users.

Currently, there are two major types of programs

for the prevention of HIV infection among IV drug

users: needle exchange programs and bleach distribution programs. Forty-four States and the District

of Columbia prohibit the use, sale, or distribution of

hypodermic devices, and 21 States regard the

finishing of such devices to adolescents under age

18 as a felony (277). Despite strict laws, three cities

(New York City; Boulder, Colorado; and Tacoma,

Washington) have established needle exchange programs (277).69 Needle exchange and bleach distribution programs appear to complement each other

(60,143). However, the available evidence suggests

that these adult programs are being used by older,

more experienced drug users and not by younger,

less experienced drug users (60,158,266).

It is not only IV drug use that presents an AIDS

risk for adolescents. Use of other drugs may lower

adolescents’ (and adults’) inhibitions about engaging in sex. Because drug use has been associated

with sexual activity (141), it is particularly important for adolescents that efforts for the prevention of

AIDS and STDs address both risky sexual and

drug-using behavior,

Early Diagnosis of Adolescents With

HIV Infection and STDs

An important component of controlling the spread

of HIV and STDs among the adolescent population

is effective diagnosis and treatment of those adolescents infected with HIV or with STD agents who are

either symptomatic or asymptomatic (234). One of

the major obstacles for adolescents seeking immediate treatment is that many adolescents do not know

and do not understand that people infected with HIV

or STD agents may be asymptomatic for a period of

time (18,67,88,149,176,234).

Some STDs (e.g., herpes) and HIV infection are

not curable (234). Nevertheless, early treatment for

all STD and HIV infections is necessary for several

66K~tler ~d z~~~ define ~ocial ~rketlng ~ ‘ ‘tie desi~implemen~tio~ ~d con~ol of pro-s ~C~ated to Muence the acceptability of

social ideas and involving considerations of product pl arming, pricing, communications, distribution and marketing research’ (119). Black and Farley

note that social marketing is different from health education because specific products, such as condoms, rather than abstract ideas (e.g., disease

prevention) are promoted (19).

bTFor a discussion on the number of adolescents who are currently using IV drugs, s= ch. 12, “Alcohol, Tobacco, and Drug Abuse: Prevention and

Services, ‘‘ in this volume.

6SIt is not Clem why few IV ~g users practice safe sex practices (59, 143), Among o~er r~sons immediately related to (hg effects, SODle have

suggested that IV drug usem have difficulty in discussing sexual relationships because they fear the breakup of the relationship (58,59,203).

6~nda New York’s public he~~ laws, tie Smte He~~ Commissioner can au~o~e groups or ~divid~s to pOSSNS needles if he deems such

possession necwsary for the public health (166,277). New York City’s needle exchange program was limited to one distribution site, and was

discontinued after a short time.
II-294 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

reasons. First, many STDs (e.g., chlamydia) can be

cured with appropriate treatment (176), but if left

untreated, can result in infertility, ectopic pregnancy, PID, urethritis, gonococcal arthritis, chronic

pelvic pain, mental retardation, and even death70

(18,177,272,234). Second, early treatment of HIV

infection with zidovudine71 has been shown to

prolong the lives of patients who are seropositive for

HIV and have not yet developed symptoms (193).

(In fact, one important argument in support of testing

people for HIV infection is that more HIV-infected

people may be able to participate in clinical trials of

experimental treatments (67).) Finally, given the

high rate of sexual activity among the adolescent

population, early treatment can prevent the spread of

STDs to sexual partners.

Almost all States have enacted legislation specifically authorizing minors to consent (without parental approval) to health services related to STDs or

‘‘venereal diseases. ’ ’72 Forty-two States have statutes allowing minors of any age to consent to STD

services. 73 74 Despite the availability of STD treatment services, adolescents are slow to seek treatment for several reasons. First, they may not be

aware of STDs or their symptoms and may not

believe that they could be infected (7,186,160). Data

from the National Adolescent Student Health Survey indicate that from 40 to 60 percent of 8th and

10th grade adolescents did not recognize various

signs and symptoms of STDs (see table 9-7).75

Further, many adolescents indicate they would avoid

health services if parental involvement were required for care (88). A large proportion of 8th and

10th grade adolescents in the 1987 National Adolescent Student Health Survey (76 percent) incorrectly

believed that the public health department would

inform their parents of their infection with an STD,

and most (79 percent) thought that parental permission would be required for minors to be treated in

clinics 76 (see table 9-7). This level of misinformation was higher among younger adolescents (7).

Shame and embarrassment may be factors in

avoiding care. Students in the National Adolescent

Student Health Survey were more concerned about

their friends finding out they had an STD than about

their parents finding out (74 and 49 percent,

respectively) (7). Other reasons why adolescents are

slow to seek treatment for an STD include lack of

transportation, difficulty in paying for treatment,

and not knowing where to go for medical care (7).

Many adolescents may not be aware that treatment for STDs is free in certain locations, such as in

some public health clinics. Some public health

programs use a sliding fee scale, so that adolescents’

charges will be based on their personal income, not

on their families’ income (10). Although data on the

availability of services for STDs are scarce, available information suggests that, in some communities, adolescents’ concerns about the unavailability

of free treatment services may be well founded. A

1990 survey by the National Association of County

Health Officials (NACHO) found that 27 percent of

local public health departments do not actively

provide STD services (146a) .77 Generally, local

health departments serving smaller populations, and

having fewer full-time employees, were less likely

than larger local health departments to provide STD

services (146a). The availability of STD services

varied by region, as well. Only 20 percent of local

health departments in DHHS Public Health Service

70~ne~ly,~~dsn~~~wmt for ~ most d~ths due to STDS (84). However, the latest national data available indimte that no adolesc~~

between the ages 10 and 19 have died of syphilis (243). No numbers are provided for PID.

yl~s~gW= formaly cdkd ~dothymidine (AZT) (289). It is also called RetroVir@.

~FOr a discussion Of minors’ rights, see ch. 17, “Consent and Contldentiality in Adolescent Health Care Decisionmaking,” in this volume.

73A few s~tes, which have n. sta~te aufio~~ a fiorto consent to health StTViUX for STDS, have a statute aUfhOti@ fiors to co~ent to

diagnosis and treatment for “infectious, contagious, communicable, and reportable” diseases or some variant thereof (see ch. 17, “Consent and

Confidentiality in Adolescent Health Care Decisionrnrdcm“ g,” in vol. m).

TdFor ~mdiwmsion of Cement ~ ~olewent he~~ Cme d~sio~, we ch. 17, “Com~t md Confldmtialily k Adolescent H(Ath Care

Decisionmakmo g,” in vol. m.

75~oPfiom in~lud~ ~o~ who respond~ ~corr~uy as well as thOW who answered “Don’t k130W.’

T~e~of ~~c (e.g., STD or public h~r.h) is not defined in the National Adolescent Student Healti SurveY (7).

77A ~~tively broad def~tionof a IW~ pub~c ~~dep~ent WaS USCXI by NACHO : “an administrative or service unit of local or State

govemmenc concerned with healtQ and carrying some responsibility for the health of a jtukdiction smaller than the State.’ J.meal health departments

were identified using three sources, including the U.S. Conference of Local Health OMcers and NACHO mailing lists, and contacts with each State health

agency. In total, 2,932 such departments were identified and surveyed. The overall response rate of 77 percent (2,258 departments) was quite respectable

for such a survey, but 11 States had response rates between 50 and 80percent of surveyed departments, and 5 States had response rates of under 50 pement

of surveyed departments (146a).
Chapter 9-AIDS and Other Sexually Transmitted Diseases: Prevention and Services . //-295

Region 1 (Connecticut, Maine, Massachusetts, New

Hampshire 78) reported providing STD services,

compared to almost 100 percent providing STD

services in Regions 3 (District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia79),

Region 4 (Alabama, Florida, Georgia, Kentucky,

Mississippi, North Carolina, South Carolina, Tennessee), and Region 9 (Arizona, California, Nevada80) (146a). The findings of the NACHO survey

should be viewed with some caution, however.

I.meal health departments were only queried as to

whether they were ‘‘active’ in providing STD

services to individuals; the level and type of such

activity was not requested (146a) .81

Services and Interventions for the

Treatment of AIDS and Other STDs

CDC has developed guidelines for treating and

screening people infected with STDs and recommends that appropriate care for treating STDs

include obtaining a medical and behavioral risk

assessment (including questions regarding same

gender sexual contact), doing a physical examination, laboratory diagnostic services, counseling and

education (appropriate to age, race, sex, socioeconomic status, and interpersonal skills), and identify--

ing sex partners (65,234,242a,263). CDC also recommends that people seeking health care unrelated

to STD infection be assessed for STD risk. If an

individual reveals that he or she has STD symptoms,

that individual should undergo a physical exam and

appropriate laboratory tests (234). Recommended

treatment regimens vary depending on the STD, and

some regimens dictate that clients take medication

several times a day for up to a week (234). Although

the CDC guidelines note that those people who are

under age 25 are at greatest risk of infection, they do

not provide specific guidelines (e.g., appropriate

dosages, length of time) for treating STD-infected

adolescents.

CDC did include specific mention of adolescents

in its April 1991 guidelines for prevention and

management of PID (242a). In CDC publication,

Photo credit: Education Week

In a recent set of guidelines for prevention and

management of pelvic inflammatory disease, the Centers

for Disease Control (CDC) recommended that “any health

care program that serves adolescents should either

provide STD evaluation and treatment or should be able

to refer teenagers rapidly to a facility that offers

such care.” CDC further suggested that clinics located

in schools can provide “effective, convenient STD

clinical services for sexually active adolescents.”

adolescent-specific guidelines spoke to the organization of STD services for adolescents, rather than to

the clinical management of PID. These new CDC

recommendations note that adolescents are “highly

vulnerable’ to acquiring STDs. Thus, CDC recommends that ‘‘any health-care program that serves

adolescents should either provide STD evaluation

and treatment or should be able to refer teenagers

rapidly to a facility that offers such care” (242a).

Further, it suggests that ‘‘school-based clinics can

provide effective, convenient STD clinical services

for sexually active adolescents” and recommends

that regular, consistent use of condoms by all

sexually active adolescents be encouraged by health

care providers and presumably by others (242a).

The development of STD treatment guidelines

specifically for adolescents is important for several

reasons. Because adolescents and adults metabolize

drugs differently, adolescents may require different

dosages (90,184). Adolescents who receive adult

l’8~ode I~lmd ~d Vcmont we ~~o ~~ of Region 1, but hey ~d no local heal~ dep~en~ as defined h the NACHO repOfi.

~elaware is also part of Region 3, but Delaware had no local health departments as defiied in the NACHO report

80Hawaii, the U.S. Trust Territories, American Same% Guam, and the North Mariana Islands are also part of Region 9, but Hawaii had no local health

departments as defined in the NACHO repo~ and the scope of the report was limited to the continental United States, Alask& and Hawaii.

81 Fif~-sevenwrmnt of lo~ public heal~ dep~ents ~espond@ to he NACHO s~ey qofi~~t ~ey provid~ COunse@ and teSt@ fOr~S

(146a). Although more local public health departments reported providing STD services than AIDS testing and counseling, the same pattern with respect

to size of the population served and number of full-time employees that was found for STD services was found for AIDS testing and counseling (146a).
II-296 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

dosages of drugs to treat STDs maybe undertreated

in some cases and overtreated in others. The end

result of underdosage may be the evolution of

resistant strains of STD organisms (278). Although

adolescent compliance rates with STD treatment

regimens have not been studied extensively (16), it

has been suggested that health care providers

consider the record of poor compliance and low

return visits with other therapies in choosing an STD

therapy (10,152). A study from Baltimore determined that only 54 percent of female adolescents

and 33 percent of male adolescents kept their

followup appointments for STD care (40). This

finding may reflect medical practitioners’ failure to

provide clear, explicit instructions to patients to

return for a visit in more than half of observed

encounters (122).

Attitudinal studies of adolescents have suggested,

that clinician friendliness, understanding, and willingness to take their time are important to adolescents’ appointment-keeping behavior and compliance with an STD treatment regimen. In one study,

patients who expressed satisfaction were much more

likely to keep future medical appointments than

were patients who were dissatisfied (124). In another

study, clinicians who were skilled in interacting with

adolescents promoted better patient compliance

(10). On the basis of their clinical experience, Bell

and Hein suggest that single dose regimens work

best for adolescents because they ensure compliance

as well as confidentiality (16). For some STDs,

chlamydia for example, only multiple dosage regimens are possible (117).

As of 1989, zidovudine was the only drug

approved for the treatment of AIDS and HIV

infection (21,50), although dideoxyinosine (DDI)

has been approved under special circumstances for

use in adolescents (78). Little is known about how

zidovudine works in adolescents compared to adults

or children (90,209). Still, many clinicians prescribe

zidovudine to adolescents with AIDS or HIV

infection (90)0

82 There are currently no specific

guidelines available on treating adolescents with

HIV infection or AIDS (e.g., guidelines on appropriate drug dosages, how often drugs should be

administered, toxicity levels, appropriate laboratory

and neuropsychological assessments) (90,184).

Clinical trials of new drugs are sponsored by the

Federal Government, drug companies, or private

research organizations to test potentially effective

drugs in volunteers, who include people with HIV

infection but no symptoms, AIDS-related complex,

or people with AIDS. Traditionally, the Food and

Drug Administration has required that drugs be

tested in three sequential phases before others

outside the trials can receive the treatment (see table

9-1 1) (260). AIDS clinical trials were originally

established for adults over age 18 and then for

children and early adolescents ages birth through 13

years (91a). Adolescents between the ages of 13 and

17 have only recently been made eligible for

enrollment in clinical trials for all kinds of drugs,

including zidovudine (90,184,254). Often, adolescents are included in clinical trials for adults over

age 18 (258). As of August 16, 1989, adolescents in

various age groups could participate in 115 Federal

clinical trials (259).83 In almost half of these trials,

however, only 18-year-olds were eligible to participate (259). Adolescents are also eligible to participate in over 35 nonfederally-funded trials (8).

Eligibility for trials, however, does not ensure

access. Because adolescents tend not to use the

traditional health care system and because consent

and confidentiality issues are central,84 adolescents

are not actively sought to be included in trials

(90,184). As of October 5,1989, only 47 adolescents

ages 12 to 21 having various stages of infection were

involved in federally sponsored AIDS clinical trials

(see table 9-12).85 Of the 47 participants, 44 (94

percent) were male, and 3 (6.4 percent) were female.

Forty-three (92 percent) were white (254).

Many legal issues surface regarding adolescents

and their involvement in clinical trials. Currently,

adolescents under age 18 must get permission from

a parent, legal guardian, or person with power of

attorney before entering federally sponsored trials

(259). While emancipated minors can give consent

for participation in trials (75), the issue of consent is

82untfl he Food ad ~mg A&s@ation app~ved zidovu~e for we in c~ldren ~d adolescents, clinicia faced liability concerns (75), Such

concerns may recur if another drug is found to be effective in treating HIV infection and AIDS.

83~ese ~~s ~ not adolescent Specflc but group adolescents ~d ad~ts or adolescents md children together.

~For tier discussion of these topics, see ch. 15, “MiiJOr Issues Pe rtaining to the Delivery of Primary and Comprehensive Health Services to

Adolescents” and ch. 17, “Consent and Cotildentiality in Adolescent Health Care Decisionmaking, ” in Vol. III.

85~ecdot~ evidence ~dicate~ tit most p~nts of infected adoles~nts fo~d out about bklk throllgh their physicians (75).
Chapter 9-AIDS and Other Sexually Transmitted Diseases: Prevention and Services . II-297

Table 9-1 l—Steps in AIDS Drug Testing

Range in

number of

Type of trial patients Length Purpose Method

Phase 1 . . . . 20 to 100 Several months To see if drug Is safe All patients get the drug

being tested.

Phase 2 . . . . Up to several Several months to To test effectiveness In phases 2 and 3, dochundred 2 years and short-term safety tors compare results for

two randomized groups;

the first gets the drug

Phase 3 . . . . Several hundred 1 to 4 years To test safety, effec- being tested; the secto several thou- tiveness, dosage level ond gets another drug,

sand or no drug (placebo).a

acurrently, Vew few Cliniml trials of experimental AIDS drugs use Placebos.

SOURCES: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health,

National Institute of Allergy and Infectious Diseases,“AIDS Clinical Trial: Talking It Over,” NiH Pub. No.

89-3021, Bethesda, MD, August 1989; U.S. Department of Health and Human Services, Public Health

Service, National Institutes of Health, National Institute of Allergy and Infectious Diseases, “Where Do

AIDS Drugs Come From?” Bethesda, MD, no date.

Table 9-12—Sex, Race, and Ethnicity of the 47 Patients

Ages 12 to 21 Involved in Federally Sponsored AIDS

Clinical Trials, October 5, 1989

Patients Percent Count

Sexa

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93.6% 44

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.4 3

Race

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.5 43

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.5 3

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 1

Ethnicity

Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.0 8

Non-Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83.0 39

aThe large proportion of males is due primarily to the large proportion of

adolescent males with hemophilia involved in clinical trials.

SOURCES: U.S. Department of Health and Human Services, Public Health

Service, National Institutes of Health, Bethesda, MD, unpub

Iished data on patients involved in federally sponsored AIDS

clinical trials, Bethesda, MD, October 1989; and D. Sondheimer, Coordinator, Adolescent and Maternal AIDS Branch,

Center for Research for Mothers and Children, National

Institute of Child Health and Human Development, National

Institutes of Health, Public Health Service, U.S. Department of

Health and Human Services, Rockville, MD, personal communication, Dec. 28, 1989.

not clear regarding young people involved in the

foster care, child welfare, and prison systems.

Although no systematic data have been collected,

these adolescents rarely seem to participate in

clinical trials (75).

As discussed throughout this Report, there are not

many health centers that are geared to the needs of

adolescent patients in general.86 According to Hein,

there is in addition a serious shortage of health

personnel knowledgeable about adolescents’ HIV

infection and a scarcity of programs serving highrisk and HIV-infected adolescents (91a). Two programs, funded as part of the Pediatric AIDS Health

Care Demonstration Project of the Health Resources

and Services Administration in DHHS, are developing new standards for comprehensive medical and

social services for HIV-infected adolescents (91a).

In the Montefiore Adolescent AIDS program in New

York City, a multidisciplinary team provides a

comprehensive range of medical and psychosocial

evaluation and services for individuals age 13 to 21

(91a). The program reaches out to bring at-risk and

infected individuals in for services; in turn, the

program refers patients out of the program to

agencies that can provide nonmedical services such

as housing or coordinate care for adolescents who

are being cared for by multiple agencies (91a). The

program is also developing and evaluating new

strategies for behavior change in at-risk and infected

adolescents (91a). A similar pediatric AIDS health

care demonstration project is funded by DHHS to

serve high-risk and infected adolescents in Los

Angeles (91a). As Hein notes, although these

programs are located in high-risk areas for adolescent HIV infection, together they touch only some of

the at-risk and HIV-infected adolescents in the

United States (91a).

The number of adolescents diagnosed with AIDS

at present is small, but the apparent inadequacy of

prevention efforts may mean an increase in the

number who become HIV infected. This makes the

existence of barriers to treatment such as the lack of

86sw especially, Ch. IS> “Major Issues in the Delivery of Primary and Comprehensive Health Services to Adolescents, ” in Vol. III.
II-298 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

clinical trials specific to adolescent dosages, and the

limited access to AIDS clinical trials by adolescents

generally (especially by black and female adolescents), exceedingly important to address. Unfortunately,

no mechanism has been set up so that adolescent

health care practitioners can participate in the AIDS

Clinical Trials Group, which is the consortium of

federally sponsored centers carrying out trials (90,157).

Major Federal Programs Related to HIV

Infection, AIDS, and Other STDs

All levels of government-Federal, State, and

local-have taken on some responsibility for controlling the spread of HIV infection, AIDS, and

STDs within the adolescent population. Within the

Federal Government, the primary responsibility

rests with DHHS, particularly the Public Health

Service. Federal support for AIDS- and STD-related

activities is provided through block grants to the

States and through funding for research and demonstration projects.

Federal support to States for AIDS- and STDrelated activities is provided through block grants

under Title V of the Social Security Act (maternal

and child health services block grants) and Title XX

of the Social Security Act (social services block

grants). States are given wide discretion in determining what services to support with block grant money

and in determiningg which groups should be eligible

for services. States use portions of their block grant

money to support AIDS- and STD-related services

for all age groups, including adolescents, although

the exact amounts are difficult to determine. Reporting requirements from the States to DHHS are

minimal. 87

DHHS funds demonstration and research projects

related to AIDS and STDs. DHHS’ HIV/AIDS and

STD-related projects that included or targeted adolescents 1989-90 are listed in table 9-13. Most of the

projects include adolescents as part of a larger

population, but some target adolescents specifically.

According to information collected in OTA’s

survey of Federal agencies involved in adolescent

health, 88 the Public Health Service and other agencies within DHHS typically spend no more than 10

percent of their budgets on adolescent-specific

activities. Most of the funds for adolescent-specific

activities are spent on programs and projects related

to the consequences of adolescent sexual intercourse. As table 9-13 illustrates, DHHS agencies

generally give greater emphasis to projects related to

HIV infection and AIDS than to projects related to

traditional STDs. This emphasis is not surprising

given the fact that DHHS has identified AIDS as the

Nation’s highest health priority (214). According to

OTA’s survey, DHHS agencies spent over $150

million in fiscal year 1990 supporting AIDS- and

STD-related efforts—including research, prevention, service, and treatment activities--that target

adolescents (207,208,214,227,25 1,257,258).

AIDS and STD prevention, treatment, and research activities that include or target adolescents

and are being supported by DHHS are discussed

further below.

Federal Programs Related to AIDS and

STD Prevention

DHHS supports numerous preventive intervention and research efforts to control the spread of HIV

infection and STDs among a larger, more general

population receiving Federal funds. This approach

may increase the types of AIDS and STD preventive

interventions available to adolescents but limit the

appropriateness and usefulness of these interventions for adolescents. The National Institute on Drug

Abuse within the Alcohol, Drug Abuse, and Mental

Health Administration, for example, has supported

many studies of preventive interventions for HIV

infection relative to drug use and sexual behaviors;

however, few studies of preventive interventions

have focused on drug use and sexual behaviors

among adolescents, and data from mostly adult

participants cannot be generalized to adolescents

(215). The Division of Sexually Transmitted Diseases and HIV Prevention within CDC’s Center for

Prevention Services supports partner notification

efforts and screening for STDs at various locations

(e.g., family planning clinics, outpatient obstetricsgynecology clinics) as major approaches for identifying people who are potentially infected with STDs

(117). If issues in partner notification efforts for

87Unt11 ~wendy, for ~-pie, s~te~ ~me ~w~~ o~y t. rew~ intended ux of Tifle XX SOCM Servias block ~~tfunds to the Secretary of DHHS

(200). The Family Support Act of 1988 (Public Law 100-485) required States to begin to report detailed information on services actually funded.

g6For a more in.dep~ di~ussion of theF~~@vernment’s activities related to adolescent health ad a description of 0~’ss~ey, see ch. 19,

“The Role of Federal Agencies in Adolescent Heal@” in Vol. III.
Table 9-13--U.S. Department of Health and Human Services HIV/AIDS- and STD-Related Projects and Grants That Include or

Target Adolescents, 1989-90a

Includes Targets

Agency Demonstration or research project grants that include or target adolescents adolescents adolescents — — — Off Ice of Human Development Services (OHDS)

Public Health Service (PHS)

Alcohol, Drug Abuse, and Mental Health

Administration (ADAMHA):

● National Institute on Drug Abuse (NIDA)

● National Institute of Mental Health (NIMH)

Centers for Disease Control (CDC):

● Center for Chronic Disease Prevention and

Health Promotion

—Division of Adolescent and School Health

HIV Prevention:

Interagency agreement with the Public Health Service to mobilize national resources for

youth with HIV infection and AIDS-related complex.

HIV Prevention and Related Research:

1. Five grants focusing on HIV preventive intervention strategies that promote changing

risk-related behaviors in minority, adolescent, and homeless women (213).

2. AIDS Comprehensive Community Outreach Demonstration Projects: develop effective

preventive strategies for reaching IV drug users not in drug treatment and their sexual

partners (203).

3. AIDS Targeted Outreach Demonstration Contracts: focusing on IV drug users (203).

4. Eleven Prevention-Intervention Studies ranging from on-the-street contact to multiple

skills training sessions (213).

5. Multimedia Cocaine Abuse Prevention Campaign: radio, print and television public

service announcements to help prevent cocaine use among older adolescents and young

adults (213).

6. AIDS and Its Behavioral Causes: Children’s Knowledge and Emotions: research that is

developmentally based and studies 6-to 12-year-old chi Idren’s knowledge, attitudes and

feelings related to AIDS, sexuality, and substance abuse (see NIMH and NICHHD also)

(262).

HIV Prevention and Related Research:

1. AIDS extramural grants to the HIV Center for Clinical and Behavioral Studies and the

Centerfor AIDS Prevention Studies: HIV prevention efforts targeting adolescent students,

sex offenders, runaways, and sexually active adolescent females ages 14 to 20 (203).

2. Multisite, multipopulation studies: test behavioral interventions to stop the spread of HIV

infection (1).

3. AIDS and its Behavioral Causes: Children’s Knowledge and Emotions: research that is

developmentally based and studies 6-to 12-year-old children’s knowledge, attitudes and

feelings related to AIDS, sexuality, and substance abuse (see NIDA and NICHHD also)

(262).

HIV Preventiorx

1. Cooperative agreements with 20 national, 55 State, and 16 local education agencies:

help implement effective programs of school health education to prevent the spread of

HIV (227).

2. Technical assistance to State, territorial, and local departments of education: development and implementation of an anonymous self-administered questionnaire to high

school students about their HIV-related knowledge and behaviors (231).

HIVand STD Prevention:

Assisting the Division of Reproductive Health within CDC’S Center for Chronic Disease

Prevention and Health Promotion in developing the Youth Risk Behavior Surveillance

x

x

x

x

x

x

x

x

x

x

x

x

x

System: will periodically measure changes in health risk behaviors, including dtug use and

sexual intercourse that can result in AIDS and STDS (108,227,231).

Continued on next page
Table 9-13--U.S. Department of Health and Human Services HIV/AIDS- and STD-Related Projects and Grants That Include or

Target Adolescents, 1989-90a

--Continued

Includes Targets

Agency Demonstration or research projects/grants that include or target adolescents adolescents adolescents

. Center for Infectious Diseases

—Division of HIV)AIDS

. Center for Prevention Services

—Division of Sexually Transmitted Diseases

and HIV Prevention

. National AIDS Information and Education

Program (NAIEP)

Health Resources and Services Administration

(HRSA):

● Bureau of Maternal and Child Health

HIV Prevention and Related Research:

Research and prevention projects: study HIV prevalence and risk factors for adolescents

attending clinics in Bronx, New York, and Washington, DC (227)

HIV Prwentiorx

1. AIDS Community Demonstration Projects: evaluate strategies for preventing HIV

transmission (5 out of 7 target school-aged youth) (240).

2. Cooperative Agreements for Minority Community-Based Human ImmunodeficiencyMrus

(HIV) Prevention Projects.

STD Prevention and Related Research;

1. Partner notification and screening efforts to reach infected individuals, including

adolescents, at risk for STDS (117).

2. Development and review of STD curricula in the schools (1 17).

3. Grants and cooperative awards to 10 STD Preventiotiraining Centers: train professionals, physicians-in-training, and other staff of STD Control and HIV Prevention Programs

in diagnosis, management, prevention, patient counseling, and standards of care for

STDS and HIV infection (55 FR 7570,227).

4. National STD Hotline (1 17).

5. Preventive Health Services-Sexually Transmitted Diseases Research, Demonstration,

and Public Information and Education grants: develop, improve, and evaluate innovative

approaches to the clinical care of STDS and study the role of health behaviors in

transmitting STDS (55 FR 17308).

H/V Prevention

1. Multimedia “America Responds to AIDS” campaign phase targeting adolescents and

parents: promote communication about HIV and AIDS between adults and adolescents,

encourage adolescents’ adoption of less risky behaviors, and increase the general

public’s awareness of adolescents and AIDS (1 83,21 8).

2. National AIDS Hotline.

3. National AIDS Clearinghouse.

AIDS Treatment and Related Research:

1. Subacute Care Demonstration Project Grants: provide medical care and treatment to HIV

infected individuals (55 FR 12918).

2. AIDS Regional Education and Training Centers.

3. Community and migrant health centers.

4. Pediatric AIDS Health Care Services Demonstration Projects: meet the needs of HIV

infected children and adolescents by providing comprehensive services through the

collaboration of community agencies (100).

5. Pediatric AIDS Comprehensive Center Demonstration Projects: form a consortia to

provide services, conduct research, and provide training to professionals, volunteers, and

other individuals working with pediatric AIDS populations (100).

6. National Issues of High Priority in Pediatric AIDS (100).

7. Special Projects of Regional and National Significance (SPRANS) grants? fund

Hemophilia Diagnostic and Treatment Centers that provide comprehensive care to

children and adolescents with chronic illness (252).

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

:

. .
Table 9-13--U.S. Department of Health and Human Services HIV/AIDS- and STD-Related Projects and Grants That Include or

Target Adolescents, 1989-90a-Continued

Includes Targets

Agency Demonstration or research projects/grants that include or target adolescents adolescents adolescents

National Institutes of Health (NIH):

●

●

●

●

National Cancer Institute (NCI) Research Related to AIDS Treatment

Expanded eligibility criteria to include HIV-infected adolescents with hemophilia in AIDS x

treatment protocols (257).

National Center for Research Resources Research Related to HIV Prevention:

Biomedical research support grant program: HIV Center for Clinical and Behavior Studies x

used the funds to conduct pilot interviews with adolescents living on the streets and 10th

grade public high school adolescents to increase understanding of their attitudes and

knowledge regarding AIDS prevention (159,257).

National Institute of Allergy and Infectious

Diseases (NIAID) Research Related to AIDS Treatment

1. AIDS vaccine evaluation units (282). x

2. AIDS clinical trials units. x

3. Cooperative agreements: increase the participation of individuals from racial and ethnic x

minority groups in clinical trials.

Research Related to STD Treatment

1. Research forthedevelopment of vaccines for gonorrhea, chlamydia, syphilis, and herpes x

simplex virus type 2.

2. Research on the natural history and therapy of the human papillomavirus. x

National Institute of Child Health and Human

Office of Population Affairs (OPA)

x

Development (NICHHD) Research Related to AIDS Prevention and Treatment

1. AIDS and its Behavioral Causes: Children’s Knowledge and Emotions: research that is x

developmentally based and studies 6-to 12-year-old chi Idren’s knowledge, attitudes and

feelings related to AIDS, sexuality and substance abuse (also see NIDA and NIMH) (262).

2. Research on the transmission of HIV from mothers to children (258). x

Research Related to STDS: x

Research on pelvic inflammatory disease (258).

Research Related to AIDS and STDS: x

Research on the relationship between STDS, including AIDS, and ferti Iity related behavior

(258).

AIDS and STD Treatment

Demonstration projects under Title X (Family Planning Services and Population Research

Act of 1970 [Public Law 91 -572]) of the Public Health Service Act and llle XX (Adolescent

Fami Iy Life Demonstration Projects) of the Public Health Service Act: direct services related

to AIDS and STDS.

Office of Minority Health (OMH) HIV Prevention

Minority HIV Education/Prevention Grant Program to 4 national and 23 community-based x

minority organizations: expand innovative educatiotiprevention activities to racially and

ethnically diverse populations (22).

a~d ~nmanly on OTAIS suwey of F4ralagenaes involved in adolescent health.

bNum~rs in ~arenthe~e~ are referenc~ to citations. FuII citations are l~ted at the end of this chapter.

CSp~NS grants are sumrted through a I G to 15-perc@ Federal set-aside from the Maternal and Child Health Services block grant appropriation each fiscal year (249).

SOURCE: Office of Technology Assessment, 1991.
//-302 . Adolescent Health—Volume //: Background and the Effectiveness of Selected Prevention and Treatment Servjces

adolescents differ from the issues for adults, they

may receive inadequate attention.

As shown in table 9-13, some federally supported

AIDS and STD prevention projects do target adolescents. Often, though, young adolescents either do

not receive the preventive intervention or receive the

same intervention as older adolescents. There is

little recognition of adolescents’ differing developmental perspectives and needs. The Division of

Sexually Transmitted Diseases and HIV Prevention

within CDC’s Center for Prevention Services, for

example, is supporting cooperative agreements for

prevention projects for racial and ethnic minority

communities; this effort is not adolescent-specific,

but the development of activities for adolescents

living on the streets is considered a priority (55 FR

9955). In the grant announcement for the projects,

however, no mention is made of the differing needs

of younger and older adolescents who live on the

streets. A 10-year-old is unlikely to require the same

types of interventions as an 18-year-old.

The Division of Adolescent and School Health

within CDC’s Center for Chronic Disease Prevention and Health Promotion focuses solely on adolescents unlike the other DHHS agencies. In fiscal year

1990, the Division of Adolescent and School Health

awarded over $24 million in cooperative agreements

to 20 national, 55 State, and 16 local education

agencies to develop effective programs of school

health education to prevent the spread of HIV (227).

In fiscal year 1989, the Division of Adolescent and

School Health awarded 5-year contracts to IOX

Assessment Associates, Macro Systems, Inc., and

Westat, Inc. to perform evaluation and survey

research pertaining to HIV and AIDS (227). The

Division of Adolescent and School Health has also

provided technical assistance to State and local

departments of education to develop and implement

an annual school-based survey of 9th to 12th grade

students in public and private schools (227,231);

during 1989, the survey questionnaire focused on

students’ HIV-related knowledge, beliefs, and behaviors. Finally, the Division of Adolescent and

School Health has worked with State and local

departments of education and other Federal agencies

to develop a surveillance system--the Youth Risk

Behavior Surveillance System-that will periodically measure changes in adolescents’ high-risk

behaviors, including sexual activity resulting in the

transmission of HIV infection and STDs, between

1991 and 2000 (108,227,231).8

9 The system will

provide comparable data across national, State, and

local populations of adolescents.

As this Report was going to press, CDC was

hoping to issue requests for proposals to fund

coalitions to identify and provide outreach and

preventive services to adolescent populations at high

risk of HIV infection and other health problems,

such as out-of-school youth (272a). Under this

program, coalitions would be funded in 3 cities with

the highest caseloads of HIV infection (272a). One

city would be named a training and demonstration

site which would bring together individuals from

organizations working with adolescents (e.g., local

education agencies, local health agencies, detention

centers, runaway shelters). These individuals would

then be trained in AIDS/HIV prevention methods

and encouraged to build coalitions in their city.

(272a).

Three Federal agencies that do support research

on young adolescents are the National Institute of

Child Health and Human Development within the

National Institutes of Health and both the National

Institute of Mental Health and the National Institute

on Drug Abuse within the Alcohol, Drug Abuse, and

Mental Health Administration. These DHHS agencies support research that is developmentally based

and studies 6- to 12-year-olds’ knowledge, attitudes,

and feelings related to AIDS, sexuality, and substance abuse (262).

From responses to OTA’s Federal agency survey

and the list in table 9-13, it is clear that HIV

prevention efforts among adolescents receive much

more emphasis at the Federal level than do STD

prevention activities (207,208,214,227,25 1,257,258).

Even the one division within CDC that in the past

was devoted to STD control is now called the

Division of Sexually Transmitted Diseases and HIV

Prevention and has as one of its current priority areas

the reduction of HIV infection (227). Since 1985,

HIV prevention efforts have received a larger share

of financial and personnel resources than have STD

prevention efforts at both the Federal and State

levels (240). In fiscal year 1990, for example, CDC’s

Division of Sexually Transmitted Diseases and HIV

8~e ~rev~enw ofo~erh~~ risk ~~viors that will be measured include drug use, alcohol use, tohcco use, ~e~Patte~* fid~te PhYsi~

activity, and behaviors resulting in accidental injuries (231).
Chapter 9--AIDS and Other Sexually Transmitted Diseases: Prevention and Services . II-303

Prevention, received an estimated $23.7 million for

adolescent STD and HIV activities; the Division of

Adolescent School Health, where most funds are

being used to support the development of effective

HIV education for adolescents, received over $36.5

million (108,1 18,227).

DHHS may be emphasizing the prevention of

HIV/AIDS among adolescents for several reasons.

First, although STDs other than HIV infection are

more prevalent in the adolescent population, HIV

infection has potentially greater consequences for

affected individuals, their families, and society.

There is no cure for AIDS, and AIDS is a fatal and

often costly disease; most STDs, on the other hand,

are curable. An additional reason for DHHS emphasis on AIDS prevention rather than STD prevention

is that Congress has earmarked funds for AIDS

prevention. For example, although the mission of the

Division of Adolescent and School Health in CDC

is broad in relation to adolescent health, most of the

Division’s funding has been provided specifically to

help schools prevent HIV infection among adolescents (108,227).

It is important to note that the methods that

individuals adopt for preventing the sexual transmission of HIV infection and STDs are virtually

identical-abstainin g from sexual intercourse or

modifying sexual or drug-using behaviors that put

one at risk of infection. While federally supported

STD educational curricula incorporate AIDS information, the importance of STDs other than AIDS

tends to be ignored in most HIV educational

curricula (1 17). Federally supported surveys often

question adolescent students about their knowledge

and attitudes related to AIDS but do not ask similar

questions about their knowledge and attitudes related to STDs. An exception was the National

Adolescent Student Health Survey; this survey—

supported by DHHS through the Office of Disease

Prevention and Health Promotion, CDC, and the

National Institute on Drug Abuse--did ask adolescents in school questions about their knowledge of

both AIDS and STDs (7).

Generally, most of the money from DHHS that

supports AIDS and STD prevention projects for

adolescents goes to projects that are located in the

schools and in major metropolitan areas. This focus

is reasonable because most adolescents are in school

and metropolitan areas have had the highest reported

prevalence rates of AIDS and STDs. On the other

hand, prevention activities in schools will not reach

out-of-school adolescents who are at increased risk

of infection, such as runaway and homeless adolescents, and prevention efforts concentrated in metropolitan areas will not reach adolescents in rural and

other areas that are not yet reporting high rates of

infection.

As directed by Congress, most funds for HIV

prevention efforts by the Division of Adolescent and

School Health in CDC are directed to adolescents in

schools. CDC guidelines state that HIV prevention

efforts should be consistent with community and

parental standards (232) so State and local school

boards of education have control over the scope and

content of HIV and STD preventive messages in the

schools. The role of the Division of Adolescent and

School Health in determining the content of educational messages about AIDS and STDs to adolescents in school is quite limited. In some communities, teachers are not permitted to discuss condoms

as a method of protection against HIV and STDs for

fear that such discussion promotes sexual activity.

Thus, students in those communities, who do engage

in sexual intercourse, may not receive basic information about how to protect themselves against HIV

infection or STDs. A recent survey by the National

Association of State Boards of Education found that

only three States actually had policies indicating that

condom use should be discussed as either a recommended or unreliable method of protection (147).

Increasingly, agencies within the Public Health

Service are targeting money for prevention efforts to

out-of-school adolescents (e.g., dropouts, runaways)

who may be at increased risk of infection. As shown

in table 9-13, CDC’s Division of Sexually Transmitted Diseases and HIV Prevention is supporting the

evaluation of strategies for preventing HIV transmission through seven AIDS community demonstration projects. Five of the seven demonstration

projects target school-aged adolescents, particularly

those who are on the streets (240). In addition, the

National Institute of Mental Health (within the

Alcohol, Drug Abuse, and Mental Health Administration) and the National Center for Research

Resources (within the National Institutes of Health)

are supporting AIDS extramural grants to the HIV

Center for Clinical and Behavioral Studies for HIV

prevention efforts targeting specified groups of

adolescents, including runaways and sex offenders

(159,203,216,257). Finally, the National Institute on

Drug Abuse (within the Alcohol, Drug Abuse, and
11-304 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Mental Health Administration) provided $715,486

in fiscal year 1989 for an AIDS Community

Outreach Demonstration Project in San Antonio,

Texas, targeting AIDS education to adolescent

runaways (214), and the National Network of

Runaway and Youth Services in fiscal year 1989-90

received $156,000 from the Division of Adolescent

and School Health in CDC to ensure that its

youth-serving agencies throughout the United States

operate AIDS prevention and education programs

(209,227).

Because of limited funds and higher reported

prevalence rates of HIV infection and STDs within

major metropolitan areas, most Federal funds are

directed to urban areas. CDC’s Division of Sexually

Transmitted Diseases and HIV Prevention, for

example, provides grants and cooperative agreements to 10 STD Prevention/Training Centers, all of

which are located in large metropolitan areas such as

Newark, Baltimore, Chicago, Dallas, Denver, and

Seattle (227) (54 FR 8828; 55 FR 7570). This

Division also supports two demonstration projects,

one in New York City and one in San Francisco

(227). Recently, CDC has provided funding for

community-based education in several cities

through the U.S. Conference of Mayors, including

New York, San Francisco, and Los Angeles, in

addition to providing money to the States to

distribute to localities (198). The U.S. Conference of

Mayors received $857,000 in 1991 and planned to

award grants to 17 nonprofit, nongovernmental,

community-based organizations (198a). Out-ofschool youth and racial and ethnic minorities are two

priority groups receiving education from these

community-based efforts. Given that overall AIDS

cases are becoming increasingly common in rural

and noncoastal areas (77), direct funding of efforts

in these areas as well may help prevent further

transmission of infection into yet uninfected populations.

The most effective way for adolescents to avoid

acquiring an HIV infection or STD is to abstain from

sexual intercourse. For adolescents who do not

abstain from sexual intercourse, however, the proper

use of condoms is the most effective method to

reduce the chances of infection (222). Few federally

supported projects are studying adolescents’ attitudes toward condoms in relation to the prevention

of HIV and STDs. CDC’s Division of Sexually

Transmitted Diseases and HIV Prevention is supporting applied research projects that not only will

study people’s attitudes toward condom use but will

evaluate strategies using condoms for controlling

syphilis, but those projects are not adolescentspecific (54 FR 8828). In addition, during fiscal year

1987-88, the National Institute of Health’s National

Institute of Child Health and Human Development

made the development of safe, more effective

contraceptives that would help to prevent the transmission of HIV infection and STDs one of its

priorities. The reason for the lack of Federal support

for HIV and STD prevention projects related to

adolescents and condoms is unclear, but it may bean

unintended result of the Federal Government

nearly exclusive emphasis on getting adolescents to

abstain from sexual intercourse. Some of the limitations of relying exclusively on abstinence to control

the spread of HIV and STDs among adolescents

were noted earlier in this chapter.

DHHS is increasingly directing money for HIV

and STD prevention efforts to members of racial and

ethnic minority groups at increased risk of HIV and

STDs. As directed by Congress in fiscal year 1988,

for example, the Office of Minority Health in the

Public Health Service awarded approximately $1.4

million to 4 national and 23 community-based

minority organizations for HIV prevention and

education efforts directed at racial and ethnic

minority populations, including adolescents (22).

Five of these HIV prevention projects specifically

address the needs of racial and ethnic minority

adolescents; interventions include a peer teen HIV

prevention program for black youth in Los Angeles

and family-based HIV prevention strategies for a

Hispanic community in Salt Lake City. In addition,

CDC’s Division of Sexually Transmitted Diseases

and HIV Prevention has made street outreach

programs to assist adolescents on the street get HIV

and AIDS risk-reduction counseling a priority activity in its Cooperative Agreements for Minority

Community-Based HIV Prevention Projects (55 FR

9955). These projects may increase understanding as

to how to most effectively target interventions to

adolescents in racial and ethnic minority groups with

high reported prevalence rates of HIV and STDs.

Federal Programs Related to AIDS and

STD Treatment

Primarily because relatively few adolescents are

diagnosed with AIDS, federally funded AIDS treatment services are rarely specific to adolescents.

Most AIDS treatment and treatment-related research
Chapter 9-AIDS and Other Sexually Transmitted Diseases: Prevention and Services . II-305

efforts include adolescents within populations of

adults or children. The primary agencies within

DHHS that provide AIDS treatment services or

AIDS treatment-related research are the Bureau of

Maternal and Child Health in the Health Resources

and Services Administration and the National Institute of Allergy and Infectious Diseases in the

National Institutes of Health. Both the Health

Services and Resources Administration and the

National Institutes of Health are components of the

Public Health Service.

The Bureau of Maternal and Child Health of the

Health Resources and Services Administration funds

various AIDS treatment-related activities that include adolescents. As shown in table 9-13, these

include subacute care demonstration projects, pediatric AIDS health care services demonstration projects (as described above), pediatric AIDS comprehensive center demonstration projects, and national

issues of high priority in pediatric AIDS (100,249).

The Bureau of Maternal and Child Health also

administers the maternal and child health block

grants to States. As discussed at the beginning of this

chapter, however, services funded with these grants

are determined by the States receiving the grants.

The Federal Government’s ability to target block

grant funds for AIDS or other services is limited to

the 15 percent of the block grants that is set aside to

fund “special projects of regional and national

significance (SPRANS). Through SPRANS, the

Bureau of Maternal and Child Health supports

hemophilia diagnostic and treatment centers, which

have been recognized by the DHHS Secretary’s

Workgroup on Pediatric AIDS as models for comprehensive care for children and adolescents with

chronic illness90 (90,209,252). An interdisciplinary

team of professionals provide medical and dental

care, physical therapy, orthopedic care, psychosocial care, vocational counseling, and genetic counseling in inpatient and outpatient settings in the

context of an adolescent’s family (209). With the

help of a $6.2 million transfer from CDC, the 25

regional hemophilia centers will focus on the serious

AIDS-related problems of hemophiliacs and their

families (253).

The National Institute of Allergy and Infectious

Diseases within the National Institutes of Health

recently made adolescents eligible to participate in

adult AIDS clinical trials by dropping the age of

eligibility from 18 to 13.91 Because adolescents are

not actively sought to participate in trials, however,

many eligible adolescents are not involved (90,91a,

184). To encourage the participation of individuals

from racial and ethnic minority groups who are

underrepresented in clinical trials, the Institute has

set aside $3.6 million for cooperative agreements,

but these agreements are not specific to adolescents

(283). The National Institute of Allergy and Infectious Diseases also supports research efforts to study

potential vaccines and treatments for STDs (e.g.,

gonorrhea, chlamydia, syphilis, and herpes simplex

virus type 2).

Adolescents can receive services for family planning and STD-related services through the 4,000

family planning clinics supported by Federal funds

under Title X of the Public Health Service Act

(Family Planning Services and Research Program

[Public Law 91-572]). These grant programs are

administered by the Office of Population Affairs

within the Public Health Service of DHHS. Among

the current priority areas for Title X monies are

STDs, AIDS, the involvement of families, and

abstinence (207).92 Adolescents can receive STDrelated services through some demonstration projects funded under Title XX (Adolescent Family Life

Program) of the Public Health Service Act (as

amended by Public Law 97-35). Title XX of the

Social Security Act, as amended by Public Law

97-35, authorizes funds to be provided to States for

the provision of social services, including family

planning services (207). The Federal Government’s

emphasis on encouraging abstinence from sexual

activity and the requirement that organizations not

provide abortion services (207) may have the effect

of limiting sites providing STD and AIDS services

to adolescents. Adolescents who continue to engage

in sexual intercourse despite the Federal Government’s emphasis on abstinence, therefore, may be

placed at unnecessary risk for HIV infection and

STDs because access to appropriate STD and AIDS

services may be limited.

Vor a discussion of adolescents wihh chronic illness, see ch. 6, “Chronic Physical Illnesses: Prevention and Services,” in this volume.

91~e ~sti~tti of tie Natio~ ~ti~tes of H~~ provide Semices ody h Conjmction with their research efforts.

~For f~er discussion of ~ltles X ad ~of tie ~blic He~~ Semice Act, sw ch. 10, ‘‘~e~cy ~d Parentig: Prevention ad SeNiCeS, ” in

this volume, and ch. 19, “The Role of Federal Agencies in Adolescent Heal@” in Vol. III.
//-306 Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Recently, the Federal Government passed the

Ryan White Comprehensive AIDS Resources Emergency Act (Public Law 101-381), which authorizes

$4.4 billion in Federal funding to metropolitan areas

hardest hit by the AIDS epidemic. The Health

Resources and Services Administration and CDC

within DHHS are the agencies primarily responsible

for the implementation various aspects of the act

(198b).

Conclusions and Policy Implications

AIDS and other STDs are important adolescent

health concerns. Although AIDS can be classified as

an STD,93 it has sometimes been distinguished from

other such diseases for reasons related to risk factors,

consequences of the diseases, strategies for prevention, research, and implications for the delivery of

treatment services.

Perhaps the most compelling difference between

AIDS and other diseases that can be transmitted

sexually is that AIDS is almost inevitably fatal.94

This almost certain fatality, paired with the long

period between initial infection and the appearance

of symptoms of AIDS (now thought to be 8 to 10

years), during which time an infected person can

unknowingly transmit the virus to others, makes it a

particularly frightening disease. Thus, AIDS has

been designated the Nation’s number one health

priority by DHHS.

Concern about HIV infection and AIDS among

adolescents seems to have lagged behind. Perhaps

one reason for the lag is that the long latency period

means that few adolescents (568 cases, or less than

1 percent of AIDS cases in the United States through

August 31, 1990)95 were among those actually

diagnosed as having AIDS.

The fact that few adolescents have been diagnosed

with AIDS, however, may result in a false sense of

security. Small samples of adolescents whose blood

has been tested for HIV suggest that the rate of HIV

infection may be as high as 3.4 percent for runaway

and homeless adolescents seen in New York City.

Even more disturbing is the finding that people who

are diagnosed with AIDS in their early twenties

make up 4 percent of AIDS cases in the country,

suggesting that HIV infection may be higher than

currently known in adolescents.% For these reasons,

AIDS among adolescents should be of critical

concern to the Nation’s health policymakers.

If one uses prevalence and ease of transmission as

benchmarks, paired with long-term implications for

infertility and other serious chronic health problems,

some diseases other than AIDS that can be transmitted sexually should also be a critical concern. Yet

another basis for concern about traditional STDs is

that the presence of some STDs may facilitate the

transmission of HIV. Available data, incomplete

though they are, suggest that the rate of STDs among

adolescents is high. Rates for chlamydia infection,

the most prevalent STD among adolescents, varies

from 3 to 37 percent depending upon the population

surveyed (see table 9-6). Rates for gonorrhea vary

from 3 to 18.5 percent and would probably be higher

if the rates were based on the number of sexually

active adolescents rather than the entire adolescent

population (239,240). Given the asymptomatic nature of many STDs, diverse State laws for reporting,

adolescents’ lack of knowledge about STD symptoms and about the availability of and confidential

treatment, the picture of STDs among the adolescent

population may be even worse than it appears.

Efforts to prevent both HIV infection and other

STDs are stymied by a lack of information about

adolescent behaviors. Unfortunately, little is known

about the extent of risky sexual practices among

adolescents (including nonuse of condoms and

sexual intercourse with older, perhaps infected,

individuals) or about adolescents’ perceived or

actual access to preventive and treatment services.

gsAlr.hough tie ViIUS that causes AIDS (HIV) can be, and usually is, transmitted sexually in adolescents, there are Other WdtX Of ~“ssio& such

as through IV drug use and through the transfusion of contaminated blood and blood products for the treatment of hemophilia, that arc not common to

many other STDS although they may occur. Thus, prevention strategies for AIDS must entail efforts directed at other means of transmission such as

blood transfusions.

~As of my 1990, 61 Pmcent of tie 130,252 c~u~tiveAIDS ~ses reported ~o~adults and adolescents ages 13 and over kd died (237).

95c== me through Aug. 31, 1990, and represent adolescents ages 13 to 19 (237a).

%~e fact tit older adolescent ~d yo~g ad~t men ~~ely to engage in .wxti intercourse with younger females (See Ch. 10, “pre~cy ~d

Parenting: Prevention and Services”) and, apparently, males provides additional cause for concern. Fortunately, female-to-male sexualtnmsrnission

appears to be more difficult than male-t~female transmission so that females who in turn have sexual intercourse with adolescat mates around their

own age are probably not as likely to continue the chain of transmission. Sexual practices involved in male-to-male transmission however, make AIDS

a health problem of extreme concern for sexually active homosexual adolescents.
Chapter 9-AIDS and Other Sexually Transmitted Diseases: Prevention and Services . Il-307

Given the heterogeneity of the population and the

current levels of infection already present in the

population, controlling the spread of HIV infection,

AIDS, and other STDs within the entire adolescent

population has proven difficult. Despite the current

ongoing efforts, more remains to be done for

adolescents who are already infected and for those

who are not.

Prevention of HIV Infection, AIDS, and Other

STDs in Adolescents 97

As noted throughout this chapter, the most

effective way for adolescents to avoid acquiring an

HIV infection or other STD is to abstain from sexual

intercourse and IV drug use.98 For those adolescents

who do not to abstain, however, the only way to

prevent infection is to adopt safer practices, such as

the use of condoms and the refusal to share IV drug

needles. Most education-based AIDS and STD

prevention efforts are designed to convince adolescents to change their behaviors so they do not get

infected at all; additionally, most efforts are directed

at changing adolescent sexual behavior rather than

behaviors related to IV drug use. To OTA’s knowledge, most prevention efforts focus on HIV and

AIDS and do not address other STDs, though an HIV

prevention course would clearly provide a good

opportunity to discuss STDs.

Conclusions and policy implications related to the

design of effective prevention programs for HIV

infection and STDs are difficult to draw. For many

reasons, including time and fiscal restraints, few

careful evaluations of AIDS and STD prevention

projects for adolescents have been conducted. Most

programs use measures other than infection rates,

such as measures of knowledge and attitudes, to

determine an intervention’s success. The use of

measures other than infection rates may be due, in

part, to the relatively infrequent occurrence of STDs

and especially HIV within a targeted adolescent

population. With the evidence that is available,

however, several conclusions about STD and HIV

prevention can be drawn.

For adolescents, particularly younger adolescents, who have not yet initiated sexual intercourse,

evidence from pregnancy prevention programs indicates that interventions begun before the initiation of

sexual intercourse have been effective in delaying

sexual intercourse.99 The most effective interventions may be those that combine a variety of

approaches, including discussions of responsible

sexuality. Pregnancy prevention programs that delay

the initiation of sexual intercourse probably indirectly affect the rates of HIV and STDs, although

their effect on HIV and STDs has not yet been

demonstrated.

Evidence that some adolescents lack accurate

information about HIV and STDs suggests that, at a

minimum, adolescents-especially older adolescents who are sexually active-need information

about condoms and other methods of protecting

themselves from infection. When STD and HIV

education programs in the schools have been provided, they have proven useful in increasing adolescents’ knowledge over short periods of time. Over

longer periods of time, however, increases in knowledge seem to disappear. Because education-based

prevention efforts in the schools are often of limited

duration, it is not surprising that knowledge increases are not maintained especially given the

amount of time adolescents spend outside of school

in other activities and with other people who may

provide inaccurate and often conflicting information.

Education-based AIDS and STD prevention programs in the schools that appear to be particularly

promising are those that are implemented before

adolescents engage in risky sexual and drug-using

behaviors. Thus, educational approaches that address HIV infection and other STDs may be most

effective if they are begun in elementary and middle

school rather than in high school when such

behaviors may have already occurred. Efforts are

underway to develop age-appropriate and culturally

relevant messages, but to OTA’s knowledge, they

have not been evaluated for their effectiveness.

~B~au~e ~Sis ~au~ed by infection ~th HV, effofi often focus on preventing tie initial infection of HIV. Therefore, activities in W SeCtiOn

are referred to HIV prevention efforts rather than AIDS prevention efforts.

98~1~ ~~pt~ f~~used swc~lc~y on preven~g ~~smission through sex~ ~terco~se and Iv ~g use. other routes of transmission% iIICIUding

the transfusion of contaminated blood and blood products for the treatment of hemophilia, require different prevention efforts, such as blood donor

screening, which are not discussed here.

$’$Tor a discussion of pregnancy prevention programs, see ch. 10, “Pregnancy and Parenting: Prevention and Services, ” in this volume.
11-308. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Photo credit: Planned Parenthood Federation of America®

Published with permission.

Some AIDS booklets, such as this one for sexually active

young teenagers, use a comic-book-sized, colorful format.

The booklet includes instructions for condom use, scripts to

use in negotiating condom use, comparisons of risks

related to alternative sexual behaviors, and basic facts

about the human immunodeficiency virus (HIV).

The booklet was designed for adolescents reading

as low as the third-grade level.

Given that most adolescents live at home and that

adolescents often view their parents as credible

sources of information, AIDS and STD preventive

interventions within families may be promising, at

least for adolescents with strong familial bonds. Few

family-based efforts related to HIV prevention have

been evaluated to date, and virtually no activities

have been directed to families for the prevention of

STDs.

Conclusions related to the effectiveness of educationbased prevention efforts in modifying the behaviors

of adolescents who have already begun engaging in

sexual intercourse and IV drug use are not encouraging. It does appear that some adolescents report

adopting preventive behaviors as a result of a fear of

AIDS. Despite recent HIV and STD education

efforts by schools, however, most adolescents have

not consistently adopted safe sex or needle practices.

Few studies have specifically looked at adolescents and their attitudes toward condom use as a

method of HIV and STD prevention. There is some

evidence to suggest that adolescents who perceive

that condoms reduce pleasure or are embarrassing to

buy or use are highly unlikely to use them. Although

adolescents can obtain free condoms in a few

locations, little is known regarding the impact of

these programs on adolescents’ attitudes, behavior,

and incidence of HIV and STDs. Additionally,

because most prevention efforts aimed at IV drug

users target adults, little remains known about

effective prevention programs for adolescents.

Innovative approaches, such as distributing condoms through vending machines and by individuals

who deliver them directly to a person’s door, are

currently taking place on college campuses and

universities in the United States for young adults and

in high schools in other countries, such as Canada

(44,123). More innovative condom distribution programs such as these may be needed in order to

control the spread of HIV infection and other STDs

among adolescents who choose not to abstain from

sexual intercourse. These programs may be most

appropriate for older adolescents who are more

likely to be sexually active than younger adolescents. It seems reasonable to expect that the more

effective programs will be those that address adolescents’ perceptions related to the difficulty in using

condoms. Limited access to condoms because of

inconvenient dispensing locations may be an additional barrier to adolescents who want to practice

safer sex.

Given that adolescents’ sexual and drug-using

behaviors are tied intricately with adolescents’

personal values, perceptions of peers’ attitudes,

feelings about themselves, perception of risk, comfort in discussing and negotiating less risky behaviors, and community norms-behaviors that have

evolved throughout adolescence-it may be unrealistic to expect that a small number of classes, a

pamphlet, or a public service announcement will

dramatically change an adolescent’s sexual and

drug-using behaviors. Preliminary evidence suggests that the most promising approaches to changing behavior may be those that combine role playing

exercises and involve other same-aged adolescents

to improve decisionmaking and communication

skills that deal with real and perceived peer pressures in negotiating safer sex and drug-use behaviors

with unwilling or ambivalent partners.

Many AIDS and STD prevention efforts have

been unable to or have not reached runaway,

homeless, and incarcerated adolescents, groups which

may be at increased risk of infection because of high

levels of sexual activity and low consistent use of
Chapter 9-AIDS and Other Sexually Transmitted Diseases: Prevention and Services . //-309

contraception (262b).100 It seems reasonable to

expect that for these adolescents, the most successful

approaches may be those that address other additional concerns, concerns that these adolescents

perceive as more important, such as shelter and food.

Treatment of AIDS and STDs in Adolescents

For adolescents who are already infected with

HIV or STDs, clearly the best treatment is treatment

that is given early (early treatment of HIV with

zidovudine has been shown to reduce symptoms and

prolong individuals’ lives). For many reasons,

including the fact that STDs are often asymptomatic,

however, adolescents tend to delay treatment. Active and flexible approaches to encourage adolescents with HIV infection or other STDs to seek

treatment and return for followup care are needed.

For example, despite the fact that States have waived

parental consent requirements for treatment of STDs

because of serious public health concerns, threequarters of adolescents are unaware of the availability of free, confidential treatment (7). Clinicians who

are responsive to adolescents and their health

problems and who are perceived by adolescents to be

friendly, understanding, and willing to take their

time may be the most effective in getting adolescents

to return for care. Additionally, because single dose

regimens ensure compliance and confidentiality,

clinical experiences suggest that therapies involving

single-dose regimens rather than multiple-dose regimens may be more effective in treating adolescent

STDs. Treatment for some STDs, including

chlamydia infection, however, is only effective

using multiple doses, so continued research is

needed to develop therapies that may be more

effective in treating AIDS and STDs in adolescents.

Relatively few adolescents are enrolled in federally sponsored AIDS clinical trials. Access to these

trials appears particularly difficult for those adolescents who do not have regular access to the health

care system. Typically, parents find out about

clinical trials through physicians, but those adolescents at greatest risk may not be living with their

parents. Research protocols may need to be more

adolescent-specific to increase adolescents’ participation in clinical trials. Often, for example, adolescents are included with adults up to age 99. Many

adolescents do not use the traditional health care

system; therefore, eligible adolescents may need to

be recruited through agencies and other systems,

such as the child welfare system. The National

Institute of Allergy and Infectious Diseases of the

National Institutes of Health in DHHS has set aside

$3.6 million for cooperative agreements to encourage the participation of individuals from racial and

ethnic minority groups who are underrepresented in

clinical trials; these agreements are not specific to

adolescents (283).

Data from the Health Resources and Services

Administration’s hemophilia diagnostic and treatment and Pediatric AIDS Health Care Demonstration Project centers may provide essential information for appropriate comprehensive care for children

and adolescents with serious AIDS-related problems

and their families.

Federal Agencies’ Role in Prevention

and Services

Responsibility for controlling the spread of HIV

infection, AIDS, and other STDs within the adolescent population rests with Federal, State, and local

governments. Within the Federal Government, several agencies of DHHS are playing a major role in

attempts to control the spread of HIV infection,

AIDS, and STDs. Whether their activities are

sufficient, and specific enough, in relation to adolescents, however, is open to question. The requirements for reporting HIV, AIDS, and STDs, for

example, are determined at the State and local level.

In order to more clearly define the extent of the HIV,

AIDS, and STD problem within the adolescent

population and more appropriately target preventive

interventions, the Federal Government may want to

support more thorough research related to epidemiology and the differences in the occurrence of

disease between younger and older adolescents;

homosexual, bisexual, and heterosexual adolescents; in-school and out-of-school youth; and among

various socioeconomic groups. Additionally, although reporting requirements are determined at the

State level, the Federal Government may want to

more strongly encourage States to collect and report

additional demographic data, such as smaller age

breaks, socioeconomic status, and race, to CDC.

Typically, the Federal Government provides technical and limited monetary support for prevention

and research activities to States, localities, and

Imsee ch, 14, “Home] cssness: Pre~’ention and Services, ’ in this volume
//-310 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

organizations serving adolescents. Given the heterogeneity of the adolescent population, prevention

strategies need to address the sexual and drug-using

behaviors within the entire adolescent population

and in certain subgroups, such as homosexual and

bisexual adolescents, racial and ethnic minority

groups, homeless adolescents, and incarcerated adolescents in order to control the transmission of HIV

and STDs within the adolescent population. While

most of the content and message of prevention

efforts is determined at the State level, CDC’s

guidelines for effective school health education to

prevent HIV do not address the actual sexual and

drug-using practices of adolescents and have been

slow to include prevention education address efforts

for out-of-school adolescents. In addition, the Federal Government’s general emphasis on abstinence

and restrictions on support for programs that maybe

perceived as encouraging homosexuality may have

the effect of limiting the more effective activities for

controlling the spread of HIV, AIDS, and STDs

among adolescents who are most at risk of infection,

namely those adolescents who choose to remain

sexually active. It is encouraging, however, that the

CDC has recently stated that sexually active adolescents should be encouraged to use condoms.

Most federally supported educational prevention

activities for adolescents are limited to students and

adolescents living in metropolitan areas. Few address adolescents’ differing developmental needs,

and most include younger and older adolescents

together. More specifically, adolescents who are

homosexual and bisexual, adolescents who are not in

school (such as runaway and homeless youth), and

adolescents who live in rural areas receive relatively

little Federal financial support. Although the number

of Federal AIDS prevention activities reaching

racial and ethnic minorities of all ages has increased

recently, only a few projects specifically target

adolescents from minority groups. Finally, there are

few federally supported prevention efforts targeting

adolescent IV drug users.

To increase funding to these adolescent groups

who receive little Federal support, the Federal

Government may want to consider providing setasides in the social services and maternal and child

health services block grants to the States. There is

precedent for this type of funding. For example,

because Members of Congress became concerned

about child sexual abuse, Congress appropriated a

$25 million increase in the Title xx Social Services

Block Grant program finding in fiscal year 1985 for

use by the States in providing training and other

related activities to child day care staff (200).

Additionally, in order to reach adolescents in low

prevalence areas, the Federal Government needs to

do more than fund cities with high prevalence of

HIV, AIDS, and STDs.

Because DHHS has made AIDS the Nation’s

number one health priority, the importance of STDs

other than AIDS as a public health problem and the

money allocated to control them has been directly

affected. In fact, HIV efforts have received a larger

share of financial and personnel resources than have

STD prevention efforts since 1985 at both the

Federal and State levels (240). Given that more

adolescents have other STDs than have AIDS, that

adolescents may perceive themselves at greater risk

for STDs than for HIV infection, and that the

presence of STDs may facilitate the transmission of

HIV, the Federal Government as well as State

governments may want to ensure the integration of

STDs into HIV educational efforts. Federal and

State governments could require that STD education

be incorporated within HIV education as a condition

for funding at the local school level. Additionally,

Federal funding for HIV-related activities targeting

out-of-school adolescents and racial and ethnic

minorities could also be made contingent upon the

incorporation of STD with HIV/AIDS information.

DHHS also provides financial assistance for the

treatment of AIDS and STDS. While the Federal

Government has developed guidelines for treating

certain STDs, however, many of the guidelines are

not specific to adolescents, and neither are the

guidelines for treating adolescents with AIDS.

Because adolescents receive many, often conflicting, messages from the media, peers, adults, and the

Federal Government, interventions need to provide

unambiguous yet developmentally and culturally

appropriate messages to adolescents who are not yet

engaging in sexual intercourse or drug use and those

who are. Unless more creative approaches are found .

to control HIV, AIDS, and STDs among adolescents

who are not yet infected and those who are already

infected, adolescents will continue to contract HIV

infection and STDs. Prevention of infection is the

most effective approach to control, but careful

evaluations are needed and much more remains to be

done to make adolescents as well as society aware of
Chapter 9--AIDS and Other Sexually Transmitted Diseases: Prevention and Services . //-311

the risk of HIV infection, AIDS, and STDs to

adolescents.

Chapter 9 References

1.

2.

3.

4,

5.

6.

7.

8.

9.

10.

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Chapter 10

PREGNANCY AND PARENTING:

PREVENTION AND SERVICES

Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .323

Background on Adolescent Pregnancy and Parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . 323

Sources and Limitations of Data on Adolescent Sexual Activity, Pregnancy, Childbearing,

and Abortion . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .323

Trends in the Incidence and Prevalence of Adolescent Sexual Activity, Pregnancy,

Childbearing, and Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .326

Sexual Activity and Contraceptive Use Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326

Pregnancies Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . . . . . 326

Births Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328

Abortions Among Adolescents . . . . . . . . ., , . . . . . ., . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . 329

Out-of-Wedlock Childbearing Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331

Adolescent Fatherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .332

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332

Consequences of Adolescent Sexual Activity, Pregnancy, Abortion, and Parenthood . . . . . . . . . . . . . . . . . 334

Consequences for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336

Consequences for Children of Adolescent Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339

Risk and Protective Factors in Adolescent Pregnancy and Parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340

Risk and Protective Factors Related to Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340

Risk and Protective Factors Related to Pregnancy Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345

Demographic Differences Related to Adolescent Pregnancy and Pregnancy Outcomes . . . . . . . . . . . . . . 348

Prevention of Adolescent Pregnancy and Associated Negative Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356

programs That May Help Prevent Adolescent Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356

Programs That Emphasize Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357

Programs That Provide Contraceptives to Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .372

programs That Seek To Enhance Adolescents’ Life Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389

Economic Incentive Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394

Conclusions About the Effectiveness of programs To Prevent Adolescent Pregnancy . . . . . . . . . . . . . . . 394

programs Designed To Prevent Negative Outcomes of Adolescent Pregnancy and Parenthood . . . . . . . . . 397

Programs That Offer Alternatives to Parenthood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .397

Programs That Offer Maternity Care or Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399

Programs That Offer Specific Types of Services to Pregnant Adolescents and Adolescent Mothers . . . 400

Programs That Offer Comprehensive Services to Pregnant Adolescents and Adolescent Mothers . . . . . 403

Programs for Adolescent Fathers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405

Conclusions About the Effectiveness of Programs To Prevent Negative Outcomes of

. . . . . . .

Adolescent Pregnancy and Parenthood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406

Major Federal programs and Policies Pertaining to Adolescent Pregnancy and Parenting . . . . . . . . . . . . . . . . 408

The Title X Family Planning Services and Research Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408

The Title XX Adolescent Family Life Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

Other Federal Programs Pertaining to Adolescent Pregnancy and Parenting . . . . . . . . . . . . . . . . . . . . . . . . . 412

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417

Chapter 10 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
.

Boxes

Box Page

1O-A. The True Story of Keesha: An Unwed Teenage Mother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324

1O-B. Examples of New and Emerging Contraceptive Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .376

1O-C. The Six General Conclusions of the National Academy of Sciences’ Panel on

Adolescent Pregnancy and Childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3%

1O-D. Roadblocks to the Provision and Coordination of Care for Pregnant and Parenting Women

and Children: Findings of the National Commission To Prevent Infant Mortality . . . . . . . . . . . . . . . . . 407

Figures

Figure Page

10-1. Number of U.S. Females Ages 15 to 19, Number of Sexually Experienced U.S. Females

Ages 15 to 19, and Number of pregnancies Among U.S. Females Ages 15 to 19

Pregnancies Among U.S. Females Ages 15 to 19,1970-85 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327

10-2. Trends in Pregnancy Rates, Birth Rates, Abortion Rates, Miscarriage Rates, and

Out-of-Wedlock Birth Rates Among U.S. Females Ages 15 to 19,1970-87 . . . . . . . . . . . . . ........ 327

10-3. Trends in Sexual Experience Rates Among U.S. Adolescent Females Ages 15 to 19 and Pregnancy

Rates for Sexually Experienced U.S. Females U.S. Females Ages 15 to 19, 1970-85 . . . . . . . . . . . . . 328

10-4. Birth Rates, Abortion Rates, Miscarriage Rates, and Pregnancy Rates Among Females

Ages 15 to 19 in 11 Countries, 1983 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .329

10-5. Trends in Birth Rates Among U.S. Females Ages 10 to 19, 1970-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . 330

10-6. Trends in the Percentage of Pregnancies Ending in Abortion Among U.S. Females

Under Age 20,1970-85 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .330

10-7. Trends in Pregnancy Rates, Birth Rates, and Abortion Rates Among U.S. Females

Ages 15 to 19,1973-85 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331

10-8. Trends in Out-of-Wedlock Childbearing Among U.S. Females Under Age 20, 1960-88 . . . . . . . . . . . 331

10-9. Overview of U.S. Adolescent Pregnancy and Parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .335

10-10. A Conceptual Model for Pregnant/Parenting Teens and Their Male Partners:

Pregnancy Resolution Decisions, Life Style Adaptations, and Well-Being . . . . . . . . . . . . . . . . . . . . . . . 341

10-11. Trends in Out-of-Wedlock Childbearing Among U.S. Females Under Age 20 by Race, 1%9-87 .... 354

10-12. Percentage of U.S. Female Contraceptive Users Experiencing Contraceptive Failure

During the First 12 Months of Use, by Age and Method of Contraception. . . . . . . . . . . . . . . . . . . . . . 373

Tables

Table Page

10-1. U.S. Mothers and the Reported Age of the Fathers of Their Children, by Child’s Race, 1988 . . . . . . . 333

10-2. Adolescent Fathers: Distribution of Male Participants in the 1984 NLSY Who Reported

Having Fathered a Child Before the Age of 20, by Father’s Age at Child’s Birth and

Marital Status at Conception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .334

10-3. Adolescent Fathers: Distribution of Male Participants in the 1984 NLSY Who Reported

Having Fathered a Child Before the Age of 20, by, Race/Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

10-4. State Education Agencies and Large School Districts’ Position on the Teaching of

Selected Topics in Sex Education, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359

10-5. Evaluations of School-or Community-Based Sex Education, Life Skills Training, and

Other Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360

10-6. Evaluation of a Multimodal Pregnancy Prevention Program That Included Schooland Community-Based Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

10-7. Overview of Contraceptive Methods Most Commonly Used by U.S. Adolescents . . . . . . . . . . . . . . . . 374

10-8. Evaluations of Contraceptive Provision Policies and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379

10-9. Evaluations of Youth Employment Demonstration Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392

10-10. Overview of Title X and Title XX of the Public Health Service Act . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Chapter 10

PREGNANCY AND PARENTING: PREVENTION AND SERVICES

Introduction

In 1988, roughly one million U.S. adolescents

became pregnant, and nearly half a million gave

birth. In recent decades, sexual activity rates among

U.S. adolescents have been increasing, but birth

rates among U.S. adolescents have generally been

declining .

2 Since 1960, however, births to unmarried U.S. adolescents have increased dramatically

(195c). About two-thirds of the almost 488,941 U.S.

females under age 20 who gave birth in this country

in 1988 (as compared to about one-fifth in 1960)

were single mothers (195c). Some of the immediate

difficulties encountered by unmarried adolescents

who become pregnant and bear children out of

wedlock are illustrated by one mother’s story in box

1O-A.

Early out-of-wedlock childbearing increases dramatically the chance that a mother and her child (or

children) will live in poverty. Because of their need

for economic and other support, adolescents who

become mothers and their children cost U.S. taxpayers a substantial amount of money. Families started

by adolescents account for the majority of families

receiving benefits under Aid to Families With

Dependent Children (AFDC) program; and in 1985,

AFDC, Medicaid, and Food Stamp Program costs

for families begun by a birth to a teenager were

estimated to be $16,65 billion (149).3 In 1988,

Federal, State, and local governments spent an

estimated $20 billion on AFDC, Medicaid, and food

stamps to support families started by women when

they were under age 20 (33).4 These estimates do not

include other public costs commonly associated

with family support such as housing subsidies, foster

care, or day care (33).

Adolescent pregnancy and parenthood are not

new phenomena in this country. In recent decades,

however, numerous societal and other transformations have changed the context in which these

phenomena occur and heightened perceptions that

pregnancy and childbearing among U.S. adolescents

are serious problems (13,148,149,235). Among the

concerns are recent increases in births to adolescents

as a proportion of all births and the rising number of

these that are out of wedlock (51a,89a). Black

adolescents have much higher rates of premarital

pregnancy and out-of-wedlock births than white

adolescents, but in recent decades, a large increase

in out-of-wedlock childbearing rates has taken place

among whites (51a,196).

This chapter examines the problems of adolescent

pregnancy and parenting. The first section of the

chapter presents background information on sexual

activity, pregnancies, births, and abortions among

U.S. adolescents. Subsequent sections review programs that may help prevent adolescent pregnancy,

programs that may help prevent negative outcomes

associated with adolescent pregnancy and parenting,

and major Federal policies and programs pertaining

to adolescent pregnancy and parenting. The chapter

ends with conclusions and policy implications.

Background on Adolescent Pregnancy

and Parenting

Sources and Limitations of Data on Adolescent

Sexual Activity, Pregnancy, Childbearing,

and Abortion

Data on U.S. adolescents’ sexual activity, contraceptive use, pregnancy, childbearing, and abortion

are available from a variety of sources described

below. Data on births among adolescents, as noted

below, are considerably more accurate than data on

sexual activity, pregnancies, or abortions,

Data on U.S. adolescents’ sexual activity have

been collected in several surveys, although the type

IAlthough & focus of OTA’S adole~~nt he~th repofl ;s on adolescents ages 10 ~ough 18, much of the data on adolescent pregnancy preSentd

in this chapter is for adolescents ages 15 to 19. Those are the ages covered in most published data on adolescent pregnancy.

~irth rates among black U.S. adolescents declined in the 1970s, but increased during the 1980s (202 f). Also an upswing in birth rates occurred among

15- to 17-year-olds and 18- to 19-year-olds in 1988 and bears watching (202~.

s~ese ~d o~er Federal programs relevant to low-income adolescents are discussed in ch. 18, “Issues in the Delivery of Services to Selected Groups

of Adolescents, and in ch. 19, ‘‘The Role of Federal Agencies in Adolescent Health, ’ in Vol. III.

IAccordlng t. tie center for popu]atlon Optloms, the components of fiese esti~tes were as follows: $10.07 billion for AFDC, $6.53 billion for

Medicaid, and $3.23 billion for food slamps (33).

-II-323-
II-324 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and treatment Services

Box 10-A—The True Story of Keesha: An Unwed Teenage Mother1

At the age of 11, Keesha moved in with her grandmother because of problems with her mother at home; after

only a year with her grandmother, she moved in with an aunt. Life was hard with her aunt, who beat Keesha, and

told Keesha that she was never wanted by her mother. Finally, after telling her mother about beatings by her aunt,

Keesha was sent to live with another aunt, and later back to her grandmothers.

When Keesha was 16, her mother became very ill. After being turned away from one hospital because she had

forgotten her insurance card, Keesha’s mother was admitted to another hospital, where doctors discovered a

cancerous tumor on her kidney. At that time, she had surgery to remove the tumor and one of her kidneys. After

staying in the hospital for a couple of months, she was discharged on Christmas Eve so she could spend the holidays

with her family. Because she was so ill, however, and was having trouble with falling down, she was readmitted

to the hospital in a few days. Her condition continued to decline, and shortly after the New Year, she died.

In elementary school, Keesha was a popular and successful student, but after moving so many times, she began

to have problems in school. Finally, when her mother became ill, Keesha dropped out of school to stay home with

her mother.

Keesha had sexual intercourse for the first time at the age of 15, and shortly before her mother died, Keesha

became pregnant. When Keesha was 3 months pregnant, her grandmother, with whom she had been living, had a

fatal heart attack Keesha then began moving around from place to place, first with a friend, then with a friend of

her mother. Keesha had a difficult pregnancy, and at 7 months, she was hospitalized until the birth of her daughter.

After the birth, Keesha went to stay with a friend who helped her and the baby out by getting them some clothes

from a charitable agency. After a few months, Keesha and her daughter moved to another friend’s house. Nothing

ITMS stow is based m a autobiographical note; the name has been changed to prottit confidentiality.

and level of information are often insufficient for ous fetal losses, and prenatal care) are available from

program and policy purposes (100a).5 In 1971, the

frost epidemiological study of U.S. adolescents’

sexual activity was conducted by researchers

Zelnick and Kantner at Johns Hopkins University,

and these researchers conducted subsequent studies

in 1976 and 1979 (47a). A more recent survey that

collected data on U.S. adolescents’ sexual behavior

and pregnancies is the National Longitudinal Survey

of Labor Market Experience-Youth Cohort (NLSY)

(47a). Sponsored by the U.S. Department of Labor,

NLSY was begun in 1979 with a youth cohort of

over 12,000 males and females ages 14 to 21. One

positive feature of this survey was oversampling of

black and Hispanic youth and of white youth from

socioeconomically disadvantaged families to provide sample sizes large enough for statistically

reliable ethnic and socioeconomic comparisons.

the National Survey of Family Growth conducted

periodically by the National Center for Health

Statistics in the U.S. Department of Health and

Human Services (DHHS) (47a,213). This survey has

been tracking fertility patterns and contraceptive use

of American women ages 15 through 44 since the

early 1970s. Cycle III of the survey was conducted

from August 1982 through February 1983 and

interviewed a sample of about 8,000 U.S. females of

childbearing age (ages 15 through 44). Cycle III

included unmarried adolescents for the frost time and

sampled black women and adolescents ages 15 to 19

at higher rates than other women (202e). Data on

younger adolescents are not available from this

survey. Cycle IV of the National Survey of Family

Growth was conducted in 1988 among about 8,500

U.S. females ages 15 to 44 (59a).

Data on U.S. adolescent females’ sexual activity Among the other sources of data on U.S. adoles-

(and other items, including contraception, spontane- cents’ sexual activity are the High School and

Srt is important tO note that the term ‘‘sexuufly active ‘‘ is often used in the literature to denote whether an individual has ever had heterosexual

intercourse. It does not necessarily mean that an individual is currently having sexual intercourse, or indicate the number of partners or number of times.

As a rule, those individuals, including adolescents, who have ever had sexual intercourse do report having had intercourse in the past 3 months, which

is one measure of current sexual activity levels (59a). In the 1988 National Survey of Family Growa 92.3 percent of the 15-to 19-year-olds who reported

having ever having had intercourse also reported having had intercourse in the 3 months prior to the survey date (59a). The term ‘sexually experienced’

is also used as a synonym for ever having had sexual intercourse.
Chapter 10-Pregnancy and Parenting: Prevention and Services ● II-325

ever really seemed to work out, and Keesha and her daughter kept moving from place to place, staying for a little

while with someone and then moving on. Some of the neighborhoods they lived in were pretty dangerous. In some

places they stayed, there was a lot of drug traffic, and violence and shootings were common.

Keesha tried to find some kind of social services program that could help her and the baby, but she was refused

from all of them for a variety of reasons: some were full, some wouldn’t take children, and some required that she

become award of the county, which Keesha didn’t want to do because she feared it would result in her losing custody

of her baby. She found that regular emergency shelters for the homeless would not take in families with parents

under age 18. There were few places designed to serve adolescent mothers and their infant children.

When she was 18, Keesha became pregnant again. She considered having an abortion, but the people she was

staying with told her that if she terminated the pregnancy, she would no longer be able to stay with them. Late in

her pregnancy, Keesha moved in with another aunt. While living with her aunt, Keesha met a man whom she liked,

and she and the baby moved in with him; they continued to stay with him after her second daughter was born. Keesha

and her boyfriend had some problems, and Keesha left him several times. One of the things they argued about was

whether she would get pregnant again. Keesha said she didn’t want to have anymore children now, but her boyfriend

argued that she should have his baby, since she already had babies fathered by two other men.

Keesha left this man and moved into a one-bedroom basement apartment with another mother of two young

children; this housing lasted only a month, and after that, Keesha and her children continued to move from place

to place. Then Keesha’s children were taken away by the State social services department. She had left both children

with the father of the older child (now 21/2) when he was arrested on a Federal warrant. She had been testifying in

court on behalf of the father of the younger child (now about 1)-this man had been accused of murder. Keesha

moved back with her aunt and worked for a while in a fast food outlet, but when last heard from she was living in

a shelter for women. She can’t get her children back until she obtains permanent housing and completes a parenting

education course. When last seen, Keesha was pregnant again. While pregnant, she was sexually assaulted.

Beyond Survey conducted from 1980 to 1984 and from the birth registration offices of all States, New

the National Survey of Adolescent Males conducted

in 1988. The High School and Beyond Survey

followed about 13,000 individuals who were sophomores in 1980 (47a). The National Survey of

Adolescent Males, fielded by the Institute for Survey

Research at Temple University, interviewed 1,880

U.S. never-married males ages 15 to 19 between

April and November 1988 about their patterns of

sexual activity (187).

There is no independent and valid measure of

pregnancies or pregnancy rates, and these are

typically calculated using live birth and other data

(e.g., by summing the numbers of live births,

induced abortions, and fetal losses (214)). Estimates

of the number of pregnancies and pregnancy rates

among U.S. adolescents are available from the Alan

Guttmacher Institute, a private organization. Estimates of pregnancies and pregnancy rates for the

United States from 1976 through 1985 are also

available from the National Center for Health

Statistics in DHHS (214).

Data on live births are among the vital statistics

available from the National Center for Health

Statistics in DHHS (81a,202e). The National Center

for Health Statistics obtains information on births

York City, the District of Columbia, Puerto Rico, the

U.S. Virgin Islands and Guam (202e). Each year, the

National Center for Health Statistics publishes the

number of births according to age, race, marital

status, and State of residence of the mother. Because

data on births among U.S. adolescents are based on

a 100-percent sample of birth certificates (which are

fried for more than 99 percent of all births), data on

births are considerably more accurate than data on

sexual activity, pregnancies, or abortions (8). The

major Federal report on health indicators in the

United States—Health United States-tabulates birth

rates by race but not by income or other factors

indicative of socioeconomic level (202e,202f).

Data on aggregate numbers and rates of induced

abortions are available from the Alan Guttmacher

Institute. The Alan Guttmacher Institute obtains

information on the number of abortions in each State

from periodic surveys of abortion providers

(8,81a,8lb,202c). A limitation of the Alan Guttmacher Institute data on abortion is that they do not

provide information regarding the age, race, and

marital status of the women obtaining abortions

(148). Data on abortions performed by or under the

supervision of a licensed physician are also available
II-326 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

from the abortion surveillance system of the Centers

for Disease Control within DHHS (202e). This

system currently obtains data on the number of

abortions and characteristics of abortion recipients

reported by central health agencies in reporting areas

that include the 50 States, New York City, and the

District of Columbia (202c). the States. The total

number of abortions reported to the Centers for

Disease Control’s abortion surveillance system is

considerably smaller than the number estimated

independently by the Alan Guttmacher Institute and

is probably less accurate (202c,202e). By integrating

the Centers for Disease Control data on abortion

with the Alan Guttmacher data, one can estimate the

incidence and rates of abortions among age, race,

and marital subgroups (148). In surveys such as the

National Survey of Family Growth, abortions are

severely underreported (59a).

The reporting estimates of spontaneous fetal

losses (miscarriages and stillbirths) among U.S.

females is not very accurate (148). Estimates of fetal

losses among U.S. females ages 15 to 19 can be

tabulated on the basis of 1982 data from Cycle III of

the National Survey of Family Growth (214), but

these estimates are likely to be undercounts, because

early miscarriages are not always detected by the

women in whom they occur.

The national adoption reporting system was

discontinued in 1975, so there are no systematically

collected national data on the number of adoptions

or trends in adoption (148). Currently, the only

system that collects annual information on adoptions

is the Voluntary Cooperative Information System,

operated by the American Public Welfare System.

This system collects data on the characteristics of

adopted children and adoptive families placed for

adoption by public child welfare agencies. It does

not collect data on private placements.

Trends in the Incidence and Prevalence of

Adolescent Sexual Activity, Pregnancy,

Childbearing, and Abortion

Sexual Activity and Contraceptive Use

Among Adolescents

Available data suggest that U.S. adolescents are

becoming sexually active at increasingly earlier

ages. According to the National Survey of Family

Growth, the proportion of 15- to 19-year-old U.S.

females who reported having had premarital sexual

intercourse has increased steadily since 1970 (202d).

The percentage of 15- to 19-year-old U.S. females

who reported having had premarital sexual intercourse was 28.6 percent in 1970, 36.4 percent in

1975,42 percent in 1980,44.1 percent in 1985, and

51.5 percent in 1988 (202d). The largest relative

increase in the percentage of 15- to 19-year-old

females who reported having had premarital sexual

intercourse occurred among females age 15 (from

4.6 percent in 1970 to 25.6 percent in 1988).

Comparable time-series data on adolescent males

are not available, but the 1988 National Survey of

Adolescent Males found that 64 percent of 15- to

18-year-old males had had sexual intercourse, 33

percent of them by the time they reached 15

(186b,187). There are no national level data on

adolescents under age 15.

Cycle IV of the 1988 National Survey of Family

Growth, which was conducted in 1988, found that

among U.S. females at risk of pregnancy, females

ages 15 to 19 were more likely than females age 20

and over to be using no contraceptive method (59a).

The 1988 survey found that 78.8 percent of sexually

active adolescent U.S. females ages 15 to 19

reported ‘‘current’ use of some method of contraception, as compared to 90.1 percent of all women

ages 15 to 44 (143). Still, the percentage of sexually

active 15- to 19-year-olds who reported using

contraception in 1988 (78.8 percent ) was higher

than in 1982 (71 percent) (59a). The 1988 National

Survey of Adolescent Males had similar findings,

with 76.6 percent of 15- to 19-year-old males

reporting some form of contraceptive use at last

intercourse (186b). Neither survey collected data on

contraceptive use among younger adolescents.

Pregnancies Among Adolescents

Each year since 1974 in this country, there are

estimated to have been over 1 million pregnancies to

mothers between the ages of 10 and 19. It has been

projected that as many as 43 percent of the 17

million female adolescents in this country may

become pregnant at least once before they reach the

age of 20 (58).

The vast majority of pregnancies among U.S.

adolescents occur among females ages 15 to 19. In

1985, for example, an estimated 1,031,000 U.S.

females under age 20 became pregnant, and all but

31,000 of them were ages 15 to 19(8 la). Figure 10-1

shows the number of U.S. females ages 15 to 19, the

estimated number of sexually experienced U.S.

females ages 15 to 19, and the estimated number of
Chapter l&Pregnancy and Parenting: Prevention and Services . II-327

Figure 10-1—Number of U.S. Females Ages 15 to 19,

Number of Sexually Experienced U.S. Females Ages

15 to 19, and Estimated Number of Pregnancies

Among U.S. Females Ages 15 to 19, 1970-85

Millions

12 ~ — 1

I

‘°F—--’=--l

I I

“ L—---. –,—

1970 1975

Year

+ U.S. females ~

ages 15 to 19

~ Pregnancies among

U.S. females

ages 15 to 19

1 , : —4

1980 1985

Sexually experienced

U.S. females

ages 15 to 19

SOURCE: Office of Technology Assessment, 1991, based on National

Academy of Sciences, National Research Council, Commission

on Behavioral and Social Sciences and Education, Committee

on Child Development Research, Panel on Adolescent Pregnancy and Childbearing, Risking the Future, Adolescent Sexualify, Pregnancy, and Childbearing, Volume 1/: Working Papers

and Sfafistica/Appendixes, S.L. Hofferth and C.D, Hayes (eds.)

(Washington, DC: National Academy Press, 1987); and S.K.

Henshaw, Alan Guttmacher Institute, New York, NY, personal

communication, May 23, 1990.

pregnancies to U.S. females ages 15 to 19 from 1970

to 1985.

Pregnancy rates are typically presented as numbers of pregnancies per 1,000 women of a given age

or ages in the population. In 1988, the estimated

pregnancy rate among all U.S. females ages 15 to 19

was 109 pregnancies per 1,000 females (124a). As

shown in figure 10-2, this rate was fairly stable

throughout the 1980s (195a). Not unexpectedly,

pregnancy rates are higher among older U.S. adolescent females (those ages 15 to 19) than among

younger adolescent females (those under age 15). In

1985, for example, the pregnancy rate was 109.8

pregnancies per 1,000 population among U.S. females ages 15 to 19 and 16.6 pregnancies per 1,000

population among U.S. females under age 15 (81a).

As noted above, National Survey of Family

Growth data indicate that about half of 15- to

19-year-old U.S. females in 1988 were not sexually

active and were therefore not at risk of pregnancy

Figure 10-2-Trends in Pregnancy Rates, Birth Rates,

Abortion Rates, Miscarriage Ratesj

a and

Out-of-Wedlock Birth Rates Among U.S. Females

Ages 15 to 19, 1970-87

Number/1,000 female adolescents

120 I — 1

80

1

0 ~—r—--r. --

1970 1975 1980 1985

Year

‘

- Pregnancie s +– Births + Abortions

~ Miscarriages +– Births to unmarried females

i

1987

aMisarriage rates are derived from the numkr Of m i~rriages calculated

by Alan Guttmacher Institute as 20 percent of births plus 10 percent of

abortions.

SOURCE: Office of Technology Assessment, 1991, based on K.A. Moore

and T.M. Stief, “Changes in Marriage and Fertility Behavior:

Behavior Versus Attitudes of Young Adults,” paper prepared for

Child Trends, Inc., Washington, DC, July 1989; National Academy of Science, National Research Council, Commission on

Behavioral and Social Sciences and Education, Committee on

Child Development Research and Public Policy, Panel on

Adolescent Pregnancy and Childbearing, Risking the Fufure.’

Adolescent Sexuality, Pregnancy, and Childbearing, Volume 11:

Working Papers and Statistical Appendixes, S.L, Ho fferth and

CD. Hayes (eds.) (Washington, DC: National Academy Press,

1987). S.K. Henshaw, Alan Guttmacher Institute, New York, NY,

personal communication, May 21, 1990.

(202d). Trends in sexual experience rates among

U.S. females ages 15 to 19 are shown in figure 10-3.

Between 1970 and 1985, sexual experience rates in

this group rose steadily, but estimated pregnancy

rates among sexually experienced 15- to 19-year-old

U.S. females declined (see figure 10-3). The decline

in pregnancy rates among sexually active 15- to

19-year-old females up to 1985 may reflect an

increase in older sexually active U.S. adolescents’

willingness or ability to use effective contraceptives

(25,125,148,187), Estimated pregnancy rates among

sexually experienced adolescent females increased

between 1985 and 1987, however, and this is a

development that bears watching.

Adolescent pregnancy rates are considerably higher

in the United States than in many other developed
//-328 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 10-3-Trends in Sexual Experience Rates Among

US. Females Ages 15 to 19 and Pregnancy Rates

Among Sexually Experienced U.S. Females

Ages 15 to 19, 1970-88

Number/1,000

600 l—--

500

L

400 /

M

100

I

() t-. -r-—~—T—- -

1970 1974 1978 1982 1985 1988

Year

‘%- Females ages ‘– Annual number

15 to 19 who have of pregnancies

ever had sexual among sexually

intercourse experienced

females ages

15 to 19

SOURCE: Office of Technology Assessment, 1991, based on National

Aeademyof Scienees, National Research Council, Commission

on Behavioral and Social Sciences and Education, Committee

on Child Development Research and Public Policy, Panel on

Adolescent Pregnaney and Childbearing, Risking the Future:

Adolescent Sexuality, Pregnancy, and Childbearing, Volume 11:

Working Papers and Statistical Appendixes, S.L. Hofferth and

C.D. Hayes (eds.) (Washington, DC: National Academy Press,

1987);J.D. Forrest and S. Singh, “The Sexual and Reproductive

Behavior of American Women, 1982-1988,” Family Planning

Perspectives 22(5):208-214, 1990; and S.K. Henshaw, Alan

Guttmacher Institute, New York, NY, personal communication,

May 21, 1990.

nations (see figure 10-4), despite similar rates of

adolescent sexual activity in these countries (148).

The higher adolescent pregnancy rates in the United

States have been attributed to various factors, among

them attitudes regarding sexuality, the nature of

media programming, and lack of access to contraceptives (182).

Births Among Adolescents

Of the roughly 1 million U.S. females under age

20 who become pregnant each year, about half give

birth. In 1988, there were 488,941 births to U.S.

females under age 20 (207b). Of these, 478,353

births were to females ages 15 to 19, and 10,588

births were to adolescents under age 15 (207b).

According to a 1987 report by the Panel on

Adolescent Pregnancy and Childbearing of the

National Academy of Sciences, U.S. adolescents

under age 15 are more than five times as likely to

give birth as girls in any other Western developed

country of the world (148,149).

In 1988, the birth rate for U.S. females ages 15 to

19 was 53.6 births per 1,000 females (207b). Not

surprisingly, 10- to 14-year-old females have much

lower birth rates (1.3 births per 1,000 females) than

15- to 17-year-olds (33.8 births per 1,000) or 18- to

19-year-olds (81.7 births per 1,000) (see figure

10-5). Birth rates among all U.S. females under age

20 began declining in the 1960s and leveled off after

about 1976.

The largest decline in birth rates since the early

1970s has occurred among U.S. females ages 18 and

19 (203). Their birth rates dropped from 114.7 births

per 1,000 females in 1970 to 81.7 births per 1,000 in

1981 and have remained roughly at that level ever

since (figure 10-5) (202f). Birthrates among females

ages 15 to 17 and ages 10 to 14 have shown

somewhat different trends. Birth rates among U.S.

females ages 10 to 14 have remained relatively

stable since 1970, at about 1.2 births per 1,000

females (202f,203). Birth rates among U.S. females

ages 15 to 17 showed a steady decline from 1955 to

1980, going from 44.5 births per 1,000 females in

1955, to 43.9 births per 1,000 in 1960, to 33.8 births

per 1,000 in 1970, to 32.5 births per 1,000 in 1980

(202f). From 1980 to 1986, the birth rate among

15-to 17-year-olds females declined only slightly,

dropping to 30.6 births per 1,00015- to 17-year-old

females in 1986 (202f). In 1987, and 1988, the birth

rate among 15- to 17-year-olds rose slightly to 33.8

births per 1,000 females, the same level as in 1970

(202 f).

As discussed later in this chapter, birth rates for

black and white adolescents have differed substantially for many years. 6 Historically, black adolescents have had much higher birth rates than U.S.

adolescents as a whole, and white adolescents have

had lower birth rates than U.S. adolescents as a

whole, Racial disparities in birth rates among U.S.

adolescents have narrowed over the years but still

no some exten~ racial disparities in birth rates may reflect factors related to soeioecomic status. As discussed later in this chapter, black adolescents

are far more likely to be poor or near poor than white adolescents. National data on birth rates among adolescents tabulated by socioeconomic: status

are not available.
Chapter l&Pregnancy and Parenting: Prevention and Services . //-329

Figure 10-4—Birth Rates, Abortion Rates, Miscarriage Rates, and Pregnancy Rates Among Females

Ages 15 to 19 in 11 Countries, 1983

Number/ 1,000 women

120

1 0 0

8 0

6 0

109. 9

i 14.7

~- ‘-”

‘ 43.5

I

k

45. 4

6 . 4

40

r4An

2 0

0

79. 3

1

-

—,

12.1

1

~ 13.5 ~

——

Pregnancy rate ■ Birth rate + abortion rate + miscarriage rate

= Birth rate ~ Abortion rate

n 34. 0

53.7 p2--l

Ib.1 01. /

24. 8

717. 8

I

rl12. 0

53. 4

—---

0

I 16, 9

w

27 5

15 7

93. 3

13. 4

, 25.7

54. 2

U s . Canada Czech o- Denmark England F inland Hungary

s I ova k i a & Wales

Countries

[-~ Miscarriage rat e

52. 8

7 . 7

12. 7

15.0 2 32. n4

/

H-m5 . 3

7 . 7

.

45. 8

n

6

I

I / 33. 2

k.- 20. 2

19.6

17. 4

El 11. 7

Nether - N e w Norway Swede n

lands Zealand

SOURCE: Alan Guttmacher Institute, Teenage Pregnancy in the United States: The Scope of fhe Problem and State Responses (New York, NY: 1989),

remain striking. Thus, in 1988, the birth rates among

U.S. females under age 20 were as follows:

. 10- to 14-year-olds: all races, 1.3 births per

1,000 females, with whites at 0.6 births per

1,000 and blacks at 4.8 births per 1,000;

● 15- to 17-year-olds: all races, 33.8 births per

1,000 females, with whites at 25.5 births per

1,000 and blacks at 76.6 births per 1,000;

. 18- to 19-year-olds.” all races, 81.7 births per

1,000 females, with whites at 69.2 births per

1,000 and blacks at 150.5 births per 1,000

(202 f).

Another point that should be made here is that birth

rates among black U.S. females under age 20 have

increased rather steadily since 1984, reversing a

trend of declining birth rates among black adolescents that occurred in the 1970s and early 1980s

(202f). Birth rates among black adolescents in 1988

were at their highest levels in about a decade (202f).

Abortions Among Adolescents

The difference between adolescent pregnancy and

birth rates is due primarily to the use of induced

abortion. 7 Although over half of all adolescent

71t is ~l~o due t. ~PntmWu~ fetal l~~~e~ (~sc~ages), The n~ber of miscfiages has been es~ated by be Alan Guttmacher hlStihlle tO b 20

percent of the number of births plus 10 percent of the number of abortions, following a model developed by Bongaarts and Tietze of the Population

Council (8).
11-330. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 10-5-Trends in Birth Rates Among

U.S. Females Ages 10 to 19, 1970-88

Births/1,000 females of the same age group

120 —

100

8 0

F-;=-~

6 0 -

. .

40 T } ‘$ &

A A “ { )

2 0 -

Q A . A A A A .

09 , , 1 r r T T r r T , , T T , T , 4)

1970 1972 1974 1976 1978 1980 1982 1984 1986 1988

Year

+-Females ages 10 to 14 ---+ Females ages 15 to 17

--x+-Females ages 18 to 19

SOURCE: Office of Technology Assessment, 1991, based the following

sources: 1970-1987 data: U.S. Department of Health and

Human Services, Public Health Serviee, Centers for Disease

Control, National Center for Health Statistics, Division of Vital

Statistics, V7ta/Statistics of the Urtited States, Vo/ume 1:/Vata/ify

(Washington DC: U.S. Government Printing Office, various

years). 1988 data: U.S. Department of Health and Human

Services, Public Health Service, Centers for Disease Control,

National Center for Health Statistics, Division of Vital Statistics,

“Advance Report of Final Natality Statistics, 1988,” Monthly

Vita/ Statjstks Repofi39 (no. 4, suppl.), DHHS Pub. No. (PHS)

No. (PHS) 90-1120, Aug. 15, 1990.

pregnancies in this country are carried to term, the

use of abortion among U.S. adolescents, as among

adults, has increased substantially since the U.S.

Supreme Court ruling in the case of Roe v. Wade in

1973 (7,148 ).8

According to the Alan Guttmacher Institute, there

were an estimated 416,170 abortions among U.S.

females under age 20 in 1985 (8). Of these, 399,200

were to females ages 15 to 19, and 16,970 were to

females under age 15 (8). Twenty-six percent of all

abortions in 1985 were obtained by teenagers. In

1984, only 6 percent of the teenagers who obtained

abortions were married (8).

Data from the Alan Guttmacher Institute on the

percentage of pregnancies ending in abortions among

U.S. females under age 20 from 1970 through 1985

are shown in figure 10-6. Between 1970 and 1979,

there was a dramatic increase in the percentage of

Figure 10-6—Trends in the Percentage of

Pregnancies Ending in Abortion Among

U.S. Females Under Age 20, 1970-85a

Percentage of pregnancies ending in abortion

‘oo’r

80% I

I

60%

- . .

1970 1974 1978 1981 1985

Year

~ Females under +-- Females ages

age 15 15 to 19

aData on abortion rates for adoleseants under age 15 are not available

before 1973.

SOURCE: Office of Technology Assessment, 1991, based on Alan Guttmacher Institute, Teenage Pregnancy in the United States: The

Scope of the Problem and State Responses (New York, NY:

1989).

pregnancies ending in abortion among U.S. adolescents ages 15 to 19; the percentage of pregnancies

ending in abortions leveled off somewhat between

1979 and 1985 (8). The increase in the percentage of

pregnancies ending in abortions among U.S. females

under age 15 between 1970 and 1985 was far less

dramatic.

According to data from the Alan Guttmacher

Institute, the estimated abortion rate for U.S.

females ages 15 to 19 rose during the 1970s to 43

abortions per 1,000 females in 1980 but then became

relatively stable through 1985 (8). Still, in 1985, the

U.S. abortion rate among teenagers ages 15 to 19

was one of the highest in any country for which data

are available (8). In 1985, the abortion rate for U.S.

females ages 15 to 19 was 44 abortions per 1,000

females; thus, 4.4 percent of all women in that age

group obtained an abortion in 1985 (8). Trends in the

abortion rate for U.S. females ages 15 to 19 from

1973 through 1985 are shown in figure 10-7.

According to data from the Alan Guttmacher

Institute, the abortion rate for U.S. females under age

8See ~h. 17, f$comcnt ~dco~ldenti~ty ~ ~olescentHeal~ Care D~isio_, ’ in VOI. III for a discussion of U.S. Supreme Court decisions

that may affect U.S. adolescents’ access to abortion.
Chapter 10--Pregnancy and Parenting: Prevention and Services . //-331

Figure 10-7—Trends in Pregnancy Rates, Birth Rates,

and Abortion Rates Among U.S. Females

Ages 15 to 19, 1973-85

Number/1,000 females ages 15 to 19 150 ~..... -- —— .

130 I

I

110

L

,0

~-~–.a-—=’

‘-“ ““Y

7 0 j 1

Figure 10-8-Trends in Out-of-Wedlock

Childbearing Among U.S. Females Under Age 20, — -

1960-88

Percentage of all births outside of marriage

80

70 r 64% 65%

6 0 -

5 0 /

20 i 15% 50

[–~

~+-–+—+-—-+- +—~

—~+ -*- -*-—–*--–

1

10

30 *–_#.-

0

10 L--—-——— T- —

~–– ~ .– ~ —––1

73 74 75 76 77 78 79 80 81 82 83 84 85

Year

+ Pregnancies ‘

- Birth s ~ Abortions

SOURCE: Office of Technology Assessment, 1991, based on K.A. Moore

and T.M. Stief, “Changes in Marriage and Fertility Behavior:

Behavior Versus Attitudes of Young Adults,” paper prepared for

Child Trends, Inc., Washington, DC, July 1989.

15 increased during the 1970s through 1985 (8). In

1973, the abortion rate among U.S. females under

age 15 was 5.6 abortions per 1,000 females, in 1982,

it was 8.3 abortions per 1,000 females (8). In 1985,

it was 9.2 abortions per 1,000 females.

As noted earlier, the number of abortions reported

to the Centers for Disease Control is lower than the

number reported to the Alan Guttmacher Institute. In

1985, there were 1,328,570 legal abortions reported

to the Center for Disease Control’s abortion surveillance program, and 26.3 percent of these were to

females under age 20 (202c). Thus, according to the

Centers for Disease Control, there were an estimated

349,414 abortions among U.S. females under age 20

in 1985 (202c). The Centers for Disease Control

noted that between 1972 and 1987, the proportion of

abortions obtained by teenagers decreased steadily

from 33 percent to 26 percent, reflecting in part

upward shifts in the age of women in the population

(202C).

Out-of-Wedlock Childbearing Among Adolescents

While the overall birth rate among U.S. adolescents has actually declined since the early 1970s, the

birth rate among unmarried adolescents in this

country has skyrocketed. As shown in figure 10-8, in

1960, less than one-fifth (15 percent) of all births to

31%

22%

40%

11111

48%

59% 1.,/ 1960 1965 1970 1975 1980 1985 1987 1988

Year

SOURCE: Office of Technology Assessment, 1991, based on U.S. Congress, House of Representatives, Select Committee on Children, Youth, and Families, U.S. Children and Their families:

Current Conditions andl%cenf Trends, 1989 (Washington, DC:

U.S. Government Printing Office, 1989); U.S. Department of

Health and Human Services, Public Health Service, Centers for

Disease Control, National Center for Health Statistics, Division

of Vital Statistics, “Advance Report of Final Natality Statistics,

1988,” Monthly Vital Statistics Reporf39 (No. 4, suppl.), DHHS

Pub. No. (PHS) 90-1120, Aug 15, 1990.

U.S. females under age 20 were to females who were

not married (195c). In 1988, nearly 65 percent

(322,406 births) of the 488,941 births to U.S.

females under age 20 were to single mothers

(195a,195c,207b).

The proportion of out-of-wedlock births among

younger adolescents has increased less dramatically

since 1970 than the overall proportion for females

under 20, in par-t because it was so high to begin

with. In 1970, four-fifths (81 percent) of the births to

U.S. females under age 15 were to females who were

not married (195c); in 1985, more than nine-tenths

(92 percent) of the births to U.S. females under age

15 were to females who were not married (207b).

What accounts for the increase in out-of-wedlock

birth rates among U.S. adolescents is not exactly

known. Some unmarried adolescents who become

pregnant marry before they give birth, but the

proportion of females conceiving who marry before

giving birth has declined in recent years (148). In

1981, the proportion was 23 percent, down from

about 31 percent in 1970 (148,154). The decline in

the proportion of unmarried adolescents who marry

before they give birth probably reflects changes in

societal attitudes toward marriage. It may also
//-332 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

reflect the inability of fathers who are high school

dropouts to find jobs that provide sufficient income

to support a family (166,195a).

Adolescent Fatherhood

Much of the talk about adolescent pregnancy

focuses on females. Information on adolescent

fathers is scarce and tends to be less reliable than

similar data on adolescent females. One very limited

source of information on the extent of adolescent

fatherhood is the U.S. vital statistics system maintained by the National Center for Health Statistics of

DHHS. The vital statistics system compiles data

from State birth certificates on the ages of both

mothers and fathers of children born in the United

States. For about 40 percent of births to U.S. mothers

under age 20, however, information about the child’s

father is not reported on the child’s birth certificate

(l,47a,52,203,207b). The percentage of mothers

under age 15 who report information about their

child’s father is smaller than the percentage of

mothers ages 15 to 19 who do, probably because

younger mothers are also much less likely to be

married than older adolescent mothers. Black adolescent females are substantially less likely to report

the age of the father than white females.

In 1988, 18 percent of U.S. mothers ages 15 to 19

who did report the age of their child’s father on their

child’s birth certificate reported the father’s age as

15 to 19 (see table 10-1). The percentage of

adolescent mothers under age 15 with adolescent

males as partners is probably higher.

NLSY, which as mentioned earlier is a longitudinal survey of youth sponsored by the U.S. Department of Labor, has included questions about adolescent males’ sexual behavior and parenthood experience since 1982 (128). Although NLSY is probably

the best available nationally representative data

source on adolescent male fertility and living

arrangements it is unclear whether, and if so, to what

extent, the available survey data accurately reflect

the total population of adolescent males who have

fathered a child. Even when adolescent males are

asked, they do not always know that they have made

a sexual partner pregnant or fathered a child. Even if

they do know that they have fathered a child, they

may be reluctant to acknowledge that fact, even in a

survey where confidentiality is protected (la).

According to Marsiglio, 6.8 percent (555) of the

nationally representative sample of 5,550 young

males surveyed in the 1984 round of NLSY (when

the males surveyed were ages 20 to 27) reported that

they had fathered a child before the age of 20 (128).9

As shown in table 10-2, more than three-fourths

(446) of these adolescent fathers reported that they

had been single at the time of conception. One-third

of those who were responsible for a nonmarital

conception reported that they had married within 12

months of conception, and half of all the young men

lived with their child shortly after the child’s birth

(128). As shown in table 10-2, three-fourths of the

555 males who had fathered a child before the age of

20 reported they were ages 18 or 19 at the time; these

older adolescent fathers were more likely to report

being married at the time of conception than younger

ones (128). Sixty-two percent of adolescent fathers

with a marital conception reported being high school

dropouts, but all adolescent fathers-regardless of

marital status at first birth-were much more likely

to be high school dropouts than were other male

teenagers.

NLSY data analyzed by Marsiglio indicate that

black adolescent males, economically disadvantaged white adolescent males, and Hispanic adolescent males were all substantially more likely to

become adolescent fathers than white adolescent

males from nondisadvantaged backgrounds (128)

(see table 10-3). Black adolescent males were

especially likely to report having fathered a child

out-of-wedlock. Furthermore, only 15 percent of

black teenagers lived with their first child, as

compared with 48 percent of Hispanics, 58 percent

of disadvantaged whites, and 77 percent of nondisadvantaged whites (128).

Summary

An overview of U.S. adolescent pregnancy and

parenting is presented in figure 10-9. The United

States leads all other Western developed countries in

its rates of adolescent pregnancy, abortion, and

childbearing, although the age of initiation and rates

of sexual activity in these counties are comparable

(8,149). Although it is encouraging to note that the

pregnancy rate among sexually active U.S. females

ages 15 to 19 declined between 1970 and 1985, an

increase in the pregnancy rate in this group between

1985 and 1987 is cause for concern.

9A11 ~rcenuge~ ~epofled in ~c ~slgllo ~icle tie wei@t~ s~tistics, but repofled smple sizes reflwt add frequency co~ts (128).
Table 10-1—U.S. Mothers and the Reported Age of the Fathers of Their Children, by Child’s Race, 1988

Age of father

Under 15 15 to 19 20 to 24 25 to 29 30 to 34 35 years Not

Race of child Total years years years years years and over stated

and age of mother Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent

All races, all ages . . . . . . . . . . . . . . . . . . 3,909,510 100% 376 —’70 110,685 3% 617,124 16% 1,055,417 27% 903,800 23% 636,741 16% 585,367 15%

Under 15 years . . . . . . . . . . . . . . . . . . . 10,588 100 110 1 2,241 21 759 7 112 1 23 — 21 — 7,322 69

15 to 19 years . . . . . . . . . . . . . . . . . . . . 478,353 100 140 — 87,018 18 153,525 32 34,371 7 6,940 1 3,007 193,352 40

White, all ages . . . . . . . . . . . . . . . . . . . . . 3,046,162 100 211 — 79,543 2 494,426 16 894,849 29 766,167 25 518,275 17 292,691 10

Under 15 years . . . . . . . . . . . . . . . . . . . 4,073 100 26 — 1,031 25 498 12 69 2 18 — 17 — 2,414 59

15 to 19 years . . . . . . . . . . . . . . . . . . . . 315,471 100 83 — 61,959 20 119,525 38 27,089 9 5,347 2 2,256 1 99,212 31

Black, all ages . . . . . . . . . . . . . . . . . . . . . 671,976 100 146 — 27,166 4 100,230 15 116,019 17 85,647 13 71,413 11 271,355 40

Under 15 years . . . . . . . . . . . . . . . . . . . 6,182 100 80 1 1,137 18 208 3 32 — 3 — 3 — 4,719 75

15 to 19 years . . . . . . . . . . . . . . . . . . . . 146,326 100 49 — 22,046 15 28,588 20 5,604 4 1,222 1 583 — 88,234 60

NOTE: Percentages may not total 100 because of rounding. Percentages less than 1 percent are indicated by a “-”.

a,,All r=es~~ includes rams other than white and black. ~parate data for Hispani~ are not available (see text). Hispanics may be either black or white.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Division of Vital Statistics, “Advance Report

of Final Natality Statistics, 1988,” Monthly Vital Statistics Reporf39(No. 4 suppl.), DHHS Pub. No. (PHS) 90-1120, Aug. 15, 1990.

I

I

I
//-334 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 10-2-Adolescent Fathers: Distribution of Male Participants in the 1984 NLSY

Who Reported Having Fathered a Child Before the Age of 20, by Father’s Age

at Child’s Birth and Marital Status at Conceptiona

Males who reported

having fathered a Single at Married at

Father’s age child before age 20b

conception conception

at child’s birth N = 555 N = 446 N = 109

Age 11 to 16 . . . . . . . . . . . . . . . . . . . . . . . . . . 66 (10.1%) 66 (127%) o (0.0%)

Age 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 (15.8) 76 (18.3) 9 (5.8)

Age 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 (30.6) 158 (32.8) 23 (22.1)

Age 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 (43.5) 146 (36.2) 77 (72.0)

Age 11 to 19 . . . . . . . . . . . . . . . . . . . . . . . . . . 555 (100.0) 446 (100.0) 109 (100.0)

a~ata are from the 19&l round of National Longitudinal Surveys of Labor Market Experience-Youth Cohort (NLSY),

sponsored by the U.S. Department of Labor. The survey was begun in 1979. In 19“84, male participants were ages

20 to 27.

bThetotal num~rof males in the NLSY sample in 1984was 5,550. According to Marsiglio, who usd weighted statist~

to report percentages (as noted in table 103), 6.8 percent of male participants in the 1984 NLSY reported that they

had fathered a child before the age of 20.

SOURCE: Office of Technology Assessment, 1991, based on W. Marsiglio, “Adolescent Fathers in the United States:

Their Initial Living Arrangements, Marital Experience, and Educational Outcomes,” Fami/y P/anrring

Perspectives 19(6):240-251, 1987.

Table 10-3—Adolescent Fathers: Distribution of Male Participants in the 1984 NLSY

Who Reported Having Fathered a Child Before the Age of 20, by Race/Ethnicitya b

Race/ethnicity

White

Marital status at conception Total Hispanic Black Not poor Poor

and age at child’s birth (N= 5,550) (N= 858) (N= 1,402) (N= 2,475) (N =815)

Percent of male participants 6.8% 10.9% 14.8%4. 4.6% 11.9%

who fathered a child before

age 20 . . . . . . . . . . . . . . . . . . . . . . . . .

Single . . . . . . . . . . . . . . . . . . . . . . . . . 5.5% 7.0% 14.2% 3.4% 9.1%

Ages 11 to 17.. . . . . . . . . . . . . . . 1.7 2.6 5.8 0.7 3.4

Ages 18 to 19 . . . . . . . . . . . . . . . . 3.8 4.4 8.4 2.7 5.7

Married . . . . . . . . . . . . . . . . . . . . . . . . 1.3% 3.9% 0.6% 1 .2% 2.8%

aData are from the 1964 round of the National Longitudinal Surveys of Labor Market Experience-Youth ~hort (NLSY)

sponsored by the U.S. Department of Labor. The survey was begun in 1979. In 1984, male participants were ages

20 to 27.

b~e NLSY is a nationally representative survey that inctudes 12,686 male and female respondents with an

oversampling of blacks, Hispanics, and economically disadvantaged whites. These subgroups can be weighted to

represent a national cross-section of American youth ages 14 to 21 as of January, 1979. All percentages reported in

this table are weighted statistics, but reprted sample sizes reflect actual frequency counts.

SOURCE: W. Marsiglio, “Adolescent Fathers in the United States: Their Initial Living Arrangements, Marital

Experience, and Educational Outcomes,” FamJyPkmning Perspectives 19(6):240-251, 1987. Reprinted by

permission.

Birth rates among U.S. adolescents as a whole

seem to have leveled off since the late 1970s, after

an initial sharp decline due to the legalization and

increased availability of abortion. In 1988, however,

birth rates among 10- to 14-year-old adolescents and

among 15- to 17-year-old U.S. adolescents were at

their highest levels in 10 years (202f). The reasons

are not known. Another cause for concern is the fact

that birth rates among black U.S. adolescents

increased during the 1980s (202f). Again, the

reasons are not entirely clear. There are about half a

million births to adolescent mothers each year. It is

troubling that the proportion of births to unmarried

adolescents has increased dramatically in recent

years, and currently, about two-thirds of births to

adolescent mothers are out-of-wedlock births. Data

from the U.S. vital statistics system, through limited,

suggest that perhaps half of adolescent pregnancies

involve males age 20 or above; the rest of adolescent

pregnancies involve younger males as fathers.

Consequences of Adolescent Sexual Activity,

Pregnancy, Abortion, and Parenthood

It is often assumed that adolescent pregnancy and

childbearing are associated with a constellation of

negative health, social, and economic outcomes for
Chapter 10--Pregnancy and Parenting: Prevention and Services ● II-335

Figure 10-9—Overview of U.S. Adolescent Pregnancy and Parenting”

Percen t

100 ‘

90 ;

I

8 0

U.S. adolescen t

7 0 males, ages 15 to 18

64 .0%

50

40

30

53.2%

2 0

I

10 olds

0 ---- - –L.– .- –—-- -1- -1

Ever had Ever had

sex u a I sex u al

i n te rc o u rs e i n te r -

course

U.S. adolescen t

females, ages 15 to 19

11%

1

4.6%

- -idT 1. .J:!!ll

Pregnant Had an Had a

in t he abor t ion m i scarpast in the r i ag e

yea r past i n the

yea r pas t

yea r

Pregnancy-related event

5%

[- . . .

-1

Gave

birth

i n t he

past

yea r

~

~:.- 3.3%..1-,

J

Had an

out-ofwed Ioc k

birth

i n t he

pas t

yea r

apercen tages of sexual inter~urse, pregnancies, and out-of-wedlock births were tabulated from 1988 data. Percentages of abortions, miscarriages, and births

were tabulated from 1984 data. Percentages of adoptions were tabulated from 1982 data.

SOURCE: Office of Technology Assessment, 1991, based on data from the following sources: Adolescent males ever had sexual intercourse: F.L.

Sonnestein, J.H. Pleck, and L.C. Ku, “Patterns of Sexual Activity Among Adolescent Males,” paper presented at the annuai meeting of the

Population Association of America, Toronto, Canada, May 1990. Adolescent femaies ever had sexual intercourse: J.D. Forrest and S. Singh,

“The Sexual and Reproductive Behavior of American Women, 1982-1 988,” Family Planning Perspectives 22(5):206-214, 1990. Pregnant in the

past year: U.S. Congress, Congressional Budget Office, Sources of Support for%olescent Mothers (Washington, DC: September 1990). Had an

out-of -wecfiock birth in the past year: U.S. Department of Heaith and Human Services, Public Health Service, Centers for Disease Controi,

National Center for Health Statistics, Division of Vital Statistics, “Advance Report of Finai Natality Statistics, 1988,” Monthly Vita/Statistics Report

39 (No. 4, suppl,), DHHS Pub. No. (PHS) 90-1120, Aug. 15, 1990. Aii others: National Academy of Sciences, Nationai Research Council,

Commission of Behavioral and Social Sciences and Education Committee on Chiid Development Research and Pubiic Poiicy, Panel on Adolescent

Pregnancy and Childbearing, Risking fhe Future: Adolescent Sexuality, Pregnancy, and Childbearing, Vol. 1, C.D. Hayes (cd.) (Washington, DC:

Nationai Academy Press, 1987).

adolescents (196). As discussed below, however, not rather than from adolescent pregnancy or childbearall adolescents experience these negative outcomes, ing per se (196). A better understanding of risk and

and there is evidence that some of the negative protective factors in adolescent pregnancy and

outcomes may actually result from lack of prenatal childbearing would undoubtedly be useful in develcare or other factors related to socioeconomic status oping appropriate interventions.
//-336 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Consequences for Adolescents

Health Consequences of Early Sexual Activity—

Adolescents who engage in sexual intercourse are at

very high risk of immediate health consequences.

One consequence for females, of course, is unintended pregnancy due to the failure to use effective

contraception (47a). As noted below, different

subgroups of adolescents are more likely to practice

effective contraception than others. Younger adolescents, for example, are less likely to use effective

contraceptive methods than older ones.10

Engaging in sexual intercourse places both male

and female adolescents at very high risk of getting

sexually transmitted diseases (STDs) and their

related side effects, infection with human immunodeficiency virus (HIV), and the life-threatening

acquired immunodeficiency syndrome (AIDS) (47a,

189). The risk of AIDS and some STDs can be

reduced through the use of condoms and other

measures discussed elsewhere in this Report.11

Health Consequences of Pregnancy and Childbearing—Pregnant adolescents are at risk for negative health outcomes including excessive weight

gain during pregnancy, anemia, nutritional deficiencies, mild and severe toxemia of pregnancy, prolonged or abrupt labors, cephalopelvic disproportion, and maternal mortality (75a,134,137,189). The

adolescents at highest risk are very young (underage

15), black, have a low gynecological age, are thin,

are of low socioeconomic status, and do not seek

prenatal care (75a). Some adolescents enter pregnancy with preexisting conditions that may produce

negative outcomes (e.g., poor nutrition, anemia,

STDs, substance abuse problems12). Thus, the problems they experience stem from those conditions.

Many of the adverse outcomes that pregnant adolescents experience can be avoided by good nutrition

and appropriate medical care (75a).

Health Consequences of Abortion—Like any

surgical procedure, induced abortion carries some

physical health risks (189). Length of gestation is the

most important determinant of abortion complications (30,189). Part of the reason is that it determines

the abortion method, and methods used later in

pregnancy have higher risks of complications. Adolescents are twice as likely as older women to obtain

an abortion after 12 weeks, and the youngest

adolescents are most likely to delay seeking an

abortion (30,189).

The most comprehensive analysis of complications of abortions among adolescents, by Cates and

his colleagues, was based on data for legal abortions

performed in the 1970s (30,189). The Cates analysis

found that the overall rate of major complications

following abortion by suction curettage at 12 weeks

gestation or earlier was similar for teens and older

women (between 1 and 2 per 1,000 in 1975-78)

(30,189). Complication rates associated with abortion by dilatation and evacuation or saline administration were lower for teenagers than for any other

age group. The Cates analysis found that between

1972 and 1978, the risk of dying from a legal

induced abortion was lower among adolescents than

among older females. Within lengths of gestation,

adolescents had the lowest death rates.

Cates concluded that the physical health risks of

induced abortion for teenagers were generally no

greater than the risks for older women (30, 189). The

one exception was the greater risk of cervical trauma

among teenagers. Adolescents who experience cervical trauma following induced abortion may be at

increased risk for adverse outcomes in subsequent

pregnancies. 13

A 1989 report by then Surgeon General C. Everett

Koop stated that firm conclusions regarding the

psychological effects of abortion were not possible

(largely because of serious flaws in much of the

existing research), but the Surgeon General’s report

did not specifically address psychological effects of

abortion for adolescents (209). Adler and colleagues’ review of the most recent methodologically

sound studies of psychological responses of’ U.S.

l~e ~ffectivene~~ of ~on~weptive me~ods most commo~y used by Us. adolescents is discussed later h ~S chapter.

1 l~e ~sk of MV ~ection, ~S,ad o~er Sms among us. ~d adolescen~ md measures to prevent these diseases are discussed bch. 9, ‘ ‘AIDS

and Other Sexually Transmitted Diseases: Prevention and Services, ” in this volume.

lz~e speci~ nu~tion~ needs of pregnant adolescents are discussed in ch. 7, “Nutrition and Fitness Problems: Prevention and Services, ” in this

volume. Substance abuse problems among adolescents are discussed inch. 12,“Alcohol, Tobacco, and Drug Abuse: Prevention and Services, ’ in this

volume.

13~e eff=t of a prior ~duced abofion on subsequent pre~cy Outcomes has not been spec~lcally evaluated for adolescents, Given the iKICr@

risk of cervical injury as a complication among adolescents and its possible association with subsequent unfavorable pregnancy outcomes, research on

the delayed effmts of induced abortion among adolescents seems warranted (1 89).
Chapter l&Pregnancy and Parenting: Prevention and Services . /1-337

women after obtaining legal abortions found that

women often experience particular distress before an

abortion but that legal abortion during the first

trimester of their pregnancy does not pose a psychological hazard for most women (4). Several studies

have found that adolescents experience more negative emotional reactions immediately following an

abortion than women over age 19 do (3,20,126).

This finding may reflect the older women’s greater

ability to make use of their support networks to

resolve negative emotions following an abortion

(1 1,62). Adler and Dolcini note, however, that

statistically significant differences between adolescents’ and adults’ psychological reactions to abortion are small, and negative reactions of both groups

are generally mild (5). Some distress preceding an

abortion is to be expected.

Studies of the long-term psychological impact of

abortion on adolescents are rare. A recent study that

followed 360 black, urban adolescents who received

a pregnancy test in Baltimore found that adolescents

who obtained an abortion were no more likely to

have psychological problems 2 years later than were

adolescents who carried their pregnancies to term or

whose pregnancy test was negative (225).

Social and Economic Consequences of Parenthood—According to Dryfoos, adolescent mothers

face “a myriad” of short- and long-term problems,

as do the babies they bear, the fathers, their families,

and, ultimately, their communities (47a). One problem that researchers have confronted in attempting

to document the consequences of parenthood for

adolescents as compared with the consequences for

older women, however, is determining the effects of

low socioeconomic status and race apart from age

(47a).

In the short-term, adolescent mothers frequently

report many stresses in their lives: reliance on their

family of origin, unstable relationships with the

child father and other male partners, unusual rates

of physical health problems for themselves and their

children, economic hardships, school changes, family conflict, loneliness, isolation, and depression

(16,55,102).

The relationship between adolescent parenthood

and educational attainment is a complex one,

especially among females (185c). A number of

studies have found that females who have babies

while in junior or senior high school complete on

average fewer years of school than their peers who

delay childbearing until their twenties and are less

likely to receive a high school degree or to attend

college or graduate school; these studies have found

that the younger the adolescent, the greater the effect

(29, 145,66). In studies conducted several years ago,

as many as three-quarters of female dropouts cited

pregnancy and/or marriage as their reason for

leaving school (185c). As discussed below, however, females who become adolescent mothers tend

to be those who lack basic skills and are low

achievers in school (47a). Thus, poor academic

performance may be a precursor of pregnancy and

motherhood rather than a consequence. Using data

from NLSY, Upchurch and McCarthy found that

female adolescents who had a baby while still

enrolled in school and who remained in school were

just as likely to graduate as adolescents who did not

have babies (195), Female high school dropouts who

had a baby, however, had their chances of eventual

graduation from high school reduced.

Some studies have found that adolescent mothers

tend to have lower status jobs and lower incomes

than other females and that they are more likely to

depend on public assistance (29,70,89); it is suggested that part of the reason may be that females

who give birth during adolescence tend to have more

subsequent births at closer intervals than their peers

who delay childbearing (90). Economic outcomes

are substantially brighter for adolescent mothers

who marry and maintain stable marital relationships

than they are for other adolescent mothers (67). As

noted earlier, most births to adolescents, especially

blacks, occur outside of marriage. Furthermore,

adolescent marriages are very likely to end in

divorce, and adolescent cohabitational relationships

are even more unstable than adolescent marriages

(14,29,66,67).

Recently, a couple of longitudinal studies have

found that there is great variability in how adolescent parenthood affects adolescent mothers’ educational and vocational attainment. Furstenberg and

colleagues conducted a longitudinal study that

followed a group of mostly urban black adolescent

mothers in Baltimore and their children for 17 years

(68,68a). They found a great deal of diversity in how

these mothers, who gave birth as adolescents in the

middle to late 1960s, responded in the long run to the

setback in education and labor force participation

associated with adolescent childbearing and parenthood. Women who had more economically secure

and better educated parents and women who had
II-338 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

been doing well in school and had high educational

aspirations at the time of their child’s birth were

much more likely to be successful later on.

At 5-year followup in 1972, Furstenberg and

colleagues found, most of the 331 mothers were in

their early twenties and were struggling to remain in

or return to school, to enter the job market and to

raise their child (68,68a). Close to one-third of the

young women were receiving welfare. Only 50

percent of the women had graduated from high

school. Having more children at a young age was

found to constrain these mothers’ ability to pursue

their education or get job experience. The mothers

who had had more children in the 5 years did less

well in school, had lower aspirations, and came from

more socioeconomically disadvantaged families than

those who had no subsequent children.

At 17-year followup in 1984, Furstenberg and

colleagues found that a substantial majority of the

Baltimore adolescent mothers had returned to

school, had gotten off welfare, and were employed

in stable jobs (68,68a). Relatively few had ended up

with large families. Nevertheless, barely more than

one-third were married, and in comparison with

samples from several national surveys, the Baltimore mothers were not as successful as metropolitan

black women who had delayed childbearing until

their early twenties. Women who had attended a

special school for pregnant women were more likely

to be economically independent at followup.

This study by Furstenberg and colleagues suggests that adolescent parenthood does not inevitably

lead to a life of poverty and disadvantage for

adolescent mothers (68).14 Furstenberg and colleagues caution, however, that the situation confronting the sample of mothers in their study maybe

very different from that of pregnant teenagers today.

During the mid-1960s, for example, abortion was

illegal, and early childbearing was not considered a

problem so long as it was accompanied by marriage;

thus, many women married to avoid the stigma of

unwed parenthood. Special services for adolescent

mothers were less available 20 years ago than they

are today. In drawing conclusions about the implications of the Furstenberg study’s findings for today’s

adolescent mothers, these changes should be kept in

mind. The effects these changes are likely to have

are not really known.

Horwitz and colleagues investigated the longterm effects of school-age pregnancy in a 20-year

followup of women who were pregnant adolescents

in the late 1960s (92a). The study population

consisted of 154 black women who had been

enrolled in a program that offered obstetric, social,

and educational series to pregnant teenagers. This

study also found that the life course and long-term

outcomes for adolescent mothers were not homogeneous. Long-term success, defined as being currently employed or supported by a spouse and

having a high school education or its equivalent, had

been achieved by 62 percent of the women in this

study at 20-year followup. Long-term success was

associated with six factors: 1) having completed

more school prior to becoming pregnant, 2) participating more extensively in life skills training sessions offered to them as pregnant adolescents, 3)

being in school with no subsequent pregnancies at

26 months postpartum, 4) feeling in control of one’s

life at 26 months postpartum; 5) experiencing little

social isolation at 26 months postpartum, and 6)

lifetime fertility control defined as one or two

children after the first.

The educational attainment of male adolescents

who become fathers during their teenage years has

been found to be negatively affected by parenthood

but to a lesser extent than the educational attainment

of adolescent mothers (29,128). Data from the 1984

round of NLSY suggest that adolescent fathers

whose first child is conceived within marriage have

the poorest high school completion patterns (128). A

number of questions remain about whether adolescent fathers who live with a child they have fathered

are harmed in their educational careers, and if so,

under what conditions (128).

Psychological Consequences of Giving Up a

Baby for Adoption—Adoption is a relatively rare

event, and the process of formalizing adoption

decisions has been highly confidential, so research

data have been difficult to obtain. Some data indicate

that placing a child for adoption results in a grieving

process that may affect many aspects of a young

woman’s life (44) and that mothers who give their

children up for adoption experience a variety of

negative psychological consequences (162). The

studies from which these data are drawn have been

based on small, self-selected samples and have not

concentrated on adolescents, however, so their

14~e Study~S findl~gs wl~ respect t. outcomes for the children of adolescent mothers were less positive, as discussed ~low.
Chapter l&Pregnancy and Parenting: Prevention and Services . II-339

applicability to the general population of adolescents who give babies up for adoption is limited.

A 1988 study comparing female adolescents who

chose to give up a baby for adoption with female

adolescents who chose to keep their baby found that

both groups of adolescent mothers experienced a

decline in satisfaction with themselves and their

lives which closely followed their decisions to give

up or to keep their baby (133). But when researchers

followed up the two groups of adolescent mothers at

least 6 months later, they found no differences

between the two groups in overall levels of self- or

life satisfaction (133). Adolescent mothers who

chose to keep their babies were slightly more

satisfied with their decisions than adolescent mothers who chose adoption.

Consequences for Children of Adolescent Parents

Health Consequences—Babies born to adolescent mothers (especially adolescent mothers under

age 15) are more likely to be premature or low

birthweight and are more likely to require hospitalization within the first 5 years of life than babies born

to women age 20 and over (71b,84,190,196). The

risks of prematurity and low birthweight can be

reduced with adequate prenatal care. Furthermore,

the fetus of an adolescent is at less than average risk

in some respects (e.g., fetal death), and many

children born to adolescent mothers tend to grow

better in the earlier years of life (71 b).

Some studies suggest that the children of adolescent parents are at increased risk of cognitive

deficits, tend to perform less well in school than

children born when their parents were older, and are

more likely to exhibit behavior problems in school

(14,70, 106,120, 140). Some data suggest higher rates

of abuse and neglect among children of adolescent

mothers (105,176), but such outcomes seem to be

affected by socioeconomic factors; when the effects

of socioeconomic variables are controlled, apparent

differences between the children of adolescents and

older mothers are substantially reduced, although

not completely eliminated (148,196).

Social and other Consequences-Furstenberg

and colleagues’ longitudinal study of mostly poor

black adolescent mothers and their children in

Baltimore found that the offspring of their sample of

mothers who gave birth in the mid- 1960s were at

greater risk of developing problems in late adolescence and early adulthood than the children of older

mothers interviewed in the National Survey of

Children who did not give birth as adolescents (70).

The children of the Baltimore mothers were interviewed at 5-year followup (when they were preschoolers), at 17-year followup (when they were

adolescents), and at 20-year followup (when they

were ages 18 to 21).

At 17-year followup, the Furstenburg study found

that the frequency of school failure, delinquency,

emotional difficulties, and other problem behaviors

was much greater among the children of the adolescent mothers than among children of older mothers

in the National Survey of Children (70). At 20-year

followup, the children of the Baltimore adolescent

mothers were not doing as well as the children of

older mothers in the National Survey of Children,

but the differences were not as large as some

observers might have been expected. Sixty-three

percent of the children of the Baltimore adolescent

mothers had completed high school or obtained a

high school equivalency degree and another 10

percent seemed likely to do so. Still, a conspicuous

minority had dropped out of school (23 percent) or

had spent time in jails or correctional institutions (17

percent), and a substantial proportion were experiencing symptoms of depression (32 percent).

Because of its ability to follow families over

generations, the Furstenberg study was also able to

address the important and controversial issue of the

transmissibility (e.g., through parental socialization

or modeling) of adolescent childbearing between

generations. This study found that early childbearing

was at least indirectly involved in increasing the

chance that one’s child would become an adolescent

parent (daughters of women who had given birth at

ages 14 to 17 were more likely than those whose

mothers were 20 or older at their first birth to

themselves give birth as adolescents). On the other

hand, the great majority (two-thirds) of the children

of adolescent mothers did not become parents before

age 19 (68,70).15

Furstenburg and colleagues unfortunately found

that the second-generation adolescent mothers were

not faring as well as their mothers had and predicted

151t ~la~, ~ important t. ~otc ~al b~ausc not all ~onlcn in their SmpIc had reached ages 1 A to 18, [he researchers calculated probabilities based on

the experiences of the sample that was available (70).
/1-340 . Adolescent Health—Volume //: Background and the Effectiveness of Selected Prevention and Treatment Services

worse outcomes for them than for their mothers in

terms of educational achievement, marriage, and

welfare dependence (68,70). The second-generation

adolescent mothers were almost twice as likely as

their mothers to have failed a grade in school (57

percent v. 33 percent), were less likely to have

married (14 percent v. 60 percent), and were more

likely to be on welfare (60 percent v. 30 percent).

Furstenburg and colleagues concluded that "secondgeneration teenage mothers in the 1980s appear

more vulnerable to long-term dependence and probably less equipped to maneuver their way out of

lifelong disadvantage than were their mothers in the

1960s” (68). They recommended that secondgeneration adolescent mothers be targeted for extensive educational and social services (68).

Risk and Protective Factors in Adolescent

Pregnancy and Parenting

In recent years, researchers have documented a

number of potential risk and protective factors

related to adolescent pregnancy and parenting.

Much of the available research was recently reviewed in a comprehensive analysis of adolescent

pregnancy and parenting by the National Academy

of Sciences’ Panel on Adolescent Pregnancy and

Childbearing (148,149), and that information is

summarized, along with other information, below. It

is important to note that there is still a paucity of

methodologically sound research on the precursors

to adolescent pregnancy and postpregnancy decisions.

In an attempt to capture the many factors that may

be associated with the determinants and outcomes of

pregnancy resolution decisions made by adolescent

females and their male partners after conception,

Marsiglio recently presented the conceptual model

shown in figure 10-10. As shown, the factors

affecting the pregnancy resolution decision alone

have many determinants, including the social structure; cultural and subcultural values and norms;

policies and programs; the flow of financial resources and social support from family, friends, and

partner; and the adolescents’ own attitudes, aspirations, and resources. The decisions made as a result

of these factors affect the process and outcomes of

a pregnancy-related decision, which in turn affect

the life-style adaptations made by the couple and

their future life options and well-being. What is

perhaps more important to note is that these factors

often interact with each other in causally complex

ways and that each couple’s decision in turn affects

the cultural values and norms of other contemporaneous couples and succeeding generations.

Models similar to the one shown in figure 10-10

could be constructed for the decisions that may lead

to a pregnancy: whether to initiate sexual activity at

all, whether to initiate sexual activity with a

particular partner, whether to use contraception, and

what method of contraception to use. Each of these

decisions has its own set of determinants. Longitudinal research focusing on the psychological, social,

and economic determinants of pregnancy and pregnancy outcomes would be useful in resolving some

of the questions about risk and protective factors in

adolescent pregnancy and parenting (171 b).

Numerous individual, familial, and social/environmental factors related to pregnancy and pregnancy

outcomes among adolescents are discussed below.

Factors affecting all events that can lead up to a

pregnancy (i.e., sexual intercourse, use or nonuse of

contraceptives) are discussed below as ‘‘factors

related to pregnancy, ’ and factors affecting events

that may occur during or after a pregnancy (abortion,

complications during pregnancy, childbearing, adoption, parenting) are discussed as "factors related to

pregnancy outcomes. ’

Risk and Protective Factors Related to Pregnancy

Individual Factors Related to Pregnancy—

Two strong predictors of adolescent pregnancy are

the initiation of sexual activity at an early age and

engaging in unprotected sexual intercourse (i.e.,

intercourse without the use of effective contraceptives). Females who first have intercourse at age 15

or below have been found to be nearly twice as likely

to get pregnant in the first 1 to 6 months of sexual

activity as adolescents who wait to have intercourse

until they are 18 or 19 (228a). One of the reasons is

that older adolescents who become sexually active

are considerably more likely than younger adolescents to use contraception and to use it effectively

(229). In general, the older an adolescent female is,

the more likely she is to report using some form of

birth control when she is sexually active (229,231),

and the older she is when she begins having sex, the
Chapter l&Pregnancy and Parenting: Prevention and Services . //-341

Figure 10-10—Conceptual Model for Pregnant/Parenting Teens and Their Male Partners: Pregnancy Resolution

Decisions, Life-Style Adaptations, and Well-Being

r

L — “-—~ PREGNANCY RESOLUTION

PROCESS AND OUTCOMES ,_ ..1

1. Abortion L

SOCIAL STRUCTURE

2, Community SES

,//

/’ /’

~

1. Sexualty/fertility

k

/ , 4. Change in leisure activities

2, Nonfertlllty /1

1--- --- ----—- -----

4 /

I

I I / /

.LL:--- ‘\ r

– ---ii ‘ ‘, x’ -~1 b’”

CULTURAL VALUES

AND NORMS

1, Sexuallty/fertility ~

2, Nonfertlllty #

‘\ FLOW OF FINANCIAL

1

/

RESOURCES AND SOCIAL ‘ \

SUPPORT FROM FAMILY, \ \

FRIENDS, AND PARTNER

\

\

\

a, education

b. work ~ ~“~”~ \ \

c. family

-/

\ . \ 1.

\

“ \

\ ‘ \ L.. .

/’ NEIGHBORHOOD/ )

\

~ COMMUNIT Y

‘$ \ 1 FUTURE LIFE OPTIONS

I SUBCULTURAL I

\

Y

AND WELL-BEING

I VALUES AND NORMS ~ 1. Economic

I 1, Sexuallty/fertillty

/

2. Emotional

2. Nonfertility )

3. Psychological

SOURCE: W. Marsiglio, “Pregnant Teens and Pregnancy Resolution Decisions: The Role of Male Partners, ” TEC Networks, Newsletter of the

Too-Early-Childbearing Networks of Programs Funded by the Charles Stewart Mott Foundation, Washington, DC, No. 29, June 1991. Reprinted

by permission.
II-342 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

more likely she is to use contraception at first

intercourse (235).16

According to the comprehensive review of adolescent pregnancy and parenting by the National

Academy of Sciences’ Panel on Adolescent Pregnancy and Childbearing, research suggests that a

number of factors are strongly associated with the

initiation of sexual activity before marriage (148).

Among the most important are individual characteristics such as physical maturation level, age, race,

socioeconomic status, religiousness, intelligence

and academic achievement, and dating behavior.

There is almost universal agreement that early

pubertal development (e.g., age of menarche for

females, body development and hormonal development for males) is strongly associated with early

initiation of sexual activity (148). During the period

of adolescence, young people undergo dramatic

biological changes that give them the capacity to

create children. U.S. females today first menstruate,

on average, at age 121⁄2 (with a range between 8 and

16), but in some cases, they cannot get pregnant for

at least a year (47a). Boys are able to father children

at age 14 or so, although they can and sometimes do

engage in sexual intercourse before that. Studies

provide evidence for the hormonal basis of sexual

motivation and behavior among white males. For

white females, sexual behavior (as opposed to

interest) seems to be influenced more by social

environment than by physical development. There

are no comparable data on black adolescents.17

Apart from pubertal development, age is associated with the initiation of sexual activity. The older

an adolescent is, the more likely he or she is to have

had sexual intercourse (148).

Race is also associated with the initiation of

sexual intercourse. Black males and females become

sexually experienced on average 2 years earlier than

white males and females (148,187). As discussed

later in this chapter, there is disagreement over the

cause of racial differences in the proportion of

adolescents who are sexually active and the age of

sexually initiation (e.g., subcultural values and

attitudes regarding the acceptability of early sexual

behavior, residence in socioeconomically disadvantaged neighborhoods) (148).

Religiousness (the tendency to be devout and

observant of religious custom, regardless of religious affiliation) appears to be a factor that distinguishes early and late initiators of sexual activity

(43,148,231).

A number of studies indicate that there is a strong

association between low intellectual ability, low

academic achievement, a lack of educational goals,

and early sexual experience among both black

adolescents and white adolescents (148). Male and

female adolescents with higher levels of academic

achievement and higher educational and life goals

are less likely than other adolescents to engage in

sexual intercourse during their early adolescent

years, and they are more likely to make consistent

use of contraceptives when they do have intercourse

(43,98a,139). Adolescent females who are experiencing academic problems, who have low academic

and career expectations, and particularly those who

have dropped out of school are more likely to initiate

sexual activity at an early age than those who are

more academically successful and ambitious (148,149).

The association between ability, educational aspirations, and life goals and the lower likelihood of early

sexual experience is undoubtedly tied to several

interacting social, economic, psychological, and

situational variables (148).

Research findings suggest that adolescents who

begin dating early are likely to have early sexual

experience (148). Research also suggests that adolescents who become sexually active at an early age

are also often involved in other behaviors that push

toward independence and adulthood (e.g., smoking,

. .

drinking, and drug use) (148).

A factor in adolescent sexuality and pregnancy

that may be important but that is rarely analyzed or

discussed is adolescent females’ perceptions about

their roles as women (56a,149,122,145a). Lewin

16Da~ on ~qofled ~on~aceptive use ~ong adolescent m~es we very l~ted, but w~t Uttle irlfomtion there is suggests thd age &is little eff~t

on adolescent males’ use of birth control methods (142); older adolescent males are no more likely to report using birth control methods than are younger

males.

ITOne issue offipo~mceis tie extent t. ~~ch fitiation of sexu~ ~terco~se is vol~@y or forced (i.e., the result of rape or incest) (86a). Currently,

there is no reliable information about this at the national level.
Chapter l&Pregnancy and Parenting: Prevention and Services . II-343

found, for example, that college-aged women felt

that it was psychologically more cost-beneficial to

accept unwanted sexual intercourse than to refuse it

(122).18 The review by the National Academy of

Sciences’ Panel on Adolescent Pregnancy and Childbearing suggested that adolescents’ increasing exposure to working women and single mothers could be

expected to influence the desirability of early

childbearing in diverse ways (149).

Not surprisingly, sexually active females who

practice effective contraception are less likely to

experience an unintended pregnancy than those who

do not (235).19 As noted earlier, the older an

adolescent female is at the time of initiation of

sexual activity, the more likely she is to use

contraception and to use it effectively (148). The

older a female is, the more likely she is to use a

prescription method of contraception such as the pill

(148,23 1). Among males, age appears to have little

effect on contraceptive use at first intercourse (148).

According to the review by the National Academy

of Sciences’ Panel on Adolescent Pregnancy and

Childbearing, studies have found that, in addition to

the age at initiation of sexual intercourse, several

factors are strongly associated with contraceptive

use by unmarried, sexually active adolescents.

These include having a stable relationship with a

sexual partner, knowledge of reproduction and

contraception, acceptance of one’s own sexuality,

academic aspirations, developmental characteristics, and parental support for the use of contraception

(148).

Adolescents who are involved in a committed

relationship (e. g., are “going steady”) are more

likely to use contraceptives than adolescents who do

not have strong ties to one partner (148). One study

found this observation to hold for black adolescents

in particular (143).

Some observers have attributed sexually active

adolescents’ failure to use contraceptives to their

lack of knowledge about reproduction and contraception (23 1). Although most U.S. adolescents

appear to know that a girl can become pregnant if she

has intercourse, significant numbers of U.S. adolescents-especially young adolescent females—

appear not to know what time of the month entails a

higher rate of pregnancy, that they can get pregnant

at first intercourse, that infrequent sex can lead to

pregnancy, and other facts about pregnancy risk and

birth control that are more well known to sexually

active adults (26a,137,248). At least one study has

found that adolescents who have had sex education

are more likely to be knowledgeable about reproduction and contraception than adolescents who have

not had sex education (107).20

Regular and effective contraceptive use among

adolescent females has been found in some studies

to be associated with adolescents’ acceptance of

their own sexual behavior (223,248). Some adolescents, especially younger adolescents, who delay

using contraceptives (often for up to a year) after

they start having sexual intercourse, may do so

because they have difficulty coming to terms with

their own sexuality (148). Positive attitudes toward

contraception and low levels of guilt about sexual

activity are strongly associated with effective contraceptive use (148). Fear that contraception will

have negative health effects and interfere with

pleasure has also been found to be related to less

frequent contraceptive use (148).21 Adolescent females who believe contraception is the female’s

responsibility are likely to be more effective contraceptors (148,168,232).

Female adolescents (blacks and whites) who have

clear educational goals and expectations and are

performing well in school appear more likely to use

contraception than those who lack a strong achievement orientation (148). Some studies have found

18cOn~accptl\, c “Sc ~unng ~nw~ted seXual intercourse was not m~sured in tis study of hypothetical situations.

l~It is impo~mt t. ~o[e t~t, for as yet unknown r~som, tie percentage of adolescents who use contraception and experience COn~aCeptlVe falllUe

in terms of preventing pregnancy is generally higher than the percentage of older women who experience contraceptive failure. Contraceptive failure

rates for adolescents are shown in figure 10-12 later in this chapter.

~~c rclatiom$hip ~tween gains in knowlc~gc abut Conccptlon and contraception~rough sex education courses and adolescents’ SCXUal aCtlVlty

or use of contraceptives is not fully understood, but it seems that information alone is not sufficient to change adolescents sexual behavior. As discussed

later in this chapter, a 1984 study by Kirby found that while sex education programs did incrciisc adolescents’ knowledge AOU[ conception and

contraception, they had 1 ittlc impact on whether adolescents became sexually active or used contraception (107). Wrious studies on the effectiveness

of efforts to prevent adolescent pregnancy through school-based scx education/family life education classes, parent-child communication programs, and

other mformationid programs ‘are discussed later in this chapter.

21Thc types of contraceptives available to adolescents and some of [heir advantages and disadvantages arc discussed later in this chapter. Also

discussed arc various programs that make contraceptives available to adolescents.
//-344 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

that adolescents who become teenage mothers are

performing below grade level at the time they

become pregnant (68, 148), suggesting a relationship

between school achievement and the likelihood of

pregnancy (148).

Some research has found that adolescent females

who have a high level of self-esteem and believe

they have a large measure of control over their lives

are more likely to be effective users of contraceptives than adolescents who have low self-esteem and

lack a sense of competence (148). Adolescent

females who tend to be passive and to hold

traditional views of male-female relationships tend

to be poor contraceptors (148). Adolescents who are

impulsive and like to take risks are more likely to be

poor users of contraceptives than other adolescents

(148).

Some research indicates that adolescents who use

illicit drugs other than marijuana are at especially

high risk for experiencing a premarital pregnancy

(223b). Such adolescents are especially likely to

engage in early sexual experimentation and to have

permissive attitudes about sexual behavior (223b).

Elliott and Morse found in a large national sample

that among young men and women ages 15 to 21 in

1981, the proportions sexually active in the last year

ranged from 21 percent among those who used no

drugs, to 45 percent among those who used marijuana, and to 89 percent among those who experimented with illicit drugs other than marijuana (51 a).

Several studies indicate that female adolescents

who have good lines of communication with their

mothers and whose mothers discuss contraception

with them in a positive way are more likely to be

effective contraceptors than adolescents who lack

such communication (57a,60,148).22 Furthermore,

female adolescents whose mothers support them in

selecting and using contraception seem to be more

consistent in their own use of contraception (118,148).

Familial Factors Related to Pregnancy—

According to the comprehensive review of adolescent pregnancy and parenting by the National

Academy of Sciences’ Panel on Adolescent Pregnancy and Childbearing, research examining the role

of family members on adolescents’ sexual behavior

and contraceptive use is limited (148). Most studies

in this area have examined mother-daughter relationships, ignoring the role of fathers and the

relationship of parents to sons. Nevertheless, several

studies have shed some light on family factors

related to adolescent pregnancy and childbearing.

One of the factors that has been found to be most

strongly associated with an adolescent female’s

initiation of sexual activity before marriage is the

sexual and fertility experience of her mother (148).

Several studies have found a strong relationship

between a mother’s sexual and fertility experience as

a teenager and that of her daughter (148,152). The

earlier the mother’s first sexual experience and frost

birth, the earlier the daughter’s experience is likely

to be (148).

Other family factors that “appear to affect the

level and quality of parental support and controls,

and perhaps in turn influence sexual behavior among

teenagers, ‘‘ include family intactness, family composition, and mother’s age at marriage (148). Several studies have also shown that females who have

grown up in fatherless families are more likely to

initiate sexual activity at an early age than those who

have grown up in two-parent families (139a,148,152).

One study found that females in families with large

numbers of siblings are also likely to become

sexually active at an early age (91,148). The

mechanism by which these factors influence the

initiation of sexual activity is not well understood.

Several plausible explanations have been offered

(e.g., girls in fatherless families may seek affection

in sexual relationships) but have not been substantiated (148).

Some studies have found that adolescents’ sexual

behavior is affected by the nature of their relationships with their mothers (148). Specifically, adolescent girls whose mothers do not combine affection

with firm, mild discipline and set clearly defined

limits on behavior are likely to engage in premarital

sexual intercourse (148). In addition, as suggested in

the previous section, some studies have found that

adolescents in homes where there is good communication between parents and adolescents about sex

tend to engage in less sexual activity and to make

better use of contraceptives and that parental support

for adolescents in seeking family planning services

results in more consistent contraceptive use (60,1 18,

96). According to Hofferth, writing in the report of

22s& &. ‘3, 1‘Puents ~d F~ilies’ ~uenc,e on Adolescent Heal~” in this Volume for a discussion of the hrlportatl~ of parents in adolescents’

lives.
Chapter 10----Pregnancy and Parenting: Prevention and Services ● II-345

the National Academy of Sciences’ Panel on Adolescent Pregnancy and Childbearing, however, parentchild relationships and parent-child communication

seem to have an ambiguous association with the

initiation of sexual activity and use of contraception

by adolescents (86a,148). Thus, “there is no clear

implication for program development’ (148).

Social/Environmental Factors Related to Pregnancy—Research on how peers influence adolescents’ sexual attitudes and behavior is limited and

exhibits a number of methodological problems (e.g.,

data are gathered at one point in time, so delayed

effects cannot be detected). Several studies indicate

that same-sex peers are a major source of information for adolescents about sex (148), and at least one

study has found that the proportion of their same-sex

peers that teenagers believe are sexually active and

how sexually active they perceive them to be are

strong predictors of sexual experience among adolescent males and females (38,148). Some research

has suggested that adolescents’ sexual behavior is

influenced more by their perceptions of peers’

attitudes and behavior than by what their friends

actually do and think (148,151). The influence of

peer pressure seems to vary by age and gender (148).

Younger adolescents (i.e., those below the age of

15), especially white females, seem to be more

susceptible to peer influences in sexual decisionmaking than others (123, 148).

Although the influence of television on adolescents’ sexual behavior has been little studied, it is

clear that television is a predominant aspect of the

lives of today’s adolescents. Studies show that both

explicit and implicit sexual behavior in television

programming increased dramatically during the

1970s (148). Contraception is almost never mentioned or referred to, and the negative consequences

of an unintended pregnancy are seldom portrayed

(148).

Knowledge of how neighborhood environments

and community institutions such as schools and

churches affect sexual activity is just beginning to

emerge ( 148). Adolescents who live in poor neighborhoods in which early childbearing and single

parenthood are the norm are more likely to become

sexually active and become pregnant than adolescents living in and going to school in more prosperous environments (9c,149).

An overview of the effectiveness and other

features of contraceptive methods available to U.S.

adolescents is presented later in this chapter. Research suggests that some adolescents find these

methods difficult to use or otherwise unappealing

and are therefore inconsistent or ineffective contraceptors (148).

As discussed later in this chapter, support for

public and private nonprofit family planning clinics

that serve adolescents and other, predominantly

low-income, women is provided through Title X of

the Public Health Service Act and other Federal,

State, local government, and private programs.23

Expansion in the availability of contraceptives and

abortion during the 1970s was paralleled by an

increase in adolescent sexual activity. Critics of

family planning programs suggest that the availability of contraceptive services has caused higher rates

of sexual activity and unintended pregnancy among

U.S. adolescents (148). As noted later in this chapter,

available research findings on this point are contradictory (e.g., 100,138).24

Risk and Protective Factors Related to

Pregnancy Outcomes

Individual Factors Related to Pregnancy Outcomes-Adolescents who become pregnant may

decide to have an abortion, or deliver their infants

and keep them, or deliver them and give them up for

adoption, Mothers who bear children out of wedlock

may remain single, cohabit without marrying, or get

married.

According to the National Academy of Sciences’

1987 report on adolescent programming and childbearing, one of the most important factors affecting

whether a pregnancy is terminated by abortion or

carried to term is whether it was intended (14 S).

Adolescents who report that their pregnancy was

unintended are more likely to have an abortion than

those who report that their pregnancy was intended

(148). As noted below, almost two-thirds of 15- to

19-year-old U.S. females giving birth in 1988 said

that their pregnancies were unintended (59a); combined with the high rate of abortions among pregnant

‘

3 Tit1c X of the Public Health Serv ice Act is discussed in the section of this chapter on Federal programs and policies related to adolescent pregnancy

and childbearing.

~4ThIS research is summarized in table 10-8 in the section of this chapter on contraceptive provision programs below.

2!)7 f{ i(; c 1 1 – 1 L QL ,1
II-346 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

U.S. adolescents, this observation suggests that most

pregnancies among U.S. adolescents are unintended.

Adolescents who are unmarried are more likely to

have an abortion than those who are married

(13,80,232); and pregnant adolescents who are

achieving academically before pregnancy and who

have a strong future orientation are more likely to

choose abortion to resolve an unintended pregnancy

than those who are not doing well in school and lack

high educational and vocational goals (148). Another attitudinal factor that has consistently been

found to discriminate between abortion and term

pregnancy groups is attitude toward abortion, with

those choosing to terminate their pregnancy expressing greater acceptance of abortion (53,1 14).

As noted earlier, pregnant adolescents are at risk

for a variety of pregnancy and birth complications

(75a,134,137,189). Furthermore, babies born to

adolescent mothers are more likely to be premature

or low birthweight and are more likely to require

hospitalization within the first 5 years of life than

babies born to women overage 19 (71b,84,190,196).

But as noted above, except in the case of the very

youngest adolescents, pregnancy and birth complications are probably not related to low maternal age

per se (63a). Some adolescents enter pregnancy with

preexisting conditions such as anemia or substance

abuse problems that may cause adverse outcomes.

Adolescents who use illicit drugs are at high risk for

experiencing poor pregnancy outcomes such as low

birthweight (under 2,500 grams) and infant mortality (223 b), and heavy alcohol use is believed to be a

risk factor for long-term damage to children (188a) .25

Other preexisting conditions that may cause problems include poor nutrition and anemia.26 Teenagers

seem to be at especially high risk of nutritional

deprivation during pregnancy (148).

Many of the physical health risks to adolescent

mothers and their babies can be significantly reduced with proper prenatal care and good nutrition

(14). 27 The standards of the American College of

Obstetricians and Gynecologists, and the American

Academy of Pediatrics recommend that every pregnant woman have a comprehensive program of

prenatal care beginning as early in the first trimester

of pregnancy as possible (9a,148). Furthermore, a

1988 OTA study concluded that available evidence

supports the value of both early and frequent

prenatal care and the provision of enhanced services

to adolescents.28

Unfortunately, many pregnant adolescents in this

country-53 percent of pregnant 15-to 19-year-olds

in 1988 (207b)--do not receive prenatal care ever or

until after the first trimester of their pregnancy

(204,207b). The problem of late or no prenatal care

is caused by numerous factors, ranging from adolescents’ failure to recognize the early signs of pregnancy to concerns about costs or confidentiality

(148). Unmarried teenagers with less than a high

school education have been found to be among the

least likely to receive first-trimester prenatal care

(96a,148,185a,199). The problems associated with

late or no prenatal care are exacerbated among

pregnant adolescents who have not been educated

about nutrition or who have poor health habits

(6,127).

Adolescents who choose to carry their pregnancies to term also need adequate care for labor and

delivery .29 Maternity care is often expensive, and

some adolescents may experience problems related

to financial access.

Following delivery, the immediate needs of adolescent mothers and their babies (e.g., food, housing,

health care, economic support, social support, child

care) are numerous (148). Individual adolescents

vary in their ability to have these needs met, and

some adolescents (e.g., those who are very young,

those who have poor parenting or life planning

skills, those with substance abuse problems) may

have greater difficulty than others. Many adolescent

parents require extensive social and economic support. A 1990 review by the Congressional Budget

Office (CBO) found that few adolescent mothers are

able to support themselves and their children during

XSW ch. 12, “Alcohol, Tobacco, and Drug Abuse: Prevention and Semices, ‘‘ in this volume. As noted in that chapter, alcohol is the most frequently

used drug among adolescents. The extent to which adolescent females drink heavily during pregnancy is unknom however.

26s= Ch. 7, “Nu~tion and Fimess Problems: Prevention and ServiCN, ” in this volume.

27prenata/ care refers t. medic~ semices delive~d from conception to labor (199). Such care encompasses a wide range of preventive, dia~ostic,

and therapeutic services delivered throughout the course of pregnancy with the goal of a healthy baby and a healthy mother (199).

MSe OTA*S 1988 report Healthy Children: Investing in the Fume (199).

Z9~aterniv care ~clude5 pmm~ c~e ~d~~ap-Care (labor and delivery care) (199).
Chapter 10--Pregnancy and Parenting: Prevention and Services . II-347

the frost few years of parenthood (195).30 According

to CBO’s analysis, the amount of support available

to married adolescent mothers varies, depending on

their husbands’ age, educational level, and employment status; however, 40 percent of married adolescent fathers were found to be high school dropouts,

and adolescent fathers were less likely than fathers

age 20 and over to have jobs (195a). Almost no

information is available on support for adolescent

mothers and their children from the absent fathers of

those children.

Familial Factors Related to Pregnancy OutcomesAccording to the 1987 National Academy of Sciences’ report, several studies of adolescent girls who

choose abortion have found that family background

factors are significant predictors (148). Adolescent

females from white families are more likely than

those from black families to terminate an unintended

pregnancy, and females from families with higher

socioeconomic status are more likely to have abortions than those from families living in poverty.

Some studies have found that parental attitudes,

especially mothers’ attitudes toward abortion, predict adolescent daughters’ pregnancy termination

decisions (50a,148). Particularly among young adolescents, parents seem to play a major role in the

decision to terminate an unintended pregnancy

(173). 31 There is some evidence of a link between

being raised in a single-parent home and early

childbearing (25a,92). Some studies have found that

adolescents who become pregnant and have an

abortion are more likely to come from two-parent

families with smaller numbers of children than

adolescents who carry their pregnancies to term

(37,63).

Studies that have examined the role of families in

helping adolescent mothers adjust to parenting roles

are scarce, and studies of the families of adolescent

fathers are virtually nonexistent (148).

In its analysis of Current Population Survey data,

CBO found that more than half of young unmarried

mothers lived with their parents or other relatives

(195a). CBO noted that by sharing living quarters

with parents and other relatives, young single

mothers were probably able to benefit from the

overall household income and other supports in the

household (195a). A relatively low 34 percent of

unmarried mothers who lived with relatives lived in

poverty (based on the cash income of the extended

family unit); available data also suggested that

adolescent mothers living with relatives were also

more likely to be able to continue their schooling

(195a).

Social/Environmental Factors Related to Pregnancy Outcomes-The incidence of abortion has

increased since the U.S. Supreme Court’s Roe v.

Wade decision in 1973 [410 U.S. 113 (1973)]. As

discussed later in this chapter, however, some

adolescents’ access to abortion is limited by factors

such as cost, geographic distance from facilities that

perform abortions, and parental consent and notification requirements.

32 According to the National

Academy of Sciences’ report, one study found that

adolescent females’ decisions about whether or not

to carry their pregnancies to term were predicted by

the attitudes of both their female friends and their

male partners, and adolescent females who have

friends who are themselves adolescent parents are

more likely to carry their pregnancies to term than

those who do not have friends who are parents

(50a,148).

Pregnant adolescents who receive early and regular prenatal care that is appropriate to their level of

risk are more likely to have healthy birth outcomes

than those who do not, but gaining access to prenatal

and perinatal services seems to be a problem for

many adolescents. As noted above, about half of

pregnant 15- to 19-year-olds in 1988 did not receive

prenatal care in the first trimester of pregnancy

(207b). One of the factors influencing adolescents’

(and other women’s) use of prenatal and other

maternity care is the availability of a payment

source.

33 Because of a loophole in the regulations

issued under the Pregnancy Discrimination Act of

1978 (Public Law 95-555), almost one-third of

privately insured adolescents are not covered for

maternity-related services by their parents’ employ30~ou~ ~ouces of suppo~, ~clufig Aid t. F~ies Witi Dependent Ctildren (AFIX), are discussed below.

slFor ~er dis~~ssi~n of tie role p~en~ play ~ adolescents’ healh Care decisions, SW ch. 3, “Parents and Families’ Influence on Adolescent

Health+” in this volume, and ch. 17, “Consent and Confidentiality in Adolescent Health Care Decisio~g, ” in Vol. Ilr.

szAdolescents’ access t. a~fion is discussed ~ tie s~tion of ~s c~pter below entitled “prOgraIIM That Offer Alternatives tO Parenthood.’

33s& ch. 16, ‘ ‘Financial Access to Health Services, ‘‘ in Vol. III. Also see OTA’s 1988 report Healfhy Children: Investing in the Future (199).
II-348 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

ment based health plans.34 Pregnant adolescents

without private health insurance who rely on Medicaid and other Federal and maternal and child health

programs to pay for their maternity care may also

experience access problems.35

As noted earlier, few adolescent mothers are able

to support themselves and their children during the

first few years of parenthood (195a). Other sources

of economic and social support, therefore, can have

a great impact on outcomes for adolescents who bear

and keep their children (128,148). AFDC benefits

are an alternative source of economic support for

unmarried (and some married) adolescent mothers.

CBO’s analysis of NLSY data found that about half

of all adolescent mothers received AFDC benefits

sometime during the 5 years after they first gave

birth, but that most were not covered by AFDC for

at least some time during those 5 years (195a).36

Overall, CBO found high levels of poverty among

adolescent mothers, particularly those who were

unmarried (195a). Almost half of all adolescent

mothers, and 81 percent of unmarried mothers living

with only their children, had family cash incomes

below the poverty line in 1985 and 1986 (195a).

Based on the level of poverty among adolescent

mothers and an analysis of available sources of

support, CBO concluded that many of the economic

problems of adolescent parenthood could be eased if

young mothers had more resources available to

support their families (195a). Improvements discussed by CBO included programs to improve the

mothers’ earning ability, programs to raise the

amount of support provided by young fathers or

other relatives, and programs to expand the benefits

offered by Federal and State governments (195a).

Demographic Differences Related to Adolescent

Pregnancy and Pregnancy Outcomes

As noted elsewhere in this Report, in 1988, more

than 8 million (26.7 percent) of the country’s 31

million adolescents lived in a poor or near-poor

family. 37 Poor and near-poor are terms defined in

relation to the Federal poverty level, a cash income

level which varies with family size and the age of

family members. Poor families are those with

incomes below the Federal poverty level, and

near-poor families are those with incomes between

100 and 149 percent of the Federal poverty level.

The health and other effects of growing up poor

are complex and not well understood, but because

poverty is often associated with a low educational

level, substandard living conditions, an inadequate

social support network, poor nutrition, unemployment, and diminished access to health care, children

growing up in poor or near-poor families probably

confront more risk factors and benefit from fewer

protective factors than their more advantaged peers.

Children and adolescents living in single-parent

households headed by a female are disproportionately poor. In 1988, nearly two-thirds of U.S.

adolescents who lived with their mothers only lived

in poor or near-poor families. U.S. adolescents from

racial and ethnic minority groups are also disproportionately poor. In 1988, about half of black, nonHispanic adolescents, half of Hispanic adolescents,

half of American Indian and Alaska Native adolescents lived in poor or near-poor families.38 Among

white, non-Hispanic U.S. adolescents, less than

one-fifth lived in poor or near-poor families.

As discussed elsewhere in this Report, data and

research on the health status of poor adolescents and

on the health effects of poverty have major limitations. How adolescents’ social class and race/

ethnicity are related to pregnancy-related behaviors

such as the initiation of sexual activity and contraceptive use, to pregnancy, or to pregnancy outcomes

such as abortion, childbearing, or parenting is not

entirely clear. Studies showing differences between

adolescents of different socioeconomic statuses or

racial or ethnic backgrounds are discussed below.

Many of these studies differ among themselves,

depending on factors such as the following:

~For tier di~cu~ion,~= tie section of this c~pter below entitled, ‘ ‘Programs Designed To Prevent Negative Outcomes of Adolescent ~“egnancY

and Parenting, ’ and ch. 16, ‘‘Financial Access to Health Services, ’ in Vol. III.

sSFor f~er discussion, s= tie section of ~s c~pter ~low enti~ed ‘ ‘Mjor Federal programs ad POllCieS PertaiIli13 g to Adolescent Pregnancy and

Parenting,’ and ch. 16, “Financial Access to Health Services, ” in Vol. III.

36cB0 feud that nearly 40 percent of recipients who were not married when their children were born left the AFDC program within 1 year and more

than 70 percent left within 4 years, as compared with about 70 percent and 90 percent, respectively, of their married counterparts (195a).

JTs= ch. Is, 4 ‘Issues in tie Delivery of Health and Related Services to Selected Groups of Adolescents, ’ in vo1. m.

38s= Ch. lg, { ‘15Sues ~ tie Delivery of He~~ and Related Services to Selwted Groups of Adolescents, ’ in VO1. ~ for filllk dhKXISSIOn.
Chapter l&Pregnancy and Parenting: Prevention and Services . //-349

●

●

●

●

the behavior or outcome that is investigated

(e.g., sexual activity v. contraceptive use v.

childbearing);

the specific races and/or ethnic backgrounds

that are compared;

the measure of socioeconomic status that is

used (e.g., various measures of the socioeconomic status of the family of origin, various

measures of socioeconomic status of the impregnating male, the adolescent’s anticipated

social class, education levels, job categories39);

and,

perhaps most importantly, the number and

types of factors that are simultaneously investigated, and subsequently statistically controlled,

in the study .40 4*

In addition, it should be understood that studies

finding differences by race/ethnicity or socioeconomic status have to be interpreted sensitively.

While such findings can be used to target specific

groups of adolescents for services, they may not be

helpful in determining the precise causes of adolescent pregnancy or variations in pregnancy-related

outcomes in specific groups or in individual adolescents. These determinations typically require further

study, 42

Socioeconomic Differences Related to Pregnancy and Pregnancy Outcomes—Available data

discussed below suggest that adolescents from

socioeconomically disadvantaged families are at

greater risk of nonmarital pregnancy and parenting

than adolescents from nondisadvantaged families. In

comparison to their more advantaged peers, these

adolescents tend to initiate sexual activity at an

earlier age, are less likely to use contraceptives when

sexually active, are less likely to have an abortion,

and are more likely to give birth to children out of

wedlock. They also seem to be less likely to give

their babies up for adoption.

Socioeconomic Differences Related to Pregnancy----

Data from the NLSY indicate a relationship between

adolescents’ mothers’ level of schooling, which is

one measure of socioeconomic status, and the age at

which adolescents initiate sexual activity (148). The

1982 NLSY included a sample of 4,657 males and

4,648 females who were age 20 and over at the

survey date. Among male adolescents whose mothers had some education beyond high school, 56

percent engaged in sexual intercourse before age 18,

in comparison with 72 percent of male adolescents

whose mothers did not complete high school.

Among female adolescents whose mothers had some

education beyond high school, 34 percent became

sexually active before age 18, in comparison with 54

percent of female adolescents whose mothers did not

complete high school (148).

Other investigators have found that adolescents’

anticipated social class (as measured by their

educational aspirations) has a greater effect on the

initiation of sexual activity than does their current

socioeconomic status. Adolescents who expect to

complete more years of schooling are more likely to

delay the initiation of sexual intercourse than

adolescents who expect to complete fewer years of

school (135a). And, not surprisingly, other investigators have found that the social class of the family

of origin and the adolescent’s anticipated social

class both influence the initiation of sexual activity

(139,144,183,192,234). However, parental expectations of an adolescent’s sexual behavior have also

been found to have an independent influence (52a).

Studies that have investigated the relationship

between socioeconomic status of the adolescent’s

family of origin and the use of contraceptives have

found results similar to those for initiation of sexual

intercourse: adolescents from socioeconomically

disadvantaged families are less likely to use contraceptives than those from those from nondisadvantaged families (152). Adolescents’ socioeconomic

status has not been found to have as much impact on

adolescents’ contraceptive use as adolescents’ age at

the time of initiation of sexual activity, adolescents’

attitudes about contraception, pregnancy, abortion,

education, frequency of intercourse, and some of the

other individual factors discussed earlier (85). Howsp~ese measures are themselves often highly intercorrelated.

40 For e~ple, ifa study o~y co11ect5 ~~on the race, but not the socioeconomic status, of adolescents in the sample, it will not be able to distinguish

outcomes by social class from outcomes by race.

411n some studies, soclmconomlc s~tus and race/ethnicity appear to affect pregnancy-related behaviors and outcomes independer@, but closer

inspection sometimes reveals a multiplier effect of economic disadvantage (e.g., 140). Some observers believe that attempts to control for socioeconomic

differences when comparing black and white adolescents have been inadequate, as they do not account for the time spent in poverty and disparity between

blacks and whites in categories of socioeconomic status (148).

4~For fuficr discussion, sec Ch. 18’ “Issues in the Delivery of Services to Selected Groups of Adolescents, ” in Vol. III.
11-350. Adolescent Health—Volume II Background and the Effectiveness of Selected Prevention and Treatment Services

ever, the influence of an adolescents socioeconomic

status may be felt in terms of access to contraceptives and the availability of contraceptives (97a) .43

Socioeconomic differences in rates of sexual

activity and in the use of contraceptives would lead

naturally to findings that adolescents of lower

socioeconomic status are also more likely to become

pregnant. To OTA’s knowledge, there is little

information directly on this point. Information on

pregnancies and pregnancy rates by adolescents’

socioeconomic status is not readily available. In an

analysis of 1979 data from the NLSY, however,

Mott and Haurin found that the lower the family

income of female adolescents and the less the

mother’s education, the more likely an adolescent

was to report a first pregnancy prior to age 16 (144b).

Socioeconomic Differences Related to Pregnancy

Outcomes—As noted earlier, the major Federal

report on health indicators in the United States—

Health United Slates--does not tabulate data on

birth rates by income or other factors indicative of

socioeconomic status. There is some evidence that

pregnant adolescents of lower socioeconomic status—

as measured by family income (61) and other

factors—are more likely to carry their pregnancies to

term than other adolescents of higher socioeconomic

status, regardless of their race (86a). One hypothesis

to explain apparent social class differences in

childbearing is that having babies is a rational

response to poverty for poor adolescents, in that by

having children poor adolescents may gain access to

family networks and support programs that otherwise may not be available to them. Several studies

have suggested that childbearing may mobilize

supportive responses from family, peers, and others

(e.g., social programs, including mentoring or educational programs) (19,72,122).44 Another hypothesis

might be that adolescents from low-income families

have less access to abortions than other adolescents.

A number of researchers have found that poverty

and poor employment opportunities are closely

associated with out-of-wedlock births (148). The

1988 National Survey on Family Growth found that

among U.S. females, females ages 15 to 19 and

females with family incomes below the Federal

poverty level had the highest rates of unintended

births (59a) .45 Reports from this survey did not

combine the factors of age and socioeconomic status

to give an estimate of childbearing by socioeconomic status for adolescents (59a). In the 1988

National Survey of Family Growth, 72.6 percent of

the 15- to 19-year-old females who gave birth

between 1984 and 1988 and 60 percent of females

with incomes under the poverty level reported that

their pregnancies were unintended (59a).46

Some observers have also expressed concern that

the conditioning of social benefits on the presence of

children in the family may encourage poor people to

have children. The largest cash assistance program

serving poor families with children is the AFDC

program administered by the Family Support Administration in DHHS.47 For the first 25 years of

AFDC, if a father lost his job and his family became

needy, State AFDC programs were forbidden to help

the family so long as the father lived at home (195d).

(In 1961, in an antirecession measure, the law was

changed so that families with jobless fathers at home

could qualify for AFDC at a State’s option (195d).)

This arrangement has been believed by some to have

encouraged out-of-wedlock childbearing and single43MOUS pmWWs ktend~ to i.ncrwe low-income adolescents’ access to contraceptives are discussed lam iII this Cbt=.

~~ol=untsfim ftili=ofhi~er soci~onomic StatUS may also bear children in order to receive support and attention from fdy~tikds.

qsunintendedbir;~ we a comb~tion of bti resulting from pregnancies thiN are “mktknd”h“Ullw~td” (59a).

46~oW fe~esof~ ages who gaveb~~~epfiod 19&$to 1988, me p~en~geof b~~tw~e ~t~d~ decreased with increasing income

level. Almost 60 percent of births to females with incomes under 100 percent of the Federal poverty level wae unintended, as compared to 42.7 percent

of births among women with incomes between 100 and 199 percent of the poverty level, and 31.8 percent among woma with incomes over 200 percent

of the poverty level.

dT~~d v~o~ o~er F~e~prow- of ~lmmce or ~ten~relev~ce to poor ~olescents me described at greater l~gthkch. 18, “ISSU~

in the Delivery of Services to Selected Groups of Adolescents, “ in Vol. III. For a further discussion of Medicaid, also see ch. 16, “Financial Access

to Health Services,” in Vol. KU.

48A rWat Welfae refom law, the F~y Suppofl Act of 1988 (~blic ~w 100-4$5), ~ter~ tis _ment by requiring thN dl S@&S titOx

AFDC programs provide AFDC to tw~parent families who are needy because of the unemployment of the principal wagecarne r-the so-called

AFDC-UP (Unemployed Parent) provision (195d). The unemployed parent must meet certain requirements pertain@ to previous employmmt and is

requirtxl to search for a job or participate in the Job Opportunities and Basic Skills (JOBS) program (195d), but overall, this provision does provide

greater support for the possibility of a father living with an adolescent mother and their children). It is too early to be able to assess the effects, if any,

of changes in social welfare program eligibility requirements on rates of out-of-wedlock childbearing among adolescents. For further discussion of AFDC

and the JOBS program, see the section on Federal policies and programs related to adolescent pnqpancy and parenting below.
Chapter 10--Pregnancy and Parenting: Prevention and Services ● II-351

parent households.48 Some evidence suggests, however, that birth rates are not related to potential

receipt of welfare benefits; real reductions in the

level of welfare benefits since the mid-1970s have

not resulted in decreases in single-parent families,

nor is single-parenthood related to differences in

levels of welfare benefits across States (14a).

Data on the number of abortions or abortion rates

by adolescents’ socioeconomic status are not available. Some observers believe that socioeconomically disadvantaged adolescents who become pregnant are less likely to have an abortion than their

more advantaged peers, as they may have problems

of access (especially financial) to abortions (13,232).

Federal funding for abortion as a method of family

planning has statutorily been prohibited for several

years.

49

The few studies that have been conducted on

adoption among adolescents indicate that adolescents who make adoption plans tend to be of higher

socioeconomic status (17 la). A recent study on the

characteristics of adolescents who choose to give

their child up for adoption indicate differences

between adolescents of different social classes:

adolescents from families of higher socioeconomic

status are more likely to choose to put their child up

for adoption than adolescents from disadvantaged

families. In addition, adolescents who have higher

educational aspirations, which has been linked to

social class, are more likely to put their child up for

adoption (19a).

Racial Differences Related to Pregnancy and

Pregnancy Outcomes--As discussed further below,

there are large racial differences in patterns of sexual

activity, contraceptive use, birth rates, and out-ofwedlock childbearing rates. According to the National Academy of Sciences’ comprehensive 1987

report on adolescent pregnancy and childbearing,

what accounts for these differences is not at all clear

(148). Some observers attribute the racial differences wholly or in part to socioeconomic differences

among blacks and whites; others maintain that the

differences are primarily attributable to differences

in the acceptability of early nonmarital sexual

activity, pregnancy, and parenthood. Research has

not yet resolved this controversy (148).

Racial Differences Related to Pregnancy—

Available data indicate that black adolescents in this

country tend to initiate sexual activity at earlier ages

than white adolescents and that the proportion of

black U.S. adolescents who are sexually experienced

is greater than the proportion of white U.S. adolescents who are sexually experienced at every age of

adolescence (16a,59a,86a,151,152,235). National data

from 1984 and 1988 show that among U.S. adolescents who have had sexual intercourse, black males

initiated intercourse 2 years earlier than whites and

black females initiated intercourse 1 year earlier than

whites (129,187). The 1988 National Survey of

Family Growth found that the percentage of 15- to

19-year-old black, non-Hispanic females who had

ever had sexual intercourse was 60.8 percent (59a),

somewhat higher than the percentage of 15- to

19-year-old white non-Hispanic females who had

ever had sexual intercourse (52.4 percent).

The National Survey of Adolescent Males found

that 19.8 percent of black non-Hispanic adolescent

males surveyed reported that they had had their frost

sexual intercourse by age 12 or under, an average of

2 years younger than white non-Hispanic and

Hispanic males (187). Almost half (47.8 percent) of

the black non-Hispanic males in this survey reported

having had their first sexual intercourse by age 14

(187). These data should be viewed with some

caution because the question about age of first

sexual intercourse was asked of males who were

already ages 15 to 18; however, the results are

consistent with other findings about the early

initiation of sexual intercourse among black children

and adolescents of both sexes. In addition, black

non-Hispanic males reported having had more

sexual partners in their lifetimes than did white

non-Hispanic and Hispanic males (187).50

Researchers disagree on the reasons for racial

differences in the timing of the initiation of sexual

intercourse and proportion of sexually active adoles-

@Feder~ reWlatiom issued by DHHS in 1988 also prohibit abortion counseling and referrals by fa.m~y pl arming clinics receiving funds under Title

X of the Public Health Service Act. For further discussion of Federal policies relatd to abortion, see the section below on Federal policies and programs

related to adolescent pregnancy and parenting.

won ~vaage for agw 15 t. 19 @en toge~er, black non.~spmic ties reported ~v~g ~d an average of 8.3 sexual partners, compared to 4.29

partners for white non-Hispanic males and 5.15 partners for Hispanic males (187). The measure of variability (i.e., the range in the number of partners

across surveyed males) was greatest for black non-Hispanic males (standard deviation of 18.62 for 15- to 19-year-olds), second greatest for Hispanic

males (standard deviation of 12.13 for 15- to 19-year-olds), and lowest for white non-Hispanic males (standard deviation of 6.71 for 15- to 19-year-olds)

(187).
II-352 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

cents (148). There is some evidence that black

females mature at earlier ages than white females

(43,75 b), but the physical differences between black

and white females are too small to account for the

greater differences in age of initiation of sexual

activity (139a,148). Furthermore, in the case of

white females, the effect of biological factors on the

initiation of sexual activity seems to be strongly

mediated by factors in the individual’s social environment (148). Some studies have found that neighborhood environments are very important in influencing adolescents’ decisions to initiate sexual

behavior (9c,148). Several studies suggest that when

comparisons are made among adolescents of similar

socioeconomic status, there is no significant difference between the ages at which blacks and whites

initiate sexual activity (35,68,144a,185). A few

studies have found, however, that even after controlling for social class (148) and mother’s level of

education (86a), racial differences still exist between

blacks and whites in the age of first intercourse.51

Overall, most of the available research indicates

that black adolescent females are less likely to use

contraception than white adolescents. Given that

black adolescents are more likely to initiate sexual

activity at an early age and that young adolescents

are less likely to use contraception than older ones,

this general finding is not unexpected. It is important

to note, however, that one investigator found that in

the majority of the research on contraceptive use,

blacks are inadequately represented and race is

confounded with socioeconomic status (142).

The 1988 National Survey of Family Growth

found that the percentage of black non-Hispanic

females ages 15 to 19 who used some contraception

at first intercourse (one, but not the only, indicator of

contraceptive use) was 54.1 percent, an increase

from 35.8 percent in 1982 but somewhat lower than

the percentage of white non-Hispanic adolescents

who used some form of contraceptive at first

intercourse (69 percent) (59a). If one controls for

socioeconomic status when comparing contraceptive practices at first intercourse, one finds that

blacks more often use a prescription method of

contraception (e.g., the pill, a diaphragm) than their

white counterparts (234). Zelnik and Shah found that

among adolescents who used contraception at first

intercourse, 41 percent of black adolescents used a

prescription method of contraception, as compared

with 15 percent of white adolescents (234). Definitive calculations of prescription contraceptive use

are not available from the National Survey of Family

Growth, but National Survey of Family Growth data

do indicate that 15.7 percent of black, non-Hispanic

females, as compared with 7.1 percent of white,

non-Hispanic females, used the pill at first intercourse (59a).

Among U.S. adolescents who do not use contraception at first intercourse (if one does not take

socioeconomic status into account), black adolescents have been found to take longer to begin using

contraception than white adolescents (85). In the

recent National Survey of Adolescent Males, however, black non-Hispanic males generally reported

greater use of contraceptives at their last intercourse

before the survey (one measure of current contraceptive use) than did white non-Hispanic or Hispanic

males (186b).52

Several studies indicate that examinations of

differences in contraceptive use must examine

factors other than race. Two studies found that black

adolescents whose parents had high levels of education used contraception more regularly than black

adolescents whose parents were less educated (38,235).

Another study looked at how black females perceived opportunities in nonreproductive roles; those

with better perceived opportunities were more likely

to be regular contraceptive users (146a).

National data on pregnancy rates among black

adolescents are not available, but the numbers of

births and abortions in the black adolescent population53 (see below) suggest that pregnancy rates

51 Some obse~ers have m~~ that effofi~ to control for social class in some studies are inadequate (e.g., because they do not account fOr the ,amo~t

of time spent in poverty and other factors) (148).

5z~i5 fimd~g ~m Wc overall and for the use of ‘condoms dOIIe or with other ‘etiods$ ‘‘ the latter of which was reported by 65.5 percent of black

non-Hisp,anic males ages 15 to 19 combined, compared to 54.4 percent of white non-Hispanic males, and 53.0 percent of Hispanic males in that age group

(186b). Black male 15- to 19-year-olds, however, reported somewhat less use of an “effective female method [e.g., oral contraceptives, diaphra~

intrauterine dcvicc, sponge) without a condom’ (14.5 percent) than did white non-Hispanic (22.2 percent) or Hispanic (15.6 percent) male 15- to

19-year-olds in this survey (186b). Only 20 percent of black 15- to 19-year-old males reported the use of ineffective or no contraceptive methods at last

intercourse (186b).

5SAS noted Cti]ier, the num~rs of bi~and abofi~m along with miscarriages and stillbirths, are used to Htimiik the IIUI_IIbtY of pre~cies ~d

pregnancy rates in a given population.
Chapter 10-Pregnancy and Parenting: Prevention and Services . 11-353

among black adolescents are substantially higher

than pregnancy rates among white adolescents

(52a,214). In 1987, the estimated pregnancy rate for

white 15- to 19-year-olds was 90 pregnancies per

1,000 population; for “nonwhite’ adolescents (including black, Asian, and other adolescents) in the

same age group, the rate was 189 pregnancies per

1,000, more than twice the rate for white adolescents

(8a).

What accounts for the higher rates of pregnancy

among black adolescents is not entirely clear. One

survey of pregnant adolescents found that 70 percent

of the blacks surveyed expected a favorable reaction

about their pregnancy from their peers and 65

percent expected that they would get a favorable

reaction from the father of their child; only 40

percent and 43 percent of whites, respectively, felt

that they would receive favorable reactions (148). A

number of studies reveal that black adolescents

prefer earlier age for first birth than marriage, while

white adolescents prefer earlier age for marriage

than for first birth (148,224a). The degree to which

differences in values and attitudes affect differences

in sexual activity is questionable, as often such

attitudes are measured after sexual experience, and

thus the attitudes expressed may be a reflection of

this experience (86a). In addition, the impact of

socioeconomic and subcultural differences in attitudes is not clear from this body of research.

One recent study of 1,590 inner city females ages

13 to 18 who used health clinics, most of whom were

black and from single-parent low socioeconomic

status homes, found that sexually active females

came from more psychosocially disadvantaged backgrounds than their sexually inactive peers (187a).

The females who became pregnant were from

significantly less stable homes than either the

never-pregnant but sexually active females or the

sexually inactive females.

Racial Differences Related to Pregnancy Outcomes—

Black adolescent females in the United States have

dramatically higher birth rates than adolescent

females of all races or white adolescent females. In

1988, as noted earlier, the birth rates among U.S.

females were under age 20 were as follows:

● 10- to 14-year-olds: all races, 1.3 births per

1,000 females, with whites at 0.6 births per

1,000 and blacks at 4.8 births per 1,000;

. 15- to 17-year-olds: all races, 33.8 births per

1,000 females, with whites at 25.5 births per

1,000 and blacks at 76.6 births per 1,000; and

● 18- to 19-year-olds: all races, 81.7 births per

1,000 females, with whites at 69.2 births per

1,000 and blacks at 150.5 births per 1,000

(202f).

During the 1970s and early 1980s, there was a

substantial decline in birth rates among black U.S.

females under age 20 (202 f). By 1984, birth rates

among black U.S. females had dropped to 4.3 births

per 1,000 10- to 14-year-olds, to 69,7 births per

1,000 15- to 17-year-olds, and to 132 births per

1,000 18- to 19-year-olds (202 f). Since 1984,

however, birth rates among black U.S. adolescent

females have been steadily increasing (202f). In fact,

birth rates among black U.S. adolescents in 1988

were at their highest levels in about a decade (202 f).

The reasons are not clear.

Differences in out-of-wedlock childbearing among

black and white U.S. females under age 20 have also

been narrowing in recent years, but they are still

striking (see figure 10-1 1). Very few births to black

adolescents are to adolescents who are married. The

reasons are unclear, although various explanations

have been offered. The shortage of black males able

to provide sufficient economic support to a family

(e.g., because of unemployment and economic

disadvantage) may partially account for the high

rates of out-of-wedlock births among poor black

adolescents (148). Furthermore, black adolescents

are significantly more likely than whites to live in

low-income communities in which rates of unemployment are high and poor, mother-headed families

have been prevalent for generations (148). When

asked, blacks in these communities report a greater

tolerance for sexual activity outside a marriage and

a greater tolerance for nonmarital childbearing

(148). Whether these attitudes reflect deepseated

subgroup values or are transient responses to economic circumstances is not known (148). Some

observers believe that differences in attitudes are

affected by the differential economic histories of the

races, in that chronic economic disadvantage affects

attitudes toward marriage and family (1,140).

Data on 1985 abortion rates for whites and

‘‘nonwhites’ (a group that includes blacks, Asians,

and other groups) are available from the Alan

Guttmacher Institute. These data indicate that 1985

abortion rates among females under age 15 were 5.0

abortions per 1,000 population for whites and 27.0

abortions per 1,000 population for nonwhites; for
II-354 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

100

80

60

40

20

Figure 10-1 l—Trends in Out-of-Wedlock Childbearing Among U.S. Females Under Age 20 by Race, 1969-67

White females Black females

Percentage of all births outside of marriage

I

100

80

60

40

Percentage of all births outside of marriage

[

o~-1

1969 1972 1975 1978 1981 1984 1987

Year

++ Under age 15 ~ Ages 15

20 1 I

o~J

1969 1972 1975 1978 1981 1984 1987

Year

to 17 K Ages 18 to 19

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Services, Public Health Service, Centers for Disease

Control, National Center for Health Statistics, Division of Vital Statistics, Vita/Statistics otfhe UnitedStates, Volume l: Nata/ifv(Washinaton. DC:

U.S. Government Printing Office, various years).

females ages 15 to 19, the rates were 71.1 abortions

per 1,000 population for whites and 127 abortions

per 1,000 population for nonwhites; for females ages

18 to 19, the rates were 55.4 abortions per 1,000 for

whites and 97.1 abortions per 1,000 for nonwhites

(81a).

Data from the National Center for Health Statistics in DHHS suggest that black adolescent females

who become pregnant are slightly less likely to have

an abortion than their white peers are (148). In 1983,

40.5 percent of pregnancies of white adolescents and

38.1 percent of pregnancies of black adolescents

ended in abortion (148). Because rates of unintended

pregnancies are higher among black adolescents

than among white adolescents, however, black

adolescents have much higher population-based

abortion rates than white adolescents (148).

As noted earlier there is no national system for

collecting information about U.S. females who carry

their pregnancies to term and give their babies up for

adoption (148). Thus, national information concerning black adolescents who give their babies up for

adoption is not available. A study in 1982 estimated

that 93 percent of unmarried black mothers ages 15

to 19 kept and raised their children (12,148). In some

cases, grandmothers, other relatives, or friends

assumed responsibility for a child’s care (12).

. . “.

Ethnic Differences Related to Pregnancy and

Pregnancy Outcomes-Data on adolescents of

Hispanic origin typically includes both black and

white Hispanics. According to the report by National

Academy of Sciences’ Panel on Adolescent Pregnancy and Childbearing, national data describing

ethnicity began to be available only in the 1970s, as

some subgroup--especially Hispanics--became more

prominent minorities in this country (148).

Ethnic Differences Related to Pregnancy-Data

on Hispanics are collected in recent surveys of

sexual and fertility behavior, but the samples are

often too small to permit disaggregation of the data

by age (148). Thus, according to the National

Academy of Sciences’ Panel on Adolescent Pregnancy and Childbearing, information on Hispanic

adolescents’ sexual activity and fertility behavior is

incomplete and not comparable to information for

racial subgroups (148).

Some studies have found that Hispanic adolescents initiate sexual intercourse at roughly the same

ages as non-Hispanic white adolescents (l2a,141a,187).

The 1988 National Survey of Family Growth found

that 49 percent of 15- to 19-year-old Hispanic

females said they had ever had sexual intercourse,

slightly lower than the percentage of 15- to 19-yearold non-Hispanic white females (52.4 percent) who

said they had had intercourse (59a). The percentage
Chapter 10-Pregnancy and Parenting: Prevention and Services . II-355

of 15- to 19-year-old Hispanic females who reported

they had ever had sexual intercourse in 1988 was

slightly lower than the percentage in 1982 (59a). The

1988 National Survey of Adolescent Males found

that 19 percent of Hispanic males reported having

had sexual intercourse by age 14 and 81 percent

reported having had sexual intercourse by age 18

(187). These were similar to the percentages for

white non-Hispanic males but far lower than those

for black non-Hispanic males (187).

The 1983 NLSY, which interviewed a sample of

683 Hispanic males and 703 females who were age

20 and over at the survey date, found that 50 percent

of the males and 24 percent of the females reported

that they were sexually active by age 17; 67 percent

of the males and 40 percent of the females reported

that they were sexually active by age 18 (148).

Although Hispanic adolescent females may be

slightly less likely than non-Hispanic whites to be

sexually active, they are considerably less likely to

be using contraception. The 1988 National Survey

of Family Growth found that the percentage of 15-to

19-year-old Hispanic females who used some form

of contraception at first intercourse was 54 percent,

while the percentage of white non-Hispanic adolescents who used some form of contraception at first

intercourse was 69 percent (59a).

National data on pregnancy rates among Hispanic

females are not available. In a 1982 study among

unmarried Hispanic females ages 15 to 19, however,

15 percent reported having experienced a pregnancy

(144). This percentage falls between that reported by

unmarried, white non-Hispanic adolescents (8 percent) and that reported by same-age non-Hispanic

blacks (23 percent).

Ethnic Differences Related to Pregnancy Outcomes—

Data on ethnicity have been included in vital

statistics reports published by the National Center

for Health Statistics in DHHS only since 1978 (148).

National natality statistics are somewhat limited

because States do not always report the Hispanic

origin of the parents on a child’s birth certificate.54

Further, many different nationalities and cultures are

often subsumed under a single ethnic category (e.g.,

Hispanic), obscuring diversity within the category .55

Data concerning birth rates among Hispanic adolescents are still somewhat incomplete and have only

been collected during the past decade.

In 1980, the overall birth rate for Hispanic

adolescents was about double the rate for nonHispanic whites and about four-fifths the rate for

non-Hispanic blacks (194). DHHS is unable to

calculate population-based birth rates for Hispanic

adolescents for the years 1980 to 1988 because truly

national data on Hispanic births are not currently

available (207 b). However, DHHS estimated that in

1988 about 1 in 6 Hispanic-origin births was to a

teenage mother in 1988, as compared with 1 in 10

white births and 1 in 5 black births (table 10-1)

(207b).56 In the States for which data were available

in 1988, there were 73,858 births to Hispanic

females under age 20 (207b). According to DHHS,

the incidence of adolescent childbearing among the

various Hispanic groups varies widely: in 1988, 17

percent of Mexican births and 21 percent of Puerto

Rican births, as compared with 6 to 8 percent of

Cuban and Central and South American births, were

births to adolescent mothers (207b).

Data collected since 1980 suggest that there has

been an increase in the percentage of births that are

out-of-wedlock births among Hispanic adolescents

ages 15 to 19, from 43 percent of births to these

adolescents in 1980 to 52 percent in 1985 (la). In

1986, 55 percent of births to Hispanic adolescents

were out-of-wedlock as compared with 46 percent of

births to white adolescents and 91 percent of births

to black adolescents (205).

National data on Hispanic adolescent mothers

who have abortions or who carry their pregnancies

to term and give their children up for adoption are

not available (148). In 1985, a tabulation by the Alan

Guttmacher Institute of national survey data of

abortion patients indicated that 50 per 1,000 Hispanic adolescent females ages 15 to 19 had abortions, as compared with 38 per 1,000 non-Hispanic

whites and 53 per 1,000 nonwhites (8).

541n 1988, ’30 states ~d fie Di~&lct of Columbia repofied he Hisp~c ofigin of tie p~ents On tie bfi ce~lcate; thiS WIS UI hlCICilSC? Of 7 S~tt2S

over the number reporting this information during the years 1983 to 1987 (207b). According to 1980 census data however, these 30 States contained

95 percent of the Hispanic-origin population (207b).

55~e Natio~ Center for Ha]~ Statistics’ 1988 repofi on na~li(y statistics did repofi Mtio~ Ofigin (e.g., M@c~ ~mo ~c~, Cub- Cenh_ld

and South American) of Hispanic mothers, as available from the States that reported information on parents’ Hispanic origin (207b). However, these

data were not further disaggregate by mother’s age.

fiHisp~C ~d nOmI-IispaniCs are included in these estimates for whites md blacks (207b),
II-356 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

According to DHHS, the number of births to

Asian and Pacific Islander adolescents in 1988 was

8,056 (207b). The lowest numbers of births to Asian

and Pacific Islander adolescents were to Chinese and

Japanese adolescents (243 and 295 births respectively). DHHS reported that there were 1,181 births

to Hawaiian adolescents, 1,527 to Filipino adolescents, and 4,810 to “other” Asian and Pacific

Islander adolescents. It is not possible to calculate

accurate current pregnancy or birth rates for Asian

adolescents (212).

The number of births (8,455) to American Indian

and Ala&u Native adolescents in 1988 was quite

high in proportion to such adolescents’ representation in the population (207b). Estimates of the

American Indian and Alaska Native population are

difficult to make, but if, as OTA estimates, there are

approximately 100,000 American Indian and Alaska

Native females ages 15 to 19 (199a), the birthrate for

this group would be 83 births per 1,OOOpopulation—

about 1.5 times that of all U.S. adolescents ages 15

to 19 combined, almost twice (1.9 times) the birth

rate for white adolescents ages 15 to 19, and

three-quarters the birth rate for black adolescents

ages 15 to 19.

Prevention of Adolescent Pregnancy and

Associated Negative Outcomes

Preventive programs related to adolescent pregnancy and parenting generally focus either on

preventing the occurrence of adolescent pregnancy

or on the provision of services designed to prevent

possible negative outcomes of early pregnancy and

childbearing. Both types of efforts and available data

on their effectiveness are discussed below.

Programs That May Help Prevent

Adolescent Pregnancy

Over the past 20 years, there has been dramatic

growth in the number and variety of interventions

aimed at preventing adolescent pregnancy (147a, 148).

According to Dryfoos, programs aimed at preventing adolescent pregnancy in this country are of three

general types:

●

●

●

The

those that seek to impart knowledge or influence adolescents’ attitudes about sexual behavior, human relationships, reproduction, and

contraception;

those that seek to improve sexually active

adolescents’ access to contraceptives; and

those that seek to enhance young people’s life

options by providing work opportunities or

other alternatives to early pregnancy and childbearing (45,148).

first two types of programs are the most

common (45). These focus on increasing adolescents’ ability to prevent a pregnancy, either by

abstaining from sexual intercourse or by using

effective contraceptive methods. The third type of

program is intended to affect adolescents’ motivation for avoiding early pregnancy and childbearing

(45).57 A recent addition to motivational programs

are programs that pay adolescents who have been

pregnant already to avoid repeat pregnancies (e.g.,

101)0

Few programs to prevent adolescent pregnancy

have been rigorously evaluated in methodologically

sound studies (28,47a). Producing scientific evidence about what works in preventing adolescent

pregnancy requires measuring changes in adolescent

pregnancy rates and attributing those changes to

some program or curriculum (47a). Because of the

difficulty of measuring pregnancies, surrogate measures (e.g., self-reports of sexual activity, knowledge

and beliefs about sexual activity, birth rates) are

often used. Questions have been raised about the

reliability of self-report data; about the relationships

between adolescents’ knowledge, attitudes, intentions, and behavior; and about the validity of birth

rates as an indicator of the effects of adolescent

pregnancy prevention efforts.58

Even in programs where information on pregnancy rates is collected, observed reductions in the

pregnancy rate may be due to factors other than the

preventive intervention. Ruling out this possibility

requires rigorous evaluation research. Rigorous

evaluation research is costly, however, particularly

when a longitudinal research design is required to

57sOme Pregwcy prevention effofis cOmb& aspects of these three general strategies. Thus, fOr example, pmWams tit aim to Prevent Pm~cY

by enhancing young people’s life options are likely to include discussions of family life and sexuality as part of their efforts. Educational programs that

seek to increase knowledge and influence attitudes may also attempt to affect adolescents’ motivations to avoid sexual activity or pregnancy.

58 DWl~es ~ teemge b~ rates cm & due to many factors ~elated to p~gnancy p~vention efforts. Swden, for example, experienced a profound

decline in teenage birth rates during the late 1970s and 1980s that was due largely to an increasing tendency of women to marry and have children later

in life to be able to take advantage of wider educational and career options (74a). Declining birth rates can also be due to the increased use of abortion.
Chapter l&Pregnancy and Parenting: Prevention and Services . //-357

determine long-term impacts on fertility behavior

(88,149). Also, although experimental research can

provide the most solid evidence of the impact of

preventive interventions, there are often methodological or perceived ethical problems associated

with creating control groups. For example, researchers may have problems deciding which adolescents

should be given access to contraceptive education or

health services. More frequently, methodological

problems arise because prevention messages are

delivered to groups that are hard to compare, or

recipients of services are self-selected.

The paucity of systematic evaluations of the

effectiveness of strategies for preventing adolescent

pregnancy was noted in the 1987 report by the

National Academy of Sciences’ Panel on Adolescent

Pregnancy and Childbearing (148,149). That report

nevertheless concluded that there was adequate

knowledge on which to base some recommendations

(47a). The report stated that “because there is so

little evidence for the effectiveness of the other

strategies for prevention, the panel believes that the

major strategy must be the encouragement of

diligent contraceptive use by all sexually active

teenagers” (47a,148). OTA’s review suggests no

reason to disagree with this recommendation, although it notes that the promotion of diligent

contraceptive use by adolescents can be a complex

task. The National Academy of Sciences also

recommended pursuing the strategies of delaying

the initiation of sexual intercourse among adolescents and enhancing ‘‘life options’ for disadvantaged teenagers (47a,148). These strategies also

seem justified by OTA’s review of available literature, so long as the strategy of promoting effective

contraceptive use among sexually active adolescents

is not ignored.

Published information concerning the impact of

programs that emphasize education, programs that

provide contraceptives to adolescents, and programs

to seek to develop adolescents’ life options on

pregnancy rates, sexual activity, or other outcomes

is presented in the discussion that follows.

Programs That Emphasize Education

Education about human sexuality, once regarded

as the responsibility of parents and guardians, is now

commonly provided in junior and senior high school

classrooms, as well as in some elementary schools

(86). A study using retrospective data from the 1984

NLSY found that about 60 percent of the females

and 52 percent of the males in the sample (all of

whom were between the ages of 19 and 27 at the time

of the survey) had taken a sex education course in

school; the percentages were somewhat lower for

blacks (57 percent for females and 49 percent for

males) and Hispanics (50 percent for females and 46

percent for males) in the sample (129). A study using

data from the 1982 National Survey of Family

Growth found that 64 percent of the sample of

females ages 15 to 19 had received school-based

instruction about contraception (41).

According to Kirby, the content of sex education

courses varies to some extent by grade level

(107,148). High school courses typically cover a

wider range of topics than courses at the junior high

level. In junior high, many courses cover anatomy,

physical and psychological changes of puberty,

reproduction, dating, responsibilities in interpersonal relations, and STDs. Some junior high schools

also cover contraceptive methods. High school sex

education courses typically include topics covered

in junior high plus teenage sexuality, pregnancy, and

childbirth. About three-fourths of the high school

courses cover family planning, contraceptive methods, and abortion.

Instruction in values as a part of sex education

varies and is somewhat controversial (148). Some

programs have emphasized enabling adolescents to

make decisions about sexual matters in terms of their

own values and beliefs. Other programs have used

other approached such as teaching what are regarded

as “basic universal values. ” Recently, many

schools have begun teaching about sexuality in the

broader context of family life education, which

includes attention to the role and responsibilities of

families and often emphasizes values (148).

The goals of school-based sex or family life

education are not always clearly specified. Some

courses are designed primarily to improve students’

knowledge and understanding about how the body

fictions and about human sexuality (86). Some

courses are also designed to help students understand the social context of sexuality, including

relationships with others and the social, moral, and

ethical restraints on its expression (86). Other goals

may be to promote rational and informed decisionmaking about sexuality, to increase knowledge of

reproduction to reduce sexual activity, or to reduce

pregnancy (148). Most schools offer brief (10 hours

or less) sex education programs that focus on the
II-358 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

basics of anatomy, human reproduction, and physical and psychological changes during puberty; these

are often integrated with other courses such as health

or physical education, home economics, or biology

(7,148). Very few schools offer comprehensive sex

education programs of more than 40 hours (148), and

Kirby estimates that less than 10 percent of all

students take comprehensive sex education courses

(107).

Information about the effects of school-based sex

education/family life education courses on adolescents’ knowledge, attitudes, sexual behavior, and

pregnancy rates is presented below.59 Also presented

below is information on the effects of a variety of

other programs that emphasize education:

●

●

●

●

school-based decisionmaking, assertiveness, and

life skills training programs that attempt to help

adolescents make responsible decisions about

sexual activity by teaching them problemsolving, decisionmaking, or interpersonal communications skills;60

programs that emphasize communication between parents and their adolescent children for

the purpose of encouraging young people to

postpone sexual activity;

community-based education efforts such as

media campaigns that focus on imparting

information about the negative consequences

of early sexual activity, pregnancy, and parenting; and

a multimodal pregnancy prevention program in

that combined school- and community-based

educational efforts with the provision of contraceptives through a school nurse.

School-Based Sex Education/Family Life Education—In 1988, researchers at the Alan Guttmacher

Institute conducted a national survey of all State

education agencies and 203 of the largest school

districts in the United States (104). Forty-nine State

education agencies plus the District of Columbia and

162 local school districts responded to the survey.

Forty States plus the District of Columbia and the

vast majority of the 162 responding school districts

either required or encouraged some form of sex

education in the schools (104).

Researchers at the Alan Guttmacher Institute

found that the topics covered in sex education

courses varied, as shown in table 10-4. About

two-thirds of the States and four-fifths of the local

school districts said they required or encouraged

schools to teach about prevention of pregnancy

(104). More States and local school districts said

they required or encouraged AIDS education, STD

education, or teaching abstinence from sex than said

they required or encouraged teaching prevention of

pregnancy (104). About four-fifths of the States and

nine-tenths of the local school districts said they

required or encouraged schools to teach abstinence.

Abstinence from sexual intercourse is, of course, one

means of preventing pregnancy. Some sex educators

believe, however, that relying exclusively on abstinence as a means of preventing pregnancy and the

transmission of STDs is unrealistic (74a). With

American females now starting to menstruate on

average at age 121/2 and many waiting longer to get

married (74a), the period prior to marriage in which

people are able to have and are interested in having

sex is likely to be prolonged.

Evaluations of Sex Education Based on Data

From National Surveys-As shown in table 10-5,

evaluations of the effectiveness of sex education

based on data from national surveys of young people

have been performed by Zelnik and Kim, by

Dawson, and by Marsiglio and Mott. Zelnik and

Kim’s study and Dawson’s study found that expos~ese pro~5 me known variously as sex education or family life education programs, vvithfarnily life educzwionapparently beqtiemomc~ent

and encompassing term (181a). According to a recent review by the Southern Center on MolesCent Pregnancy Preventio~~amiZy life education is “a

curriculum, program or framework for helping young people make responsible choices and deeisions by providing accurate and age-appropriate

information about human sexuality, and by exploring the attitudes, behaviors, and value systems that shape the development of healthy sexuality” (181a).

According to the Center’s review, “The demands and expectations of family life education today far exceed those of sex education indecadespast. . .No

longer just human anatomy and reproductive functioning, school-based [family life education] programs became forums for promoting positive health

practices, critical thinkm“ g, and values clarMcation. Classrooms ~ve become] laboratories for building skills in communication, responsible

decision-making, and assertiveness” (181a). Consistent with the Center’s analysis, a mid- 1980s survey of States and large school districts conducted

by ?he Alan Guttrnacher Institute defined sex education as ‘‘instruction in the public schools about human sexual development, the process of

reproduction and related topics” (104). However, as noted in the text it is often difficult to determine from the evaluation literature just what takes place

in any set of education programs related to human sexuality (see 104). Not all programs termed sex education programs are restricted to a reproductive

and “facts only” approach that may have characterized the sex education of the past, however (181a), and not all “family life” education programs

fulfill all the demands and expectations that many educators and parents place on them.

@Life skills and decisionmaking programs by some deftitions maybe included under sex education or family life education. They are discussed

separately from sex education programs here in an attempt to distinguish their effects from education-based programs that are strictly didactic.
Chapter 10-Pregnancy and Parenting: Prevention and Services . //-359

Table 10-4—State Education Agencies and Large School Districts’ Position on the

Teaching of Selected Topics in Sex Education, 1988a

Percentage distribution by tepid c

Abstaining Prevention of AIDS Other STD

Position on teaching from sex pregnancy c education education

State education agencies’ position:

Require/encourage . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. 82% 66% 94% 88%

Discourage/prohibit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . O 4 0 0

No position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 30 6 12

Local school districts’ position:

Require/encourage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91% 81% 96% 9370

Discourage/prohibit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . O 4 1 4

No position stated...............,...........,.. 9 16 4 6

al%e data presented in this table were obtained in a national survey of State education agenaes and the 20S largest

school districts in the United States, conducted by researchers at the Alan Guttmacher institute in 1988. Forty-nine

States (all but South Dakota) and the District of Columbia and 162 (80 percent) of the school districts responded to

the survey.

bpercentages may totai more than 100 because of rounding.

~opics listed below areas they appeared in the survey questionnaire. The topics were not specifically defined.

d[t is interesting to note that some States do not consider AIDS or STD education sex education. Thus, more states

support AIDS education (46 States and the District of Columbia) or STDS education (43 States and the District of

Columbia) than require or encourage “sex education” (40 States and the District of Columbia).

SOURCE: Office of Technology Assessment, 1991, based on data from A.M. Kenney, S. Guardado, and L. Brown,

“Sex Education and AIDS Education in the Schools: What States and Large School Districts Are Doing,”

Family Planning Perspectives 21(2):56-64, 1989.

sure to a sex education course had little or no

consistent effect on the likelihood that adolescents

would engage in sexual activity (41,232). Marsiglio

and Mott found that exposure to sex education was

positively (but weakly) associated with initiation of

sexual activity at ages 15 and 16 but not at ages 17

and 18 (129). For 15- and 16-year-olds, exposure to

sex education was a less important determinant of

the initiation of sexual activity than other factors.

Thus, the evaluations of sex education by these

investigators suggest that traditional sex education61

generally neither encourages adolescents to initiate

sexual activity nor encourages them to delay it. One

of the problems these investigators noted, however,

was that sex education programs were frequently

offered to adolescents who had already become

sexually active. Marsiglio and Mott found, for

example, that half of the females and two-thirds of

the males under age 19 had engaged in sexual

intercourse before receiving formal sex education

(129).

In terms of getting adolescents to use contraceptives, Zelnik and Kim found that females who had

taken a sex education course were more likely to

report use of birth control at first intercourse than

those who had not (232). The studies by Dawson and

by Marsiglio and Mott also found that young

females exposed to sex education were more likely

to report use of contraceptives when they became

sexually active, especially if they received instruction in both the mechanisms of pregnancy and

contraceptive use prior to initiating sexual activity

(41,129).

Zelnik and Kim found that sexually active females who had taken a sex education course were

less likely than who had not received sex education

to report having been pregnant (232); however, no

verification (e.g., hospital records) of these reports

of avoiding pregnancy was available. Dawson found

that exposure to sex education had no consistent

effect on responding females’ likelihood of becoming pregnant (41).

The validity of conclusions from the evaluations

of sex education based on national surveys of

students is open to question. These studies use data

relying on students’ self-reports and retrospective

recall for information about the timin g and content

of sex education and the incidence of sexual activity

and pregnancy. The studies also combine data from

61OTA ~S ~SSw~ tit he sex education pro~~ delivered [0 ~dlvid~ls p~cipa~g in the Mtioti surveys were ‘‘traditional” SeX edU~tiO~

that is, they did not include major Me-skills decisionmaking or life options components. In fac~ as noted below, one problem with studies based on data

from national surveys is that such studies are, in effect, averaging a potpourri of programs that differ in content, intensity, timing, goais, and biases. A

conclusion that such programs djd not include relatively new components such as life-skills decisionrnaking or life options components seems justilled

in light of the fact that all studies used data on sex education programs developed either early in or before the 1980s (41,129,232).
Table 10-5-Evacuations of School-or Community-Based Sex Education, Life Skills Training, and Other Programs

Program Participant Evaluation

Studya

characteristics characteristics method Findings

Evaluations of sex

education based on

national surveys:

Zelnik and Kim, 1982 Various-course related Nationally representative sample of

to sex education.” females ages 15 to 19 in 1976 or

1979, and males ages 17to 21 in

1979, living in Standard Metropolitan Statistical Areas.

N = 2,193.

Dawson, 986 Various-formal instruc- participants in 1982 National Survey

tion in schools or of Family Growth.

organized commu- N = 1,888 females ages 15 to 19.

nity programs.

Marsiglio and Mott, Various-” course related N = 6,015 males and 6,054 females,

1986 to sex education.” ages 19 to 27 at time of interview

in 1984.

Participants in National Longitudinal Surveys of Labor Market

Experience-- Youth Cohort (NLSY)

1979-84.

Telephone survey; included questions on sexual activity, use of

contraceptives, premarital pregnancy, and sex education courses

(including course content).

Analyzed self-report data on whether

respondents had received formal

sex education (included questions about content of sex education courses) and on initiation of

intercourse, knowledge and use

of contraceptives, premarital pregnancies.

Longitudinal analysis of retrospective self-report data.

Exposure to a sex education course was not

significantly associated with engaging in sexual

activity. Among sexually active females, those

who had taken a sex education course were

less likely to have been pregnant than their

peers who had not taken a sex education

course; among sexually active females in the

1979 survey, those who had taken a sex

education course were more likely to use birth

control at first intercourse than those who had

not.

Exposure to formal sex education had no consistent effect on responding females’ likelihood of

initiating sexual intercourse or becoming pregnant. Sexually active females who had received

sex education reported knowing how to use

more contraceptive methods than sexually active females who had received no instruction.

Among females who had ever used birth control, those who reported receiving education on

how pregnancy occurs and on how to use

contraceptive methods were more likely to

report using birth control at first intercourse than

those who had not received such information in

sex education courses.

Males in the sample were less likely than females to

have had exposure to a sex education course

before engaging in sexual intercourse. Among

female respondents, prior exposure to formal

sex education was positively (but relatively

weakly) associated with initiation of sexual

activity at ages 15 and 16 (but not at ages 17

and 18), but other factors (infrequent church

attendance, parental education of less than 12

years, black race) were stronger determinants

of females’ first intercourse at 15 to 16 years.

Among female respondents ages 17 and 18 in

1982, those who had taken a sex education

course were more likely to use effective birth

control methods than those who had never

taken such a course.
Table 10-5-Evaluations of School- or Community-Based Sex Education, Life Skills Training, and Other Programs-Continued

Program Participant Evaluation

Studya

characteristics characteristics method Findings

Evaluation of various types of exemplary sex education

programs:

Kirby, 1984

Evaluations of

school-based decisionmaking, assertiveness, and life

skills training programs:

Schinke, Blyth, and

Gilchrist, 1981

Barth, Fetro, Leland

et al., in press

Various-programs in 9

sites: peer education, parent-child,

school-based, community conferences;

5-session to yearIong programs

Life Skills Counseling

(LSC) program: In

14 50-minute group

sessions offered instruction in reproductive biology and in

use of contraceptive

methods; problemsolving training; and

communication and

assertion skills training.

Life Skills Counseling

(LSC) program: See

above

Various-primarily high school students; matched comparison

groups included in some sites.

N = 36 high school sophomores

(19 females, 17 males).

Pretest N = 1,033 high school students, with 586 in the treatment

group and 447 in the control

group (who took their school’s

standard sex education course).

Posttest N = 832 students.

6-month followup = 722 students.

Questionnaires administered to participants 3 times: pretest, posttest, and 3- to 5-month followup;

assessed knowledge, attitudes,

and sexual behavior. Estimates

of pregnancy rates obtained in

some locations.

Students were randomly assigned to

one condition of a Solomon 4-

group design (pretest, training,

and posttest; training and posttest; pretest and posttest; and

posttest only). Evaluation included

tests of problem-solving; videotapes of role-played interactions

involving sexual decisionmaking;

measures of attitudes toward contraceptive use, self-reported birth

control use, knowledge of reproduction and birth control.

Questionnaires were administered

to participants 3 times: pretest,

posttest, and 6-month followup.

These assessed knowledge, intentions to avoid unprotected sexual intercourse, current and past

use of birth control; observational ratings of teacher effectiveness in implementing the program; parental survey.

Most programs significantly increased participants’

knowledge about conception and cent raception; greater knowledge gains were found in

classes with younger students; longer, more

comprehensive programs did not produce greater

knowledge increases than short-term programs.

Parent/child programs increased parents’ comfort in discussing sex with their children, and

increased the frequency of self-reported parentchild communication. The programs had no

significant or consistent effects on participants’

initiation of sexual activity or contraceptive use.

In the 4 sites where pregnancy data were

collected, the programs had no impact on

pregnancy rates.

LSC program participants had higher levels of

knowledge about sexual facts and probabilities,

better problem-solving abilities, and better assertion skills at posttest than controls. At 6-

month followup, LSC participants were more

favorably disposed to birth control use and

reported better contraceptive use than controls.

LSC participants’ knowledge about birth control

and reported intentions to avoid unprotected

sexual intercourse improved, and improvement

was maintained at 6-month followup. LSC participants reported increased frequency of birth

control use; no change in rates of sexual activity

or pregnancy. Students who started having sex

after the program had lower rates of sexual

activity and were more likely to report using

condoms.

Continued on next page
Table 10-5-Evaluations of School- or Community-Based Sex Education, Life Skills Training, and Other Programs-Continued

Program Participant Evaluation

study’ characteristics characteristics method Findings

Howard, 1985; How- Postponing Sexual lnard, 1988; Howard volvement (PSI) Proand McCabe, 1990 gram, a public-schoolbased program, offered basic factual

information regarding reproduction and

contraceptive use; pro

vialed decisionmaking still training, “social inoculation” and

assertiveness training in 10 classroom

periods. It was

taught by trained high

school (11th and 12th

graders) students and

staff from a hospitalbased teen clinic.

Christopher and Success Express ProRoosa, 1990 gram, a Title XX Adolescent Family Life

act-funded program

consisting of 6 sessions that focused

on self-esteem, com

munication skills peer

pressure, and teaching the value that

sex should be confined to marriage. Pro

gram conducted in

8 sites, of which were

schools, and 3 of

which were unidentified community sites

Control groups were

classes in the 5

schools that did not

receive the intervention.

N = 536, 99% black, mostly lowincome, drawn from hospital’s

service population. Included 8th

graders from public schools rei

ceiving the PSI intervention (N =

395) and a comparison group of

8th graders (N= 141) from other

school systems in the same metropolitan area.

PSI program participants and corn

parison group participants were

interviewed by telephone at beginning, middle, and end of 8th

grade; followups were conducted

at beginning and end of 9th grade

were questions on sexual behavior included in a larger survey of

health habits.

N = 191 participants, 129 controls, all Questionnaires on self-esteem, qualmiddle school-aged, average age ity of family communication, and

12.8 years, 61% female, majority premarital sexual behaviors and

Hispanic (69%) or black (21%), attitudes were administered immost from low-income families. mediately before the first intervention session and 6 weeks

later at the final session. Experimental participants were more

advanced in grade level than t he

comparison group; this factor was

statistically controlled in the analysis.

Among students who had not been sexually active

before the programs began (N= 365), students

in PSI schools were significantly less likely to

have become sexually active by the end of the

year and continued to be less likely to become

sexually active through the end of the next year

(i.e., the end of the 9th grade) than comparison

group students. Among students who were

already sexualty active when the programs

began, PSI had no effect on their frequency of

sexual activity. Although more sexualty active

students in PSI schools than in comparison

schools reported using contraceptives, it is

unclear if the reported difference was statistically significant.

Only change was that participants, especially males,

reported more engagement in precoital sexual

activity than controls did (e.g., touching genitals). Interpretation of results was confounded

by the fact that 41% of participants (v. 30% of

controls) failed to complete the post-test questionnaire; these were considered program dropouts. Dropouts were more sexually active and

more likely to believe in sex at younger ages

than were non-dropouts, suggesting that the

abstinence-based program was not appealing

to large segments of the target population.

Icn

:

. .

Q
Table 10-5--Evaluations of School- or Community-Based Sex Education, Life Skills Training, and Other Programs-Continued

Program Participant

Studya

characteristics characteristics

Evaluation

method Findings

Roosa and Christo- Same as Christopher and

pher, 1990 Roosa, 1990 but in

20 sites

Eisen, Zellman, and Sexuality and contracepMcAlister, 1990 tive education program based on

health belief model

and social learning

theory. Program combined lectures, simulations, leaderguided discussions,

and role-playing (including gender-role

reversals). Experimental programs had

more active adolescent participation than

comparison pro

grams. Experimental and comparison

programs based on

traditional sex education model were

delivered in 7 varied

settings, including

schools, county

health departments,

summer work-study

programs.

N = 399, 129 controls, all early

adolescents, average age 13,

570/. female, majority Hispanic

(64%) or black (12%), family income not provided. Participant

sites included public and parochial schools, community centers, Indian reservations, and Police Athletic League branches.

Control sites were classes in

participant or neighboring

schools.

N = 1,444 at baseline, 1,328 at

immediate followup, 888 at 1-

year followup. 13-to 19-yearolds included, but 96% were 17

or younger; 52 percent female;

mostly low socioeconomic status;

15% white, 24% black, 53% Hispanic, 8% Asian; 42% did not live

with 2 parents; 62% had had

previous sex education experience; 36°A had had sexual intercourse. Differences by experimental and comparison group

not provided.

Same as above, but used age as a

covariate (controls were older).

Using multivariate analysis to control

for background variables, and

excluding Asians from the analysis because of language issues,

analyzed changes over time and

between experimental and corm

parison groups, based on selfreports of sexuality-related knowledge, beliefs and behavior, including knowledge of and use of

effective contraception; statistically controlled for some baseline and other (e.g., demographic)

factors.

No desired changes in attitudes toward abstinence

or in sexual behaviors. Incongruously, control

group significantly increased age at which they

expected to have sex for the first time by 1 1/2

years, compared to a 1/2 year increase for

participants. Study dropout rate was higher

among participants (34%) than for controls

(24%).

At immediate followup, there were significant differences between experimental and comparison adolescents in sexual knowledge but no

significant changes in health beliefs. At 1-year

followup, there were significant differences between experimental and comparison adolescent males (but not females) in maintenance of

abstinence, and significant differences in consistent use of effective contraceptives for females (but not males) who initiated intercourse

in the course of the study and for males who had

already been sexually active. Noted cumulative

effect of prior sex education. The analysis was

somewhat flawed in that all comparisons were

made at the individual level of analysis, although some of the randomizations had been

done at the group level of analysis.

Continued on nexf page
Table 10-5-Evaluations of School- or Community-Based Sex Education, Life Skills Training, and Other Programs--Continued

Program Participant Evaluation

study” characteristics characteristics method Findings

Weed and Olsen, Sex Respect Program:

1990 Public-school-based

program; classroom

instruction, student

presentations in the

community; and pubIications, videos, and

other materials made

available to school

libraries.

aFull citations are iisted at the end of this chapter.

SOURCE: Office of Technology Assessment, 1991.

Questionnaires were administered

to N = 4,000 students, 2,900

students who had been in the

Sex Respect Program previously

in junior high schools which implemented the program on a

schoolwide basis and 1,100 students who were a matched comparison group. Data reported were

from 1988-89 and included students who had not received the

program (comparison group), students who had just received the

curriculum and were evaluated

pre and post, and students who

were being followed up; students

were evaluated at various sites in

the Midwest.

Questionnaires were administered

to students in the Sex Respect

Program; pre and post curricuIum followup and every year after

for 3 years; this evaluation reported the findings for 1988-89,

which included students who did

not receive the curriculum, students who had recently received

the curriculum and who were

given pretest and posttest questionnaires, and students who had

received the curriculum in the

past and were being followed up.

Sex Respect Program participants’ attitudes and

values about the benefits of delaying sexual

activity were strengthened immediately after

receiving the curriculum and maintained to a

lesser extent over a 2-year followup period.

Differences in sexual activity rates were minimal and nonsignificant at 2-year followup; however, decreases in levels of sexual activity were

larger and more enduring for girls, for younger

students, and for those who started the program

as virgins.
Chapter l&Pregnancy and Parenting: Prevention and Services . //-365

students involved in many different types of sex

education programs; these aggregate data may

obscure results achieved by a specific program.

Thus, the inability of gross evaluations of schoolbased sex education programs to demonstrate a

significant impact on targeted behaviors may be a

result of the content, quality, and intensity of the

specific programs offered rather than the intervention strategy itself. The national surveys on which

the three evaluations described above were based

were not really able to disaggregate the impact of

specific types of sex education programs on adolescent pregnancy because they averaged the findings

of a variety of programs that differ from one another.

It is unclear from these surveys what type of sex

education class the adolescents (or adults) participated in. Even when questions were asked of survey

respondents about the format and emphasis of sex

education classes, the actual implementation of the

curricula was not observed by the evaluators. These

and other problems associated with the nature of the

data collected (e.g., the use of retrospective data) call

into question the validity of the conclusions drawn

from these studies,

Evaluation of Educational Programs Based on

Observations of Multiple Program Types—Kirby

evaluated several different types of sex education

programs in nine sites (see table 10-5). The programs, which Kirby selected for evaluation because

they were believed to be exemplary, represented a

range of different program types (e.g., a peer

education program, a parent-child program, as well

as more traditional classroom-based didactic programs) and lengths (107). Kirby cautions, however,

that it is not prudent to generalize his findings

regarding these programs to all sex education

programs.

Kirby’s study was unusual in its attempt to be

relatively methodologically rigorous (e.g., using

pretest and posttests of knowledge, attitudes, and

behavior, and matched comparison groups) and to

measure relatively long-term (3- to 5-month) effects

of the programs (107). Student and parent evaluations of the programs were also collected. In

addition, relatively objective (i.e., non-self-report)

pregnancy and birth data were obtained from clinics

at four of the sex education sites chosen.

Most of the educational programs evaluated by

Kirby significantly increased participants’ knowledge about human sexuality, especially among

younger students (107). (Kirby’s study is controversial, however, because it found that longer, more

comprehensive programs did not produce greater

knowledge increases than short-term programs.)

Overall, both student and parent evaluations of the

programs were extremely positive, findings in themselves which Kirby cites as reasons to continue

offering sex education programs (107).

None of the educational programs evaluated by

Kirby had any measurable effects on participants’

sexual activity, contraceptive use, or pregnancy rates

(107). Thus, Kirby’s findings based on a range of

exemplary sex education programs delivered in the

1980s differed somewhat from the studies based on

national survey data, in that the earlier studies found

that exposure to sex education was associated with

greater contraceptive use (41,129) and fewer selfreported pregnancies (232).

Kirby notes that the demands placed upon sex

education are more formidable than those placed on

other courses (107). As he says, most classes are not

evaluated using measures of behavior outside the

classroom: for example civics classes are not evaluated by measuring students’ later voting behavior;

English classes are not evaluated by measuring

students’ improvements in their speech and thinking

outside of class (107,107a). Sex education programs, on the other hand, are expected not only to

increase students’ knowledge about sexuality and

related topics but also to effect changes in behaviors

that are subject to many influences outside the

classroom.

School-Based Decisionmaking, Assertiveness,

and Life-Skills Training Programs-Schoolbased decisionmaking, assertiveness, or life-skills

training combine the provision of sex education with

training in problem-solving, decisionmaking, or

interpersonal communications skills (86). Some

programs of this type have no stated position on the

appropriateness of engaging in or abstaining from

sexual activity and focus instead on helping young

people identify their own values (148). Other

programs explicitly communicate the value of abstinence and postponement of sexual activity and

emphasize helping young people develop the skills

to resist pressures to become sexually active.

It may be important to note at this point that some

observers of sex education policy see an inherent

conflict in sex education that provides a ‘‘double

message—that is, that it is necessary and appropri-
//-366 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

ate to explicitly encourage students not to have sex

but also to encourage them to use contraception if

they do have sex (107a). As Kirby notes, however,

educators are beginning to recognize that adults

commonly tell adolescents that they should not do

certain things (e.g., drink alcohol, take courses

above their level of competence), but that if they do,

they should take certain precautions (e.g., drink very

little, and not drive after drinking or with someone

who has been drinking; seek tutoring). Thus, increasingly, according to Kirby, “this double message is viewed as a realistic approach to a difficult

problem and is losing some of its negative press”

(107a).

One school-based intervention that gives adolescents factual information about conception and

contraception and teaches decisionmaking and assertiveness skills without emphasizing a specific set

of values regarding sexual activity is the Life Skills

Counseling (LSC) program developed at the University of Washington (see table 10-5). The LSC

program provides adolescent participants with factual information about human reproduction and

contraception; it also provides training in decisionmaking skills related to dating, sexuality, birthcontrol, abortion, childbearing, and parenthood to

help adolescents clarify their own values and make

responsible decisions (180,18 1). The LSC program

also teaches participants communication skills and

strategies for resisting peer pressures to engage in

sexual activity, but it presents such resistance as one

of several possible alternatives rather than as the best

alternative.

In 1981, Schinke and colleagues performed an

initial evaluation of the LSC program that showed

promising results in terms of getting students not to

engage in unprotected sexual intercourse (see table

10-5). This evaluation among a group of 36 high

school sophomores (19 females and 17 males) found

that students who participated in the LSC program

had more positive attitudes toward birth control use

and greater knowledge of sexual facts, myths,

probabilities, and sequelae than a comparison group

of students who did not participate (180). LSC

participants also demonstrated significantly better

communication skills and better abilities to resist

pressure from “partners” to engage in unprotected

sexual intercourse. Six months after the end of the

LSC course, students who had participated in the

LSC program reported greater use of birth control

methods and fewer instances of unprotected sex than

comparison students (73,179,180). Schinke and

colleagues’ evaluation did not obtain information on

rates of sexual activity or pregnancy among the

students, so the LSC program’s impact on the

incidence of sexual intercourse or pregnancy is

unknown. Also, because the LSC approach was

tested on students who were asked to participate on

a voluntary basis, there is a high probability of

selection bias influencing the outcomes. Thus,

further information on the LSC’s program’s applicability for larger, more diverse groups of adolescents

is needed.

Recently, Barth and colleagues evaluated a largescale program using the LSC model in 13 high

schools in California (see table 10-5). For Barth and

colleagues’ evaluation, a diverse group of more than

1,000 sexually active and inactive adolescents was

recruited, and in most cases, the students were

randomly assigned to either an LSC curriculum or to

their school’s standard sex education curriculum

(15). (In some schools, when there were classes of

unequal size, larger classes were assigned to the LSC

group.)

Barth and colleagues found that students in the

LSC program demonstrated greater knowledge about

contraception than students who received their

school’s standard sex education curriculum did;

students in the LSC program also reported increasing the frequency of their use of birth control

methods and reported having more positive intentions of avoiding unprotected intercourse (15). Barth

and colleagues also found that students who received the LSC curriculum and who started having

intercourse after the program began were more

likely than students in the control group to report

using a condom. Overall, however, Barth and

colleagues found that students in the LSC group did

not have lower rates of sexual activity or pregnancy

than students in the control group.

In 1990, Eisen, Unman, and McAlister performed

an evaluation of a sexuality and contraceptive

program based on the health belief model and social

learning theory (see table 10-5). This program

involved lectures, simulations, and leader-guided

discussions (51). The intervention was unusual in

that it was at least in part, an explicit test of a

participatory model of sexuality education. Social

learning theory predicts that successful enactment of

a behavior (e.g., convincing a partner to delay

having sex) will encourage that behavior in the
Chapter 10-Pregnancy and Parenting: Prevention and Services . II-367

future. In contrast, many educational interventions

rely on lectures or at most discussion of sex-related

isses. 62 The evaluation showed that this more

participatory approach can have some success, in

that participating adolescent males (but not females)

were more successful than comparison males in

maintaining abstinence, and participating adolescent females (but not males) were more successful

than comparison females in using contraception

effectively (51). Like many other evaluations, this

evaluation was somewhat flawed in that it relied on

self-report data, rather than on observations of

changes in pregnancy rates, to test outcomes.

The Postponing Sexual Involvement (PSI) program developed at Emory University in Atlanta,

Georgia, a prominent example of the abstinencepromoting approach to decisionmaking and assertiveness training, was part of a larger classroombased sex education program carried out in the

Atlanta public schools (see table 10-5). The PSI

program sought not only to provide adolescents with

factual information on human sexuality but also to

help them recognize and respond to social pressures

(e.g., from advertising) and peer pressures to engage

in sexual activity through assertiveness training and

peer counseling (93,94,95).

Howard and colleagues performed a large-scale

evaluation of the PSI program in which they

compared sexual knowledge, sexual activity, and

pregnancy rates among students in the Atlanta

public schools who were involved in the PSI

program and students from county schools in a

neighboring area where the PSI program was not

offered (93,94,95). Their sample included nearly

600 mostly black, low-income eighth graders, 395 of

whom received the PSI intervention and 141 of

whom did not. Howard and colleagues found that the

PSI program seemed to be effective in helping young

adolescents (especially females) delay sexual activity (95). Although they found that the PSI program

had no effects on rates of pregnancy or frequency of

sexual activity among participants who were sexually active before the program started, they did find

lower frequencies of sexual intercourse and fewer

pregnancies among PSI participants who became

sexually active after the program had started (93,94,95).

The decreases in pregnancy rates need to be interpreted with caution, though, because small sample

sizes were used to make comparisons and the

statistical significance for these differences in rates

was not reported.

In another set of evaluations of an abstinence-only

pregnancy prevention program involving the teaching of communication skills, Christopher and Roosa

found disappointing results (see table 10-5). A

six-session program for middle-school adolescents

that focused on self-esteem, communication skills,

peer pressure, and teaching the value that sex should

be confined to marriage resulted in an increase in

precoital sexual activity (i.e., not in sexual intercourse) in program participants, but not in the

control group (36a). Another evaluation of this

abstinence-only pregnancy prevention program found

that none of the desired changes in attitudes or

behavior occurred for the sample as a whole or for

the subgroup who had never had sexual intercourse

(172a).

An example of a school-based program that

combines assertiveness skills with values clarification is the Sex Respect Program for young adolescents in the Midwest (see table 10-5). The goal of the

Sex Respect Program was to reduce participants’

sexual activity and pregnancy rates by improving

their awareness and recognition of the potentially

harmful consequences of early sexual activity, by

improving skills to help them resist pressure to be

sexually involved, and by preventing early sexual

activity (220). The Sex Respect Program planned to

infuse regular education programs for young adolescents with a greater emphasis on saying ‘‘no” and

also aimed to foster peer pressure on behalf of

self-restraint from sexual activity. There was some

emphasis on disseminating information more generally in the community.

Entire schools administered the Sex Respect

curriculum in mandatory junior high school classes.

For an evaluation by Weed and Olsen, students

participating in the Sex Respect Program were asked

to complete questionnaires before and after their

62~e difference ~~een MS ~~cipatoV pro- ad o~er p~icipatory ~e.s~ls interventions is not immediately clear. Life-skills hilklhlg

typically has a participatory component so that adolescents can learn strategies and skills for various aspects of surviving, living with others, and

succeeding in a complex society. Social lczwnin g theory-based interventions are typically based on self-efficacy theq, which focuses intensively on

one behavior at a time. The evaluators of the social learning theory-based program were not able to tell how well the theoretical aspects of the program

were actually implemented (5 1). In additiom the intervention was partially based on the health belief model of changing health-related behaviors. The

evaluation found that health beliefs did not change, however (5 1).
II-368 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

participation (220). Weed and Olsen found that

students’ attitudes and values about the benefits of

delaying sexual activity appear to have been strengthened by the Sex Respect Program, because more

students responded positively to questions like ‘‘Do

you think there are benefits to waiting until marriage

to have sex?” after receiving the Sex Respect

curriculum. Weed and Olsen found that differences

in sexual activity rates among program participants

were minimal and nonsignificant at 2-year followup;

however, decreases in levels of sexual activity were

larger and more enduring for girls, for younger

students, and for those who started the program

without ever having had sexual intercourse.

Parent-Child Communication Programs—

Some programs supported by the Office of Adolescent Pregnancy Programs in the Office of Population

Affairs in DHHS and other organizations63 seek to

prevent or delay early sexual activity among young

adolescents by improving parent-child communication (148). Such programs are based on the belief

that parents prefer and will promote sexual abstinence and responsible sexual decisionmaking among

their children (86). Many family communication

programs focus on basic interpersonal communication techniques (e.g., taking time to establish relationships, recognizing natural communication barriers focusing on the adolescent’s concerns) to enable

parents to communicate more effectively with their

adolescent children (148).

Evaluations by Kirby and others of parent-child

communication programs indicate that such programs do increase the frequency of communications

between parents and adolescent children about sex,

as reported by parents and children, and increase the

comfort of both with such discussions (60,107,107a,

186a). So far, however, there have been no assessments of the long-term impact of on parent-child

communication patterns, and there are few data on

the effect of parent-child communication programs

on adolescents’ sexual behavior or unintended

pregnancy (148). Kirby, for example, did not find

that parent-child communication programs reduced

adolescents’ sexual behavior or unintended pregnancies (107).

Community-Based Education Progras--Community-based education programs for pregnancy

prevention can take a number of forms. In recent

years, for example, community organizations (e.g.,

churches, youth organizations such as Boys’ and

Girls’ Clubs) have developed teen theater projects to

offer pregnancy and contraceptive information to

diverse groups of adolescents or to reinforce messages about the values of abstinence from sexual

intercourse and responsible sexual decisionmaking

(148). Such programs usually involve adolescents in

developing scripts and producing either live performances or radio and television pieces targeted to

other adolescents. No evaluation data to indicate the

effectiveness of such projects in increasing adolescents’ knowledge or affecting their sexual behavior

are available (148).

Some communities have experimented with media

campaigns to raise consciousness about the issues of

adolescent pregnancy and provide outreach to adolescents in need of support or services (148). Some

have used public service announcements, mostly on

the radio, to encourage sexual responsibility or

provide information about local resources (e.g., hot

line or family planning clinic telephone numbers).

These efforts have not been evaluated in terms of

their impact on adolescents’ sexual behavior.

In Los Angeles, the Center for Population Options

has initiated a media project intended to serve as a

factual resource for television programmers and to

encourage commercial television to depict more

responsible male-female relationships (148). Project

staff report that television programmers have been

slow to change their approach to sexuality issues.

Network executives consistently avoid subjects such

as contraception and abortion which are not considered entertaining and are likely to offend a segment

of their viewers.

A Multimodal Pregnancy Prevention Program

That Included School- and Community-Based

Education—The School/Community Program for

Sexual Risk Reduction Among Teens, a communitywide pregnancy prevention effort in South Carolina,

took, in retrospect, a very broad and comprehensive

approach (see table 10-6). Its most ‘programmatic’

aspect was its attempt to coordinate the messages

adolescents receive from their schools, churches,

homes, community agencies, and the public media.

63A ~em~r of O~JS AdolwRnt I-IA~ you~ AdviwV p~el, for ~~ple, p~cipated in a pmnt-child Cormmmication program on sexuality

issues that was sponsored by her local Catholic church (200).
Table 10-6—Evaluation of a Multimodal Pregnancy Prevention Program That Included School- and Community-Based Education

Program Participant Evaluation

Study’ characteristics characteristics method

. . —

Vincent, Cleane, and School/Community Program for

Schluchter, 1987 Sexual Risk Reduction Among

Teens: Implemented in one

rural South Carolina community; school teachers K-1 2

were trained to Incorporate

sex education units into existing curricula (e. g., biology,

science, social studies);

church leaders and parents

were trained in sex education: local media were involved In disseminating program messages regarding

postponing the onset of sexual intercourse, consistent use

of effective contraception

among sexually active adolescents.

Koo and Dunteman, Reanalysis of Vincent et al., 1987

1990 above, plus consideration of

effect of distribution of contraception by school nurse

and school-linked health

center.

Females ages 14 to 17 In the

target community and a comparison group from demographically similar portion of the

country in which the target

community was located, as

well as from 3 other sociodemographically similar

counties In the same State.

Same as Vincent et al. in the

target community, and acorn

pans-on group of 7 counties

with initial simiIar estimated

rates of adolescent pregnancy.

Compared estimated pregnancy rates

(calculated from local vital statistics

data regarding Iive births, fetal

deaths, and lnduced abortions) within

target group (i.e, 14- to 17-year-old

females) for years pre-intervention

and post-intervention, and compared

changes In pregnancy rates from pre

to post In target community and

comparison areas.

For number of 14-to 17-year-olds, used

published target group denominator

as in Vincent et al., and State projections for comparison group denominators. In calculating estimated pregnancies, added certain proportions

of Iive births and abortions occurring

to 18-year-olds that could be estimated to have been conceived when

they were still 17, for a “pregnancy

conception rate.” Learned about pregnancy prevention activities and programs in comparison counties, but

could not quantify. Attempted to quantify, but could not: level of “family

planning coverage” (i.e., contraceptive distribution) in target and comparison communities; content and

extent of community-and schoolbased educational interventions.

Quantified number of teachers remaining to teach pregnancy prevention education. Compared estimated

pregnancy conception rates quantitatively for pre-program period 1981-

82, program periods 1983-86 and

1984-86, and “later intervention” years

1987-88; Independent variables

varied.

+ull ~tations are listed at the end Cf this chapter.

SOURCE: Office of Technology Assessment, 1991

Findings

In the first year following the lntervention, pregnancy rates among the

target group fell from 61.7 pregnancies per 1,000 population to 25.1 per

1,000, while pregnancy rates declined only slightly (from 63.1 pregnancies per 1,000 population to 58.8

per 1,000) in the comparison portion

of the target county, and increased In

the 3 comparison counties. in the

second year postintervention, pregnancy rates in the target area remained at the same low level, whiIe

rates continued to decline slightly in

the comparison portion of the county,

and continued to increase in all 3

comparison counties.

Pregnancy conception rates in the target area decreased between the

preprogram period and the early

program period and subsequently

rose during the “later intervention”

period to a level equal to the preprogram period. Although all of the

comparison counties experienced

some decreases in their adolescent

pregnancy rates during the study

period, pregnancy conception rates

of the target area were significantly

lower than those of the noncontiguous comparison areas in 1984, 1985,

and 1986, and of the contiguous

comparison area in 1984 and 1986.

The research team could not determine quantitatively how various factors (e.g., broad-based educational

intervention, distribution of contraception) contributed to reduction and

subsequent in pregnancy conception rates, but suggested that distribution of contraceptives may have been

a substantial contributing factor.
11-370. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

The School/Community Program for Sexual Risk

Reduction was implemented in a rural community in

South Carolina beginning in 1982 (117,215). The

goal was to reduce the number of teen pregnancies,

primarily by postponing the onset of initial sexual

activity and secondarily by promoting consistent use

of birth control among adolescents who had chosen

to become sexually active. Teachers and administrative staff in schools and professionals in community

agencies within the target community were given

training in sexuality education, and sex education

was then taught at all grades in the schools. Church

leaders and parents were provided with sex education ‘‘minicourses, ’ and additional educational

programs for community adolescents were developed in some churches and community agencies.

Peer counselors were trained. The local newspaper

and radio station were used to heighten community

awareness of the program through public media

campaigns. In addition, a school nurse in the target

school provided male students with condoms, took

female students to a nearby family planning clinic to

obtain contraceptives, and provided both male and

female adolescents with information and counseling

(1 17). During the course of the School/Community

Program efforts, an onsite school-linked health

center (SLHC) known as the “Teen Life Center”

opened, and the school nurse and other family

planning staff worked in the clinic, but these efforts

were not formally part of the School/Community

Program (1 17).

Because of the nature of the School/Community

Program for Sexual Risk Reduction Among Teens

intervention, it was not possible to design a rigorous

experimental evaluation. In 1987, Vincent and his

colleagues published an analysis that compared the

pregnancy rates for the rural county where the

School/Community Program for Sexual Risk Reduction was implemented with pregnancy rates of

three other South Carolina counties with similar

socioeconomic and demographic characteristics (215).

Their assessment of results was based on locally and

nationally recorded statistics about birth, fetal

deaths, and abortion. Vincent and colleagues found

that in the first year following implementation of the

School/Community Program, the pregnancy rate

among adolescents ages 14 to 17 in the target

community declined substantially (from 61.7 pregnancies per 1,000 population to 25 per 1,000);

meanwhile, pregnancy rates among adolescents ages

14 to 17 in the three comparison areas increased (an

average increase of 8.5 per 1,000) (215). In the

second year after the program was started, the

pregnancy rate remained the same in the target

community while continuing to climb, by an average

of 4.5 pregnancies per 1,000, in all three comparison

counties (215).

A 1990 reevaluation of Vincent and colleagues’

analysis by a team from Research Triangle Institute

(RTI), using a more refined data analysis, different

comparison counties, and additional years of analysis, also found that pregnancy rates declined more in

the study area than in the comparison to other

counties (117). However, the 1990 analysis by Koo

and Dunteman found that the declines in pregnancy

rates persisted for only 3 years following the

School/Community program’s full implementation

in 1983: the 1984-85, 1985-86, and 1986-87 school

years (1 17). By the 1987-1988 school year, the

pregnancy rate for the target community was where

it had been in 1981-82.

The reason for the 1990 reevaluation by RTI was

that the original findings had become a source of

controversy. A major question was whether factors

other than the educational portion of the School/

Community Program might have influenced the

changes in pregnancy rates in the target community.

Unfortunately, because of limitations on available

data, the RTI evaluators were not able to demonstrate conclusively which specific aspects of the

program may have been responsible for the reduction in pregnancy rates. Some investigators attributed the School/Community Program for Sexual

Risk Reduction Among Teens’ apparent success in

reducing pregnancy rates to having adequate funding and time for training, implementation, and

followup; a receptive target population; and inclusion of an entire small and cohesive target community in the intervention process (1 17,215).

In their 1990 reevaluation of the School/

Community Program for Sexual Risk Reduction

Among Teens, Koo and Dunteman concluded that

the provision of contraceptives by the school nurse

was probably a key factor in the program’s success

(117). The nurse appeared to develop trusting

relationships with adolescents and provided sexuality counseling and contraceptive services in a school

system that supported her effort. The evaluators also

noted, however, that the work of the specially trained

teachers ‘‘undoubtedly’ supported that of the

school nurse, and vice versa.
Chapter l&Pregnancy and Parenting: Prevention and Services . II-371

In their 1990 reevaluation, Koo and Dunteman

tried to determine why the pregnancy rate in the

target community rose to its preintervention level by

the 1987-88 school year (1 17). A number of factors

seem to have contributed to the increase. From

interviews with community members and teachers,

Koo and Dunteman noted that the overall educational program lost much of the momentum it had

had when the School/Community Program began

and pregnancy rates began to drop (1 17). Teachers

who had been specially trained in the program

curriculum left the school system. Other teachers

reported that the requirements of a new minimum

competency test for students made them feel that

they did not have sufficient classroom time to devote

to the pregnancy prevention Curriculum.64

Perhaps most important, Koo and Dunteman

found, in 1987, the State of South Carolina banned

the distribution of contraceptives in school-based

clinics such as the Teen Life Center (117).65 As a

result of this ban and the fact that a nearby family

planning clinic was closed when the Teen Life

Center was opened on school grounds, the only

family planning services that adolescents had available to them were 9 miles away from the school.

There was no public transportation in this rural

community (215). Finally, the school nurse who had

reached out to the students, counseled them on

contraceptive use, and actually provided condoms to

the male students or driven female students to the

family planning clinic to obtain contraceptives,

resigned in 1988 (1 17).

The lesson of the School/Community Program for

Sexual Risk Reduction Among Teens and its specific implementation in the target community in

South Carolina appears to be that a comprehensive,

well-thought-out program combining the major

elements theoretically desirable for such a venture,

supported by the provision of sexuality counseling

and contraceptive services by a trusted school nurse

working within and supported by the school system,

will, based on the best available evidence, work to

reduce adolescent pregnancy (1 17). What implementers of similar programs in other communities

should learn, according to the RTI team, is to avoid

eventual complacency and to provide sufficient and

timely resources so that an appropriate and believable evaluation can be made (1 17). OTA suggests that

it is possible, but not certain, that a valid evaluation

showing that the availability of contraceptives was

a necessary (if perhaps not sufficient) part of the

adolescent pregnancy reduction effort, would have

helped to ward off the State legislative change that

inhibited adolescents’ access to contraception.

Summary of the Effectiveness of Educational

Programs--Evaluations based on national surveys

suggest that school-based sex education does increase young people’s knowledge about conception

and contraception (see table 10-10). There is little

evidence that sex education courses affect participants’ sexual activity or use of contraceptives and no

evidence that they affect participants’ pregnancy

rates. Those who favor sex education in the schools

nevertheless say that such courses are worthwhile

because they provide students with basic knowledge

they will use throughout their lives (74a).

Kirby’s evaluation of various types of sex education programs (e.g., peer education, parent-child

communication) in nine sites similarly found that

most programs significantly increased participants’

knowledge about conception and contraception (especially younger participants’ knowledge), but had

no significant or consistent effects on their initiation

of sexual activity, contraceptive use, or pregnancy

rates.

A school- and community-based, theory-based

sexuality and contraceptive education program that

combined lectures, simulations, leader-guided discussions, and role-playing increased participants’

sexual knowledge but not their health beliefs (see

table 10-5). This program seemed to affect some

participants’ sexual behavior and contraceptive use.

School-based decisionmaking, assertiveness, and

life-skills training programs such as the Life Skills

Counseling (LSC) program, the Sex Respect Program, and the Postponing Sexual Involvement (PSI)

program combine the provision of sex education

with training in assertiveness and decisionmaking

(see table 10-5). The LSC program, which does not

emphasize any particular set of values regarding

sexual activity, looks promising in terms of improving knowledge of sexual facts and getting sexually

active adolescents to use contraceptives but not in

&l-m ~omptency te~t~ ~d ~eu ~fiect on school ~nvfioments and adolescent WeI1.being are discussd more generally in ch. Q, ‘ ‘Schools and

Discretionary Time,” in this volume.

6fAccord~g t. tie R~ te~ the Souti c~olina legisla~e was reacting to pubhcity about the School/Commtity ~Ogram (1 17).
II-372 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

terms of reducing such adolescents’ sexual activity

or pregnancy rates. But LSC students who were not

sexually active at the time of their participation

reported lower rates of sexual activity and greater

use of condoms than control group students who

took standard sex education. The PSI program,

which explicitly encourages abstinence, looks promising in terms of helping young adolescents (especially females) delay sexual activity. Other abstinencepromoting efforts evaluated by Roosa and Christopher experienced large dropout rates and no apparent

success in favorably changing attitudes or behaviors

related to sex; in fact the level of reported noncoital

sexual activity among males increased. The Sex

Respect Program, which combined assertiveness

skills with values clarification, strengthened participants’ belief in the benefits of delaying sexual

activity but had minimal effects on their sexual

activity rates. Decreases in sexual activity were

larger and more enduring for girls and younger

students.

Parent-child communication programs seem to

increase the frequency of and level of comfort with

communications about sex between parents and

their children, but data on the impact of such

programs on adolescents’ sexual behavior or unintended pregnancy are generally not available. Community-based education approaches range from teen

theater to public service announcements. Public

service announcements seem to be relatively underdeveloped and potentially effective information and

outreach tools (148). The evaluation of these efforts

(and contraceptive advertising on radio and television) in terms of their impact on adolescents’ sexual

behavior is difficult, however, because of the

difficulty of determining what segment of the target

population is reached (148).

The success of the School/Community Program

for Sexual Risk Reduction Among Teens, a pregnancy prevention effort in South Carolina, was

initially attributed to intensive school-and communitybased education, but a subsequent evaluation concluded that the provision of contraceptives and

one-on-one contraceptive counseling by a school

nurse were probably important factors in reducing

the rate of adolescent pregnancies (see table 10-6).

The evaluators concluded that a comprehensive,

well-planned program combining community-wide

educational efforts and the provision of sexuality

counseling and contraceptive services by a trusted

school nurse working within and supported by the

school system could help to reduce adolescent

pregnancies.

Programs That Provide Contraceptives

to Adolescents

The distribution of contraceptives is one of the

primary approaches to pregnancy prevention taken

by traditional family planning programs, special

adolescent clinics, comprehensive school-linked

health centers (SLHCs), and condom distribution

programs. 66 Evidence on the effectiveness of such

programs in preventing pregnancy is presented

below.67

In reviewing interventions that attempt to increase

sexually active adolescents’ contraceptive use, it is

important to keep in mind the limitations for

adolescents of currently available contraceptive

methods. An overview of contraceptives available to

U.S. adolescents is provided below. Oral contraceptives (the “pill’ and the use of condoms appear to

be effective means of birth control for adolescents

when they are used properly, but research suggests

that many adolescents are inconsistent or ineffective

contraceptors (148). Part of the reason may be that

adolescents find existing methods difficult to use or

unappealing for other reasons. Some observers have

found that adolescents’ failure to use contraceptives

or their discontinuation of contraceptives is sometimes associated with a fear of side effects or belief

that contraceptives interfere with sexual spontaneity

or enjoyment (98a). Further research to identify

factors that may enhance adolescents’ motivation to

use contraceptives and the development and testing

of contraceptives that are more acceptable and

appropriate to the needs of sexually active adolescents could ameliorate this problem.68

~The distribution of con~aceptives bya school nurse was one feature of the South Carolina community’s successful multimodalpre~Cyprevent.iOn

effort discussed in the preceding section.

sTAdolescenthe~~ care ctinics and SLHCS are discussed at length iII ch. 15, ‘‘MajorIssues Pemg to the Delivery of Primary and Comprehensive

Health Services to Adolescents, ” in Vol. III.

MSOMC of tie b~ers to adolescents’ use of condoms are discussed in Ch. 9, “AIDS and Other Sexuatly Transmitted Diseases: Prevention and

Services, ‘‘ in this volume.
Chapter 10-Pregnancy and Parenting: Prevention and Services . /1-373

Overview of Contraceptive Methods Available

to U.S. Adolescents—As shown in table 10-7, the

contraceptive methods most commonly used by U.S.

adolescents include oral contraceptives (’‘the pill’ ‘),

condoms, diaphragms, vaginal spermicides, rhythm,

and withdrawal (coitus interrupts). Intrauterine

devices (IUDs) are generally not recommended for

adolescents. Oral contraceptives, diaphragms, and

IUDs must be obtained through a physician in

private practice or in family planning or other clinics

(148). Condoms, vaginal sponges, and various

spermicides can be obtained at drug stores without

a prescription (148). No contraceptive method other

than abstinence is 100 percent effective in preventing pregnancy, but some methods (e.g., oral contraceptives, condoms) are considerably more effective

in preventing pregnancy among U.S. adolescents

than others. Theoretical and actual failure rates of

various reversible contraceptive methods in terms of

preventing pregnancy among U.S. females under

age 20 are shown in table 10-7. Many contraceptive

methods are less effective in preventing pregnancy

for adolescents than they are for adults (see figure

10-12).

A large majority of sexually active adolescents

who use contraceptive methods make use of prescription methods, especially oral contraceptives

(85). Oral contraceptives are among the most

effective means of preventing pregnancy in adolescents, but one of their drawbacks is that they do not

offer protection against acquired immunodeficiency

syndrome (AIDS) or most other sexually transmitted

diseases (STDs). Condoms are a nonprescription

contraceptive method that seems to afford adolescents a level of effectiveness in preventing pregnancy that is almost as great as the level offered by

prescription methods and, at least in adults, also

provides substantial protection against AIDS and

other STDs (76).69 One encouraging trend found by

the 1988 National Survey of Family Growth was that

the use of contraceptives at first intercourse among

U.S. females ages 15 to 19 had increased substantially since 1982, rising from 48 percent in 1982 to

65 percent in 1988 (59a). Most of the improvement

Figure 10-12—Percentage of U.S. Female

Contraceptive Users Experiencing Contraceptive

Failure During the First 12 Months of Use,

by Age and Method of Contraception

Percentage of users experiencing contraceptive failurea

An.“z——

30

20

10

0

1

Oral con- Dia- Condom Rhythm Spermi- Other

traceptives phragm cides

(“the pill”)

Contraceptive method

ENSl F&rn#~s4ages

astandardized by race and marital StatUS.

SOURCE: Office of Technology Assessment, 1991, based on E.F. Jones

and J.D. Forrestr “Contraceptive Failure in the United States:

Revised Estimates From the 1982 National Survey of Family

Growth,” Family Planning Perspectives 21 (3):103-109, 1989,

was due to the increased use of condoms at first

intercourse (59a).

A recent study by the National Research Council

and the Institute of Medicine on issues affecting the

development of new contraceptives identified a

number of emerging contraceptive methods (130).

Because of the difficulties in estimating the length of

the development process for new contraceptives, it

is impossible to say when emerging methods will

become available.70 Examples of new and emerging

contraceptive technologies that may offer adolescents more effective protection against pregnancy

than existing methods are described in box 10-B.

Some of these methods are likely to have fewer side

effects than existing methods, and others will offer

the advantage of greater convenience of use or

greater protection against AIDS and other STDs.

Thus, some new and emerging contraceptive technologies may be used more consistently and correctly by sexually active adolescents, possibly

resulting in fewer pregnancies.

6~e ~ffectlvenes~ of ~ond~ms in ~revcnt~g tie &mmisslon of ~Sand Sms in adolescents is not ~o~ b~ause most studies k adolescents

have investigated condom use as a method of contraception only. See ch. 9, ‘‘AIDS and Other Sexually Transmitted Diseases: Prevention and Services, ’

in this volume for further discussion of studies of the effectiveness of latex condoms lubricated with nonoxynol-9 in preventing the transmission of AIDS

and STDS in adults.

700f tie fine con~amptlve methods detem~~ by OTA in 1982 to be ‘‘hi@ly likely’ ‘ to be available before 1990 ( 198), ody IhR/3 were &kg

marketed in the United States by mid-1989 (130).
Table 10-7-Overview of Contraceptive Methods Most Commonly Used by U.S. Adolescents

Theoretical rate of Actual rate of failure

Contraceptive failure in terms of in U.S. females under 20c

Selected advantages Selected disadvantages

methoda

preventing pregnancyb White Nonwhite for adolescents for adolescents

Oral contraceptives 0.1% 9.3% 18.1%

(“the pill”)

Condom

Diaphragm

Spermicidese

13.3 22.3

12.4 35.5

35.0 34.0

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

Relatively effective in preventing pregnancy

Not linked to sexual activity, requires less planning

May improve acne, dysmenorrhea, anemia

May protect against ectopic pregnancy, ovarian

and endometrial cancer, pelvic inflammatory disease (PID)

Inexpensive

Relatively effective in preventing pregnancy

Readily available without prescription

Protects against AIDS and most other STDs

Few side effects

Involves male in contraception

Few side effects

Protects against some STDs (with use of a

spermicide)

Inexpensive

Readily available without prescription

Few side effects

May increase lubrication during sex

Protect against some STDs

●

●

●

●

●

●

●

●

●

*

*

●

●

●

Requires gynecological examination and prescription

Can be expensive

Requires daily use by females

Minor side effects (e.g., headaches, nausea,

breast tenderness, spotting)

Small risk of serious side effects (e.g., stroke,

pulmonary embolism)

Does not protect against AIDS or most other

sexually transmitted diseases (STDs)

Linked to sexual activity, requires planning

Requires cooperation of male partner

Requires gynecological examination, fitting, and

prescription

Linked to sexual activity, requires planning

Sometimes perceived as messy, hard to use

Possibly increases risk of toxic shock syndrome

Linked to sexual activity, requires planning

Allergic reactions for some (women or partners)
Table 10-7—Overview of Contraceptive Methods Most Commonly Used by U.S. Adolescents-Continued

* Theoretical rate of Actual rate of failure

Contraceptive failure in terms of in U.S. females under 20c Selected advantages Selected disadvantages

methoda

preventing pregnancyb White Nonwhite for adolescents for adolescents

Rhythm (calendar) 10 22.8 34.1 ●

●

●

Withdrawalf (coitus 4 34.0g61.5g

●

interruptus) ●

●

No side effects ●

Virtually no cost

May help young women learn about their bodies ●

and menstrual cycles ●

Virtually no cost ●

No side effects

Involves male in contraception ●

Decreased effectiveness in women with irregular

menstrual periods (e.g., younger adolescents)

Requires periods of abstinence

Does not protect against AIDS or other STDs

Requires cooperation and self-control by male

partner

Likely to diminish sexual pleasure

Does not protect against AIDS or other STDs

aseveralmntraceptive meth~ are not includ~ in this ta~e. The intrauterine dev~e (IUD) is not included ~use it has hen im@i~ted as a possible causative agent in pe[vic inflammatory disease

and is generally not recommended for use in adolescents (189). Sterilization is not included because it is generally not considered appropriate for adolescents. Also not included are NORPLANT@

(a 5-year contraceptive implant approved by the Food and Drug Administration for use in the United States in December 1990) or cervical caps. As of early 1991, the effectiveness and safety of

these methods in adolescents had not been specifically evaluated, and other questions concerning their use in adolescents remain.

bThis ~[umn ~ho~s, ~ong those who initiate use of a method and who use it perfectfy (i.e., consistently and correctly during eati act of intercourse), the iowest eX~Cted perCentage Of women

who will experience an accidental pregnancy during the first year of use if they do not stop using the method for any other reason. The figures were derived from R.A. Hatcher, et al., 1988 (76).

~his column shows, among females under 20 who participated in the 1982 National Survey of Fam ily Growth, the percentage of females who became pregnant accidentally during the first year

of use of a given contraceptive, corrected for underreporting of abortions. The figures were derived from E.F. Jones and J.D. Forrest, 1989 (97).

dThe information in this column was derived la~gety from R.A. Hat&er, et al., 1988 (76), and A. Rosenfield, 1989 (174).

evaginal Sperm icicles ~me in ava~ety Of forms: ~ntraceptive foam, sperm icidal suppx.itories, creams and gels with sperm icidal effects (sometimes used~th a diaphragm or~r~cal CaP). Va9inal

contraceptive sponges and condoms that contain sperm icicles are also available.

fwithdrawal (coitus intermptus) is not a method suggested by f~ily Piannin9 providers.

9These figures may not accurately reflect failure rates for withdrawal, since contraceptive failures resulting from use of both withdrawal and douche, as well as other miscellaneous methods mentioned by adolescent respondents, were combined. Separate data on failure rates for withdrawal alone in this population are not available.

SOURCE: Office of Technology Assessment, 1991, based on E.F. Jones and J.D. Forrest, “Contraceptive Failure in the United States: Revised Estimates From the National Survey of Family Growth,”

Family Planning Persped”ves 21 (3):1 03-109, 1989; R.A. Hatcher, F. Guest, F. Stewart, et al., Contraceptive Technology 1988-1989, 14th rev. ed. (Atlanta, GA: Printed Matter, Inc., 1988);

and A. Rosen feld, “Modern Contraception: A 1989 Update,” Annual Review of Pubhb Hea/th 10:385401, 1989.
II-376 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box IO-B—Examples of New and Emerging Contraceptive Technologies

Efforts to develop contraceptives that are easier to administer and use, are more effective and have fewer side

effects, and are less costly than existing contraceptives could be of great importance to adolescents. In recent years,

however, several major U.S. pharmaceutical companies have abandoned their contraceptive research and

development programs (143a). Thus, public sector funding and the increased activity of nonprofit groups and small

entrepreneurial firms has become increasingly important to the development of new contraceptive methods.

Several examples of new and emerging contraceptive technologies of possible importance to adolescents,

including modifications of existing technologies, are discussed below.

Contraceptive Methods for Females-In Western Europe, Canada, and some developing nations, several

new methods for delivering contraceptive hormones to women to control their ovulation have been available for

as long as a decade; other new methods for delivering hormones to women are still being developed. Most of these

delivery systems release contraceptive steroids into the bloodstream at a constant, slow rate and in smaller doses

than existing oral contraceptives. Contraceptive steroids do not protect against acquired immunodeficiency

syndrome (AIDS) or most sexually transmitted diseases (STDs). Examples of new methods of delivering

contraceptive hormones to females to prevent pregnancy include the following:

● Contraceptive implants—In December 1990, the U.S. Food and Drug Administration approved use in the

United States of NORPLANT®, a set of nonbiodegradable progestin-releasing capsules that are surgically

inserted under the skin of a woman’s arm. A version of NORPLANT® currently available in over 12

countries provides up to 5 years of highly effective (less than 1 percent failure rate) protection against

pregnancy (83a). The capsules are somewhat visible after insertion, but if a woman wants to become

pregnant, the capsules can be removed by a trained health professional. The incidence of serious health

problems associated with NORPLANT® is low, but data on long-term health effects have not been

systematically collected (83a). Furthermore, the field trials of NORPLANT®, like those for most drugs,

excluded women under age 18. Data about NORPLANT’s effectiveness and side effects in adolescents,

therefore, are not currently available. Other contraceptive implants being tested include biodegradable

pellets. The contraceptive effects of biodegradable pellets (unlike those of NORPLANT®) could be reversed

only in the first few months following the pellets’ insertion (before they began to degrade).

. Contraceptive injections---Contraceptive injections of long-acting progestins with high rates of effectiveness in preventing pregnancy are currently available in many countries of the world. The most commonly

used progestins are medroxyprogesterone (Depo Provera®) and norethindrone enanthate (76). DepoProvera®, a progestin injection administered to a woman once every 3 months, is highly effective in

preventing pregnancy (failure rate of less than 1 percent) and is used by approximately 4 million women

worldwide. Because of concerns about its safety, the U.S. Food and Drug Administration has not approved

Subsidized Family Planning Clinics—Family out, most family planning clinics have been almost

planning services-which typically include birth exclusively female-oriented in both their approach

control information and counseling, provision of

contraceptives, pregnancy testing and counseling,

gynecological exarninations, and referrals for related services such as primary care-are available to

adolescents through private physicians and through

a variety of public and private nonprofit health

providers (e.g., public health departments, and

private nonprofit clinics supported by organizations

such as Planned Parenthood) .71

As the National Academy of Sciences’ Panel on

Adolescent Pregnancy and Childbearing has pointed

and the services they offer (148), However, new

strategies are being used in programs designed

specifically for adolescent males (see section below

on programs for adolescent males).

Adolescents, especially black females, tend to use

family planning clinics more often for obtaining

contraceptives than they use private physicians

(207a,234). In the 1988 National Survey of Family

Growth, 30.4 percent of 15- to 19-year-old females

reported one family planning visit in the 12 months

preceding the survey (207a). For their most recent

71As disCusse4 later in this chapter, about 4,000 public and private nonprofit f~y pl arming providers receive Federal grants under Title X of the

Public Healtb Service Act.
Chapter 10---Pregnancy and Parenting: Prevention and Services . //-377

it for use in the United States (76). Several other types of injectable contraceptives with high rates of

effectiveness are currently available in different parts of the world. In addition, new formulations of

injectable contraceptives that use microcapsules for gradual release of hormones over a longer period of time

are undergoing clinical testing.

. Transdermal patches containing contraceptive hormones--Transdermal patches, currently being used to

provide estrogen replacement therapy to postmenopausal women, are being tested as contraceptive devices.

Worn on the body and replaced at regular intervals by the user, these patches could provide a continuous

low-level dose of contraceptive hormones. In one system, a new patch is worn each week for 3 weeks of

the month; then the patch is removed for a week to allow menstrual bleeding to occur (143a).

● Vaginal rings containing contraceptive hormones—Vaginal rings (of about the same circumference as a

diaphragm) that continuously release contraceptive hormones are undergoing clinical trials. The rings can

be removed for a few hours without compromising their effectiveness in preventing pregnancy (a failure rate

of 3.5 percent in one trial). They would have the advantage of being readily reversible, but their use would

require a level of familiarity and comfort with their genitals that some adolescents may not have.

Research on contraceptive vaccines for females, which would immunize women against either pregnancyrelated hormones or against male sperm, is still in the early stages (143a). In theory, such methods would require

initial immunizations, possibly in a series of shots, after which periodic booster shots would be necessary to continue

to control a women’s fertility. A contraceptive vaccine would have the disadvantage for some users of not being

readily reversible. For sexually active adolescents, most of whom do not wish to become pregnant while still in

school, however, a contraceptive vaccine might be very appealing. On the other hand the use of a contraceptive

vaccine would probably not protect against AIDS or most STDs.

Two modifications of barrier methods of contraception for females that are currently being tested in the

United States are disposable diaphragms that contain spermicides, and condoms that line the vagina, are larger than

condoms for males, and may provide greater protection against STDs. Like the vaginal rings, as well as the currently

available diaphragms and the contraceptive sponge, such methods require a level of comfort and familiarity with

one’s genitals that some adolescents may not have. More effective spermicides, including spermicides that not only

protect against pregnancy but also provide greater protection against STDs, are currently being developed (143a).

Contraceptive Methods for Males-Contraceptive methods that inhibit the production of a man’s sperm or

affect the sperm’s ability to fertilize the human egg still require substantial basic research. Hormonal or vaccine

contraceptives for males are not likely to be available for general use in the United States for at least a decade.

Gossypol, a cotton seed derivative has been used as an oral contraceptive for males in China, however, and this or

other nonhormonal, nonendocrine contraceptive methods may hold promise (143a).

SOURCE: Of&e of Technology Assessment, 1991.

source of family planning services in 1988, two- higher on average than clinic fees for comparable

thirds of 15-to 19-year-olds used a family planning

clinic (207a) .72

Various factors may affect adolescents’ decision

to use family planning clinics rather than private

physicians’ services.73 One reason that some adolescents seeking contraceptive services prefer public or

private nonprofit family planning clinics to private

physicians is undoubtedly cost. Adolescents typically have limited personal incomes, and physician

fees for birth control services are almost four times

services (34).

Another reason some adolescents prefer clinics to

private physicians is concern about confidentiality

in visiting private physicians (34,112). This concern

may be well-justiified. Data from a national sample

of private physicians indicate that only 59 percent of

general and family practice physicians are willing to

provide contraception to minors without parental

consent, although 80 percent of obstetricians and

72~teres@ly, the Use Of family pl arming clinics by white adolescent females increased between 1982 and 1988 (horn 44.0 percent to 60,6 percent),

but use by black adolescent females decreased (from 73.7 percent to 65.4 percent) (207a).

TsFor ~erdis~sslon of factors that may affect adolescents’ access to services, see ch. 15, “~JOr ISSuesPeti g to the Delivery of Primary and

Comprehensive Health Services to Adolescents” and ch. 16, “Financial Access to Health Services, ’ and ch. 17, ‘‘Consent and Confidentiality in

Adolescent Health Care Decisionmakm“ g,” in vol. In.

2’)7 !) fl; —’)1 —– 1,; (JJ. .;
II-378 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

gynecologists are willing to do so (161).74 A recent

survey of primary care physicians (general and

family practitioners and internists) found that only

57 percent thought that it was acceptable to make

contraceptives available to minors without parental

consent (222). In contrast, a 1982 study found that

only 14 percent of clinic providers required parental

consent or notification for contraceptive services to

minors (69).

Some critics of family planning programs have

expressed concerns that such programs increase

adolescent sexual activity, pregnancy, abortion, and

birth rates. As shown in table 10-8, the findings of

studies using a rather global approach to examining

the effects of the availability of family planning

services are contradictory. Some studies have found

a positive association between the availability of

family planning services and higher adolescent

pregnancy rates, and some studies have found

negative associations.

A 1977 study by Moore and Caldwell found that

the availability of subsidized family planning services in States was associated with a lower occurrence

of pregnancy among black adolescents ages 16 to 18

(138). This finding did not hold for whites, perhaps

because black adolescents rely more on public

family planning services and are therefore more

affected by their availability than are white adolescents. Moore and Caldwell also found that the

availability of subsidized family planning services

was associated with lower out-of-wedlock pregnancy rates among 15- to 19-year-old blacks.

A 1981 study by Forrest and colleagues found that

areas with greater increases between 1970 and 1975

in the proportion of adolescents enrolled in subsidized family planning clinics had larger declines in

adolescent birth rates (59). The authors estimated

that for every 10 adolescents ages 15 to 19 involved

in a public family planning clinic program in 1975,

almost 3 pregnancies and 1 birth were averted in

1976. The authors also estimated that during the

1970s, over 2.6 million pregnancies to adolescents

were prevented through use of federally funded

family planning clinics (59).

But a 1982 study of family planning services in

California by Kasun found a positive association

between levels of spending for family planning

services and adolescent pregnancy rates and concluded that increased availability of contraceptive

services led to higher levels of sexual activity among

adolescents (100).

A 1986 study by Olsen and Weed found that

higher levels of utilization of family planning clinic

programs by adolescents nationwide were associated with higher pregnancy rates among adolescents

(156). Family planning enrollment by females ages

15 to 19 seemed to result in an average increase of

about 120 pregnancies per 1,000 adolescent family

planning patients. This study found a decline in birth

rates associated with family planning program

involvement by adolescents but attributed it to

family planning programs’ effects on pregnancy

continuation rather than occurrence.

A 1990 study by Lundberg and Plotnik found a

positive association between restrictive State laws

governing the availability of contraceptives and high

rates of premarital adolescent pregnancies; this

study also found a negative association between the

availability of family planning services for Medicaideligible women and high rates of premarital adolescent pregnancies (124b).

There are several possible reasons for the conflicting findings of studies using a global approach to

examine the effects of the availability of family

plamming services on adolescent pregnancy. The

studies use different levels of aggregation (counties,

States), different time periods (e.g., late 1960

through 1971 [138] V. 1979 to 1986 [124b]), and

different units of analysis (e.g., States [59] v.

individuals [124b,138]). The studies also differ in

statistical methods, measurement of policy and

program variables, and indicators of pregnancy (e.g.,

birth rates [59], nonmarital childbearing [124b],

pregnancy rates [156]).

Family Planning Clinics With a Special Emphasis on Adolescent--Some family planning and

general health clinics operate teen clinics, where

adolescents are served separately from other clinic

patients and services are tailored to adolescents’

needs for confidentiality, sexuality and birth control

information, after-school hours of operation, and

low costs (83). Others have special outreach and

followup programs for young people (e.g., work to

maintain contact with adolescent patients following

TdFor ~ di~cu~~ionof State laws ad us. Supreme co~ d~isions re~ted to consent ~d Cotildentitity in the provision of f~y phl.(lhlg S~lUS

to minors, see ch. 17, “Consent and Cont3dentiality in Adolescent Health Care Decisionmaking,” in Vol. III.
Table 10-8--Evaluations of Contraceptive Provision Policies and Programs

Program Participant Evaluation

Studyn

characteristics characteristics method Findings

Subsidized family planning clinics:

Moore and - “ 1. Percent of need for subsiCaldwell, 1977

Forrest, Hermalin,

and Henshaw,

1981

Kasun, 1982

Olsen and Weed,

1986; W and

Olsen, 1986

dized family planning

services met in State,

1969.

Il. A. Existence of State

laws limiting family

planning services to

females 18 and older.

B. Availability of

subsidized family

planning.

Family planning clinic programs that receive

Federal funds under

Title X of the Public

Health Service Act

(the Family Planning

Services and Population Research Act of

1970) in 1975to 1976.

Family planning services

in California.

Organized family planning

clinic programs in all

50 States and the District of Columbia, as

surveyed by the Alan

Guttmacher Institute in

1975.

1.1,479 black and 3,132“othet’ (mostly

white) females ages 15 to 19 in a

national probability sample; surveyed

in 1971.

Il. Out-of-wedlock birth rates among 15-

to 19-year-olds, by States, 1971.

Adolescents ages 15 to 19 in 1970 and

1975 who participated in federally

funded family planning clinic programs.

Unknown.

Females ages 15 to 19 in 1975 who

were clients of organized family planning clinic programs.

1. Used regression analysis to determine

estimated effects of meeting need for

subsidized family planning services in

respondent females’ State of residence.

Il. Compared policy and program characteristics to out-of-wedlock birth

rates, aggregated at State level.

Used multivariate analysis, with counties as the unit of analysis, to assess

the impact of family planning clinic

use on birth rates among adolescents. Used aggregates of the proportion of adolescents enrolled in

federally funded family planning clinics, the rate of births in 1976 to

adolescents ages 15 to 19 in 1975

as the outcome measure, and compared birth rates in 1970 and 1976.

Used national data on the relationship between birth rates and pregnancy rates to estimate the effect of

family planning programs on pregnancy and abortion rates among

adolescents ages 15 to 19.

Compared levels of spending for family

planning services with adolescent

pregnancy rates.

Used regression analyses, with States

as the unit of analysis, to assess the

effect of levels of enrollment of adolescents ages 15 to 19 in family

planning programs on birth rates and

pregnancy rates among adolescents.

Used available State-level estimates

of abortion rates and birth rates

among adolescents to develop estimates of overall pregnancy rates.

1. Availability of subsidized family planning

services in States was negatively associated with the occurrence of pregnancy

among older (ages 16 to 18) black females. No association for other age groupings, or between availability of subsidized

family planning services and transition to

first intercourse.

Il. A. Existence of laws limiting contraceptive services was associated with higher

out-of-wedlock pregnancies.

B. AvailabiIity of subsidized fami Iy planning services was associated with

lower rate of out-of-wedlock pregnancies among blacks only. No relationship for whites for either variable.b

For both white and nonwhite adolescents,

areas with greater increases between

1970 and 1975 in the proportion of

adolescents enrolled in family planning

clinics had larger declines in birth rates

among 15- to 19-year-olds from 1970 to

1976. For every 10 patients ages 15 to

19 who were enrolled in family planning

clinics in 1975, the authors estimated

that 2.82 pregnancies to adolescents

(for a total of 331,000 pregnancies) were

prevented in 1976. For every 10 patients

ages 15 to 19 who were enrolled in

family planning clinics in 1975, the authors estimated that 1.01 births to adolescents (or a total of 119,000 births)

were averted in 1976.

Positive association (i.e., the higher the

level of family planning spending, the

higher the adolescent pregnancy rate).

The level of enrollment of adolescents ages

15 to 19 in organized family planning

programs was associated with increased

and decreased birth rates among 15- to

19-year-olds. Although not as significant

a predictor of teen pregnancy rates as

several demographic variables (i.e., the

ratio of married to unmarried 15- to

19-year-olds in each State and the percent of the State population that was

white), family planning program enrollment by adolescents seemed to result in

an average increase of about 120 pregnancies per 1,000 adolescent family

planning program patients.

Continued on next page
Table 10-8-Evacuations of Contraceptive Provision Policies and Programs-Continued

Progra m Participan t Evaluatio n

study ’ characteristic s characteristic s metho d Findings

Lundberg and

Plotnick, 1990

Family planning

clinics with a special emphasis on

adolescents:

Chamie, Eisman,

Forrest et al., 1982

4 policy or program variables at State level; 1)

restriction on contraceptive licensing, advertising, or selling; 2)

proportion of counties

in which family planning clinics serve <50

percent of low-income

women at risk of unintended pregnancy; 3)

proportion of teenage

women at risk who obtain family planning

services; and 4) proportion of Medicaid-eligible women at risk of

unintended pregnancy

served by family planning clinics.c

Various family planning

clinics in 37 counties

throughout the United

States, all with at least

200 adolescents a

year.

11,181 white females who were ages 14 Nested Iogit analysis

to 16 in the first (1979) round of

NLSY and provided data on premarital pregnancies and other pregnancyrelated events for the period 1979 to

1986 .

d

Included 124 clinic directors, over 3,500 Using data from survey questionnaires

“teenage” clinic patients and over of all participants, compared charac6,000 adult patients (ages not speci- teristics of clinics in counties identified), plus approximately 1,000 phar- fied as having a high proportion

macists and 1,000 physicians in the (average 75 percent) of their sexucounties where the clinics were lo- ally active adolescent population

cated. served by family planning clinics

(“high-met-need” counties) with clinics in communties that had a lower

proportion (average 28 percent) of

sexually active adolescents who were

family planning clinic patients

(“low-met-need” counties).

largest (and significant) effects on premarital pregnancy were found for variables 1

and 4.

Clinics in “high-met-need” areas were more

likely to have special outreach and folIowup programs for adolescents, to provide services to minors without requiring

parental consent, to combine family plain

ning with other health services, to provide free services to adolescents, and to

see adolescents on a walk-in basis.

Although the rates of adolescent pregnancy in both types of counties were

similar (about 32 percent), adolescents

in “low-met-need” counties were more

likely to have terminated their last pregnancy, while those in “high-met-need”

counties were more likely to have given

birth.
I

Table 10-8-Evaluations of Contraceptive Provision Policies and Programs—Continued

Program Participant Evaluation

study a

characteristics characteristics method Findings

Kisker, 1984 Same as Chamie, Eis- Same participants as Chamie, Eisman, Using data from survey questionn~res

man, Forrest, et al., Forrest, et al., 1982 (see above) of all participants, factors predicting

1982 (see above) three indicators of clinic effectiveness in serving adolescents (mean

delay between teenage patients’ selfreported first intercourse and first

visit to a family planning clinic; clinic

retention of teenage patients, as

reported by clinic directors; and level

of satisfaction with clinic services

reported by teenage patients) were

studied using regression analyses.

Clinics with community education programs

geared to adolescents seem to reduce

delay in clinic visits following first intercourse by 4 to 5 months; the support of

local churches for teens’ use of family

planning services appeared to decrease

delay by about 3 months, and having

active relationships with local youth

groups also decreased delay by about 2

months. The longer teenage patients

had to travel to get to the clinic, the

longer the mean delay: every 5 extra

minutes of travel time increased the

delay in seeking clinic services by almost a month. Clinics that served more

adolescent patients on a walk-in basis

also decreased delay. Working with local

youth groups increased the ability of

clinics to retain teenage patients, as did

having at least 3 hours of clinic time in

the evening and on weekends and offering a larger range of services to adolescents (e.g., special youth programs,

abortion services, prenatal care). interestingly, clinics that reported greater

amounts of counseling and education

time with patients slightly raised the

mean delay in seeking clinic services

and slightly lowered retention of teenage patients, although it also increased

teenage patients’ satisfaction with clinic

services. The authors speculated that

teens might perceive the educational

services as “preachy,” although information about their satisfaction with the

educational and counseling services offered was not collected.

Continued on next page

●
Table 10-8-Evaluations of Contraceptive Provision Policies and Programs-Continued

Program Participant Evaluation

Studya characteristics characteristics method Findings

Herceg-Baron, Two special service compoFursterberg, Shea, nents for adolescents

et al., 1986 implemented in existing family planning programs in 9 sites: famity support services provided short-term (6

week) counseling for

adolescents and

family members, to sup

port adolescents’ contraceptive use and sexual decisionmaking,

and periodic support

in the form of weekly

telephone calls from

project staff for 6 weeks

to monitor adolescents’

adjustment to their

chosen contraceptive

methods.

Winter and Brecken- “A total service delivery

maker, 1991 system for adolescents,

from initial contract to

follovuup,” including the

following critical elements: one-to-one educational, concrete information, more frequent visits, Ionger tele

phone and on-site con

tacts with staff, special staff training in

adolescent development, encouragement

of male participation,

greater attention to adolescen tcomfort, confidentiality.

N = 469, female clinic patients ages 12

to 17, making first visit to clinics.

Approximately one-half black and

one-half white, one-third under the

age of 16; only 13.5% were not yet

sexually active.

Experimental groups: 518 adolescent

females under age 18 in 3 sites.

Control groups: 738 adolescent females in 3 control sites, 98 percent

whites.

Personal interviews were conducted at

the time of the first clinic visit, and 2

followups were conducted by telephone approximatety 6 months and

15 months later. Patients were randomly assigned to 1 of the 2 special

services groups, or to 1 of 2 control

groups (the first control group took

part in all three interviews, and the

second was contacted only for the

third interview. Patients in control

groups received only those services

routinely offered in each clinic site.

Baseline and post-treatment evaluations

at both experimental and control

sites.

-. . . . . . . Study design was compromised, since only

36% of the patients who agreed to

participate in the family support services

actually attended any counseling sessions, and only 5% of those who attended came with a parent. A total of

84% of those who agreed to periodic

support were contacted at least once;

they averaged 2.6 calls. No significant

differences in regularity of contraceptive

use or pregnancy rates were found

between special services or control

groups.

Clients in experimental site had higher gains

in knowledge, more persistent use of

contraceptives, greater ease in using

contraception, and, for continuing patients, significantly Iower pregnancy rates

(4.0 v. 7.8%). Differences in pregnancy

rates were marginally significant when

all patients (including program dropouts)

were considered.
Table 10-8-Evaluations of Contraceptive Provision Policies and Programs--Continued

Program Participant Evaluation

Study” characteristics characteristics method Findings

School-linked health

centers (SLHCs)

Edwards, Steinman, Arnold, et al.,

1980

Zabin, Hirsch,

Street et al., 1988;

Zabin, Hirsch,

Smith, et al.,

1986a&b

Kirby, Waszak, and

Ziegler, 1989

Female student population of schools

served by clinic program; female

users of famiIy planning services in

MIC school clinics (N= 403)

Students in schools linked to the clinic;

all students in both clinic schools

were black. Comparison group of

black students in socioeconomically

similar junior and senior high

schools in the same school system.

N = 667 males and 1,033 females in

intervention group, and 944 males

and 1,002 females in comparison

group, at baseline; 506 males and

695 females in intervention group,

and 860 males and 889 females in

comparison group, at end of project.

Various-included from 24% to 90% of

student population in clinic schools;

4 sites had comparison groups from

sociodemographically similar high

schools; predominantly black in 5

sites, substantial Hispanic representation in 2 sites, less than one-fifth

white in all sites.

Assessed changes over time in birth

rates among the female student population; assessed rates of continued

use of birth control in female clinic

users. (No “pm-post” statistical testing of changes over time was conducted; no comparison group.)

Self-administered questionnaire collected

data from all students regarding knew+

edge of and attitudes toward pregnancy risk and contraceptive use,

sexual behavior, and pregnancy experience. Changes over time in these

variables were assessed, by length

of exposure to the clinic program.

School system data on pregnancies

among female students in all public

schools were used to compare pregnancy rates among females in the 2

program schools with other junior

and senior high schools.

Student health survey (self-report questionnaire) used in all sites; assessed

clinic use, use of other medical services, risk-taking behaviors (e.g., drug

use, speeding), sexual activity, birth

control use, pregnancy experience.

Four sites had comparable data from

students in comparison schools; 2

sites collected baseline data before

clinics opened and posttest data 2

years later.

By the end of the 3rd year, the birth rate

among females in the clinic schools had

dropped from 79 births per 1,000 females to 35 births per 1,000; 86.4°/0 of

females who received contraceptives

from the MIC project continued to use

them for at least 12 months.

Significant increases in knowledge of pregnancy risk and use of contraceptives

among students in clinic schools; greater

knowledge gains were seen among those

with longer exposure to the program.

Females age 15 and older who had not

been sexually active at the beginning of

the program delayed first intercourse for

an average of 7 months, when compared with their peers in nonclinic

schools. Program increased the percentage of females who attended at

clinic for birth control services both be

fore their first intercourse and within a

month of initiating sex. By the end of t he

3rd year, of the project, pregnancies

among females in clinic schools had

declined by 30%, while rising 58% in

comparison schools.

None of the clinic schools had significantly

higher percentages of sexually active

students than comparison schools; at 2

sites, students in the clinic schools reported significantly later ages at first

intercourse than students in comparison

schools. At 2 sites, more students in

clinic school samples reported using

birth control at last intercourse than in

nonclinic or preclinic samples. No differences in self-reported pregnancy (or

impregnation, for males) rates were found

between clinic school students and nonclinic or preclinic samples.

Continued on next page
:

ii!

1.

Table 10-&Evaluations of Contraceptive Provision Policies and Programs-Continued

Program Participant Evaluation

Studya

characteristics characteristics method Findings

Condom distribution programs:

Arnold, 1973 Outreach workers distrib- Adolescent males. Compared fertility rates in target and Fertility rate of black adolescent females

uted condoms. nontarget areas. ages 10 to 19 declined 19 percent

compared with no decrease in nontargeted areas.

Kirby,Harvey, Claus Educational pamphlet and Adolescent males. Phone survey asking about condom Educational materials appeared to have no

senius, et al., 1983 order form mailed. Tar- use. impact on changing attitudes related to

geted males could oeder sexual behavior. The offer of free confree condoms. doms did not appear to increase levels

of sexual intercourse or increase the

possibility of using condoms at last

intercourse.

aFuil citations are listed at the end of this chapter.

bh is imp~ant t. note that although Moore ad Cal&ell reWt~ that they used multi~e regression and explor~ effects of i~epend$nt variables, they did not report how mUCh each

variable contributed to the outmme of interest. They did note, however, that much of the variance remained unexplained after their analysis (1 38).

CSOUrCeS and years of data are explained in Lundberg and Plotnick, 1990 (124b).

d~ly the ~~ion of the ~na{ys~ relat~ t. the availability of ~ntmaption and f~i~ planning ser~ces is presented here. The impacts of various policies on marriage V. premarital birth and on

abortion were also explored (124b).

SOURCE: Office of Technology Assessmentp 1991.

1=
Chapter l&Pregnancy and Parenting: Prevention and Services . II-385

clinic visits, to encourage continued use of contraceptives, or to provide outreach through community

education and contact with local youth groups)

(11 1). Teen-oriented family planning clinics are

more likely to provide free services to adolescents

and to see adolescent patients on a walk-in basis than

are clinics that are less effective in reaching adolescents (34).

Prior to a recent study by Winter and Breckenmaker (223a), studies of family planning services

with a special emphasis on adolescents had found

that such services demonstrate only a minimal

impact on adolescent pregnancy rates or birth

control use (82,1 11). In 1982, Chamie and colleagues used survey data from family planning

clinics and county-level adolescent population data

in 37 counties across the United States to devise an

index of counties with “high met need” (a high

proportion of the sexually active adolescent population being served by family planning clinics) versus

“low met need” (a low proportion of the sexually

active adolescent population being served by family

planning clinics) (34) (see table 10-8). They then

compared the counties’ level of met need to the

counties’ adolescent pregnancy, abortion, and birth

rates. Clinics in “high-met-need” counties were

more likely to have special outreach and followup

programs for adolescents, to provide services to

minors without requiring parental consent, to combine family planning with other health services, to

provide free services to adolescents, and to see

adolescents on a walk-in basis. Chamie and colleagues found that adolescent pregnancy rates in

low-met-need counties were similar to those in

high-met-need counties; however, abortions were

more likely in “low-met-need” counties and births

more likely in “high-met-need’ counties. The

authors hypothesized that more of the pregnancies in

the “high-met-need” counties might have been

intentional, but they did not collect data on pregnancy intentions.

Kisker’s 1984 analysis of the same survey data

was limited to those adolescents who had actually

used the family planning clinics (1 11) (see table

10-8). Kisker found that several factors characterized family planning clinics that appeared to be more

effective either in increasing the delay between

initiation of sexual intercourse and the receipt of

contraceptive services or in retaining adolescent

clients:

●

●

●

●

●

●

location in communities with community education programs,

the support of local churches for adolescents’

use of contraceptive services,

active relationships between the clinics and

local youth groups,

less travel time to the clinic,

service available to adolescents on a walk-in

basis, and

weekend and evening hours (1 11).

Interestingly, although adolescents reported greater

satisfaction with family planning clinics that provided counseling and education (although not specifically with these elements of the clinics’ services),

the availability of such services was associated with

a greater average delay between initiation of intercourse and seeking of services.

Chamie’s analysis and Kisker’s analysis were

both based on retrospective reporting by existing

family planning clinic programs. In 1986, HercegBaron and colleagues attempted to implement and

evaluate the effects of special service components

(family support and periodic support) for adolescents in family planning clinics (82) (see table 10-8).

Unfortunately, the study design was compromised,

because only 36 percent of the group of adolescents

scheduled to receive family support services attended any counseling sessions, and only 5 percent

of those who attended came with a parent. The group

of adolescents that was supposed to get periodic

support had been scheduled to receive six weekly

phone calls from staff to monitor the adolescents’

adjustment to their chosen contraceptive methods,

but an average of only 2.6 contacts were actually

completed. Perhaps as a result, there were no

significant differences in regularity of contraceptive

use or pregnancy rates between the special services

and the control groups.

Winter and Breckenmaker’s study in 1991 found,

however, that sites that used experimental protocols

developed by a committee of family planning clinic

personnel and staff of the Family Health Council of

Central Pennsylvania had lower adolescent pregnancy rates than control sites had (223a) (see table

10-8). It seems likely that the Pennsylvania protocols led to more favorable results than did the

intervention in the Herceg-Baron study because the

Pennsylvania protocols actually made changes in the

everyday delivery of family planning services rather

than adding on new components.
II-386 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Comprehensive School-Linked Health Centers

(SLHCs)--One model for delivering family planning services to adolescents has been the SLHC, in

which family planning and other health services are

offered to students in a clinic located on or near

school grounds.75 Data describing the services

provided by SLHCs are available from a 1990

survey of 153 SLHCs operating during the 1988-89

school year, conducted by the Center for Population

Options (95a). Almost all of the 95 responding

SLHCs, which operated on-site at schools, provided

counseling on birth control methods. About 90

percent of the 95 SLHCs conducted pregnancy tests

and performed gynecological examinations, 54 percent provided written prescriptions for birth control

methods, but only 21 percent actually dispensed

contraceptives. At some schools, clinic staff also

conduct sex education sessions in classrooms. In

comparison to office-based physicians, SLHCs may

have the advantage of making health services for

adolescents more readily accessible, approachable,

and tailored to the specific needs of adolescents.76

One of the earliest and most comprehensive

SLHCs was established in two public high schools

by the Maternity and Infant Care Project of St.

Paul-Ramsey Hospital in St. Paul, Minnesota. The

St. Paul SLHC program exemplifies a model for the

provision of family planning services and other

health services at a clinic located on the school site

(50). The St. Paul SLHC was begun as a means of

providing pregnancy prevention and care services

(e.g., prenatal and postpartum care, STDs, pregnancy testing, contraceptive information, and counseling) to the students at these schools, but it was

rapidly expanded to include a more comprehensive

range of health services (e.g., immunizations, general physical examinations) (50).77

In 1980, Edwards and colleagues evaluated the

school-based program established by the Maternity

and Infant Care Project in St. Paul (see table 10-8).

They found that the birth rate among female students

served by the clinic program dropped from 79 to 35

births per 1,000 students in the first 3 years of the

program (50); the birth rate declined even further

over time, dropping to 26 births per 1,000 students

during the 1983-84 school year (86). The program

also demonstrated a very high rate (93 percent) of

reported contraceptive continuation among clinic

patients in the year following the patients’ frost clinic

visit (50). No data were collected on pregnancy or

abortion rates, so it is unclear what proportion of the

decline in birth rates was due to a decrease in

pregnancies and what portion was due to an increase

in the use of abortion. Also, because birthrates were

declining nationwide during the time of the study,

the lack of an appropriate comparison group limits

inferences about the validity of this study’s findings.

A variation on the St. Paul model of services is the

Self Center, a clinic located near both a junior and a

senior high school in a low-income neighborhood in

Baltimore, Maryland (224). The Self Center was

established as a pregnancy prevention demonstration project by the School of Medicine at the Johns

Hopkins University. This SLHC made a range of

reproductive health care services (e.g., contraceptive

counseling, pregnancy testing, provision of contraceptives, educational programs) available after

school hours to all students at the two schools. A

team of clinic staff was assigned to each of the two

schools to participate in the schools’ sex education

programs, provide individual and group counseling

at the schools, and follow up on students who had

been seen at the clinic. The Self Center program was

able to successfully gain participation among the

male adolescents in the school. Males were most

likely to participate in informal group discussions

and to meet individually with social workers who

provided information on and distributed contraceptive devices (225).

In the late 1980s, Zabin and colleagues conducted

a relatively well-designed evaluation of the Self

Center that compared Self Center students with a

carefully matched sample of students from similar

urban Baltimore schools (227) (see table 10-8). Over

75&2 de~c.i~d ~ &15, ‘6MaJ~~ 155ues pe~~ to me Delivery of primary ~d Comprehensive Health Semices to Adolescents, ” hl VO1. ~, them

are substantial variations among SLHC programs. Although all SLHCS aim to provide a wide range of health care semices, what particular SLHCS offer

varies and depends largely on clinic resources, the particular needs of the community’s adolescents, and local attitudes towards providing reproductive

health services in a school-linked setting.

TGFor further discussio~ see ch. 15, “Major Issues Per@ining to the Delivery of Primary and Comprehensive Health Services to Adolescents,” in

Vol. III.

7TThi5 expansion of services away from a strict focus on family pl arming and other reproductive health services has occurred inmost SLHCS. Family

plarming and reproductive health care are still typically considered part of comprehensive health service delivery for adolescents, however. For further

discussio~ see ch. 15, “Major Issues Pertaining to the Delivery of Primary and Comprehensive Services to Adolescents, ’ in Vol. III.
Chapter l&Pregnancy and Parenting: Prevention and Services . II-387

3 years of the Self Center’s operation, they found,

there were significant gains in sexual and contraceptive knowledge among both boys and girls at the

schools that received classroom-based sex education

and that were linked to the clinic. Adolescent

females enrolled in the Self Center program schools

for 2 years or more were found to be significantly

more likely to delay sexual activity (for an average

of 7 months) than adolescent females in the comparison schools.

Zabin and colleagues also found that Self Center

students increased their use of contraceptives and

were more likely than comparison students to visit

the clinic for contraceptive counseling before initiating intercourse or in the first few months after

initiating sexual activity (227). These results were

strongest for those students who were exposed to the

Self Center program for 2 years or more. Finally,

Zabin and colleagues found a substantial (30 percent) drop in the pregnancy rate at the end of 3 years

for sexually active adolescent females in the Self

Center program schools, while conceptions among

adolescent females in the comparison schools increased significantly (57 percent) during the same

time period.

In drawing conclusions about the overall effectiveness of the Self Center program, it is important

to recognize some methodological shortcomings of

Zabin and colleagues’ evaluation. First, the actual

numbers of adolescents used for statistical comparisons were small because of attrition rates from the

program schools. Second, the high school students

involved in the Self Center program were of

somewhat higher academic standing than those who

were not involved.

In 1989, Kirby, Waszak, and Ziegler performed an

in-depth assessment of six SLHCs for the Center for

Population Options (110) (see table 10-8). They

compared schools in which SLHCs were located

with sociodemographically similar schools in the

same communities, and found that students in the

SLHC schools were no more likely to be sexually

active than their peers in the comparison schools

(1 10). In two of the sites, students in the schools with

SLHCs initiated sex at older ages (an average of 8

months later). Also, students in two of the SLHC

schools (those in which the health center staff

provided aggressive outreach for contraceptive education within the school) had higher rates of

contraceptive use than the comparison groups did. In

three SLHC sites in which contraceptives were

dispensed, however, students did not report higher

rates of contraceptive use. According to Kirby and

his colleagues, these findings suggest that the mere

accessibility of contraception may not be sufficient

to increase adolescents’ contraceptive use (1 10).

The 1989 study by Kirby, Waszak, and Ziegler

found that none of the six SLHC programs had a

significant impact on students’ sexual activity or

self-reported pregnancy rates, not even SLHCs that

dispensed contraceptives onsite (1 10). It may be

important to note, however, that the researchers

collected pregnancy data from all students at the

school and did not just compare clinic users to

nonusers. In the three SLHC schools in which clinic

users were compared with nonusers, contraceptive

use was found to be higher among the clinic users,

and, overall, from 44 to 90 percent of the pregnancies that occurred in the student body occurred to

students who had never attended the clinic (1 10). In

any event, the researchers concluded after careful

examination of the programs that the programs were

not as strong and integrated within the school as they

needed to be to lower pregnancy rates,

In considering the effects of SLHCs on adolescent

pregnancy, it is important to keep in mind that the

greatest amount of research to date has been

conducted on the SLHC programs in St. Paul and

Baltimore, both of which were established with the

explicit goals of reducing adolescent pregnancy and

parenting. Other SLHCs-especially those that do

not emphasize reproductive health services-may

not be able to achieve the same kinds of pregnancyrelated outcomes. Furthermore, many SLHCs operate only during the academic year, are not open after

school hours, and do not serve students who have

dropped out of school. Because of its off-campus

location and its after-school hours of operation, the

Self Center in Baltimore was able to avoid some of

these limitations; the avoidance of those limitations

and the Self Center program’s explicit and intensive

focus on pregnancy prevention may have contributed to the apparent success of this program in

reducing adolescent pregnancies.

SLHCs have been opposed on several grounds.

There are concerns among some opponents of

abortion, for example, that the real agenda of clinic

supporters is to promote abortions (74); in many

SLHCs, though, abortion counseling and referrals

are prohibited (148). Another objection is that the
II-388 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

provision of contraceptive services by a formative

public institution such as a school will legitimate

early sexual activity. Another objection to SLHCs is

that most existing data do not support the claim that

SLHCs reduce adolescent pregnancy rates (65,1 10).

Given the limitations of current evidence, however,

it is not possible to conclude that SLHCs do not

reduce pregnancy rates. Evaluation designs have

been mostly pretest-posttest research designs with

no comparison groups, and there have been limitations in the types of data collected.78

It has been argued by some that because of the

great need for health care in the low-income and

minority communities targeted for SLHC locations,

families have been reluctant to protest their establishment (74). Unfortunately, information about the

level of community support for SLHC programs is

limited, although polls conducted in several States

have found that over three-fourths of adults surveyed

favored the establishment of SLHCs (32,42,135).

Condom Distribution and Other Programs

Targeted to Adolescent Male--Contrary to popular opinion, a majority of adolescent males are likely

to acknowledge that they bear some responsibility

for preventing pregnancy in their sexual relationships and say that they are willing to make use of

contraception (166). Whitley and Schofield’s recent

meta-analysis of 134 studies of adolescent contraceptive use found that the major variables affecting

young males’ contraceptive use pertain to encouragement by their partner and favorable attitudes

towards contraception (221). Despite adolescent

males’ willingness to be involved in pregnancy

prevention, family planning and other pregnancy

prevention programs have traditionally focused on

young women and have even excluded adolescent

males (47,148).

Condom Distribution Programs-Condom distribution programs targeted to males are a notable

exception to the general pattern of male exclusion

noted above, and such programs have been increasing in number in recent years. The increase in

condom distribution programs is partly in response

to concerns about AIDS and other STDS

79 and partly

due to the recognition by service providers and

program planners that use of condoms (the birth

control method most frequently used by adolescents

at first intercourse) may help in the ‘‘vulnerable

period” for many young women between initiating

intercourse and seeking other contraceptive services

(148).

Condom distribution programs targeted to adolescent males have largely been carried out by family

planning service providers; distribution locations

have included clinics, pharmacies, community and

recreation centers, neighborhood shops and restaurants, and other places where young men gather.

Some programs have used male outreach workers to

distribute educational materials along with the

condoms, and to encourage their use (148).

In 1988, Kirby and colleagues evaluated a program that attempted to get adolescent males to use

condoms by mailing order forms (109) (see table

10-8). In 1973, Arnold’s evaluation of a condom

distribution program using outreach workers had

found that adolescent males’ use of condoms increased in the area targeted by the program both

during its implementation and at followup (10) (see

table 10-8). In the condom distribution effort that

was evaluated by Kirby and colleagues, a sample of

adolescent males was sent an educational pamphlet

and an order form for free condoms in the mail; in a

followup interview, the males who received these

items were no more likely to report using condoms

than a control group who did not receive them (109).

It seems clear from these two examples that direct

distribution of condoms would lead to greater

condom use than just a mailing of order forms. But

these studies provide no conclusive evidence of

condom distribution programs’ impact on adolescent pregnancy.

Other Efforts To Offer Contraceptives to Adolescent Males-some efforts to involve young adolescent males in family planning services have recognized that adolescent and young adult males are not

likely to make use of services that they perceive to

be geared toward young women and that the

environment of programs that offer contraceptive

services could be changed to make young men more

comfortable. Strategies such as hiring young male

staff members, offering special male clinics, and

changing the physical environment (e.g., by showTsSome s~dies, for example, ~ve collectti data on births to adolescents but have not collected data on all adolescent pregmmcies, leau to tie

assertion that lower birth rates have resulted exclusively from higher abortion rates.

T~or tier discussio% see ch. 9, ‘‘AIDS and SexdyTr-tted Diseases: Prevention and Services, ” in this volume.
Chapter 10---Pregnancy and Parenting: Prevention and Services .11-389

ing sports videos in the waiting room) may help to

reach this goal (166). Active outreach by clinic

providers to contact adolescent males through existing recreational, educational, employment, or health

care programs may be another means of increasing

adolescent males’ utilization of contraceptives (24,

171). Offering non-sexuality-specific services (e.g.,

sports physicals, recreational activities) may also

attract young men to family planning clinics (166).

In general, there are few data available documenting the strategies on either clinic utilization or

impact of contraceptive use among young males.

One effort in a health maintenance organization used

half of a l-hour clinic visit to show a highly explicit

slide and tape program, and the other half to provide

an educational personal health consultation (38a).

Participants and controls were randomly assigned to

conditions in this rare experiment. Sexually active

males who received the intervention were more

likely to use a more effective method of contraception, and all participants had greater knowledge of

fertility and STDs (38a). The program’s effects were

generally stronger among those who had not been

sexually active before the experiment, a finding that

suggests the wisdom of early intervention.

Summary of the Effectiveness of Contraceptive

Provision Programs-programs that provide contraceptives to adolescents show mixed results in

terms of preventing adolescent pregnancies (see

table 10-8). Studies of the impact of subsidized

family planning clinics on adolescent pregnancy

have shown contradictory results, so it is difficult to

come to conclusions about the effect that these

programs have had. Some studies have found a

positive association between the availability of

subsidized family planning services and reduced

adolescent pregnancy rates, and some studies have

found a negative association. Family planning

clinics with a special emphasis on adolescents have

been found in most studies to demonstrate only a

minimal impact on adolescent contraceptive use or

pregnancy rates; one recent study in Pennsylvania

found, however, that protocols that made changes in

the everyday delivery of services for adolescents

increased adolescents’ use of contraceptives and

reduced their pregnancy rates (223a). Studies of

SLHCs that were established with the explicit goal

of reducing adolescent pregnancy and parenting

have found that such SLHCs seem to increase

adolescents’ use of contraceptives but do not always

reduce pregnancy rates. Evaluations of condom

distribution programs suggest that an active effort to

distribute condoms is more likely to get male

adolescents to use condoms than is a more passive

effort such as offering condoms through the mail.

Programs That Seek To Enhance Adolescents’

Life Options

Enhancing adolescents’ “life options” is an

approach to preventing adolescent pregnancy that

has been proposed ‘‘in light of the seeming intractability of adolescent pregnancy rates, despite prolonged efforts to expand sexual education and

contraceptive services” (47a). This approach is

based on the assumption that young people will not

be motivated to avoid early pregnancy and parenthood unless they see alternative pathways to achieving adult status. It is supported by evidence that

low-income adolescents at risk for dropping out of

school are also at increased risk of early pregnancy

and parenthood.

Available information about the effectiveness of

three types of life options approaches is presented

below:

1) life planning and decisionmaking programs,

2) role modeling and mentoring programs, and

3) youth employment programs.

Life planning and decisionmaking programs rely

on a curriculum to improve adolescents’ life planning and decisionmaking skills so as to enable them

to plan for alternatives to early parenthood. The Life

Planning Project developed by the Center for

Population Options and a pregnancy prevention

program developed by the Girls’ Clubs of Santa

Barbara, California, are two examples discussed

below (47a).

Role model and mentoring programs such as Big

Brothers and Big Sisters have typically been designed to provide disadvantaged young people

(males and females) with positive role models and

social support for desirable social behaviors (148).

Such programs offer concrete assistance in the form

of academic tutoring or job interviewing skills. Most

of these programs have not focused explicitly on

sexual behavior or pregnancy prevention, but a few

programs discussed below explicitly emphasize

responsible sexual behavior.

The third kind of life options programs, youth

employment programs, offer their participants actual work experience along with social support or
11-390. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

interventions to improve their life planning. One

example is the Job Corps program for economically

disadvantaged youth. This program, which is administered by the Employment and Training Administration in the U.S. Department of Labor, provides

employment and training in primarily residential

centers for socioeconomically disadvantaged people

ages 16 to 21 (148).80 Other examples of youth

employment programs discussed below are the

federally funded Youth Incentive Entitlement Projects, the Teen Outreach Program (TOP), and the

summer Training and Education Program (STEP)

(148).

As noted earlier, adolescent pregnancy prevention

efforts have traditionally focused on adolescent

females, and some have even tended to exclude

adolescent males. In contrast, some life options

programs have included adolescent and young adult

males, recognizing that limited work and educational opportunities may defeat young males’—

especially low-income and minority males—

motivation to be involved in parental responsibilities (la).

Life Planning and Decisionmaking Program--

The Life Planning Project is a curricular program

developed by the Center for Population Options and

implemented in three communities (47a). The major

objective of the Life Planning Project is to help

adolescent participants avoid pregnancy, largely as

part of planning for their futures (148). The curricular materials emphasize job and career planning,

family planning, and methods of pregnancy prevention through various written exercises and group

activities. The Life Planning Program involves the

participation of a range of youth-serving agencies in

each community, whose staff have implemented the

curriculum among their adolescent clients (148).

Like many pregnancy prevention efforts, the Life

Planning curriculum has not been rigorously evaluated. The evaluation that has been done suggests that

although the intervention may have improved participating adolescents’ knowledge, it did not significantly affect their behavior (148). Because the

evaluation had no comparison or control group, it is

unclear if even the knowledge gains were a direct

result of the intervention itself.

Eight Girls’ Clubs have implemented a pregnancy

prevention program that includes a curriculum based

on a workbook entitled Choices: A Teen Woman’s

Journal for Self-Awareness and Personal Planning

(18), which was developed for adolescent females by

the Girls’ Clubs of Santa Barbara, California. The

‘‘Choices’ workbook provides adolescents with

written exercises and other activities designed to

encourage them to think about their future work and

family life and to enhance their goal-setting and

decisionmaking skills (18).81 The pregnancy prevention program includes two components for younger

adolescent females (mother-daughter workshops

designed to enhance communication about sex and

a variation on the Postponing Sexual Involvement

program discussed earlier) and two components for

older adolescent females (the “Choices’ workbook

and clinic services) (148). The Girls’ Clubs program

that includes the “Choices” curriculum has been

systematically evaluated (86). The results of that

evaluation are expected in the fall of 1991.

Role Model and Mentoring Programs-Little

information is available on the effectiveness of

traditional role model and mentoring programs such

as Big Brothers and Big Sisters in reaching their

goals of encouraging positive social behavior, and

none of these programs have been evaluated for their

potential effect on adolescent pregnancy.

Innovative mentoring programs that have explicitly incorporated pregnancy prevention strategies

include the Athletes Coaching Teens project developed in the Psychology Department at Virginia

Commonwealth University. This program trains

high school and college athletes to conduct sessions

for younger students on goal setting, life planning,

and responsible decisionmaking (39).

Another innovative mentoring program that explicity encourages responsible sexual behavior is a

program begun by the Urban League as part of its

Adolescent Male Responsibility Program (148).

College students in Kappa Alpha Psi, the national

black fraternity, serve as mentors to young adolescent males, meeting with them three evenings each

week and providing them with remedial education,

recreational activities, and community service opportunities. The mentors specifically emphasize responsible

80~&tio~~omtion on the Job Corps is presented in ch. 19, “The Role of Federal Agencies in Adolescent Heal@” in Vol. III.

81A ~omp~on ~ok entiti~ 1‘~lewe5’ ~&en develop~ for adolescent ~es;~s book bS not been USed as extensively, however, ~d there

seem to be no plans to evaluate its impact (47).
Chapter 10-Pregnancy and Parenting: Prevention and Services . II-391

sexual behavior. A similar project involving adolescent females with a national black sorority (Delta

Sigma Theta) has also been developed (148).

Although evaluations of all three of the innovative

mentoring projects identified above are underway,

data on the impact of these innovative efforts on

adolescent sexual activity, contraceptive use, or

pregnancy were not available as of mid-1991.

Youth Employment Programs--As noted above,

youth employment programs include large-scale

federally funded programs such as Job Corps programs, which are intended to address employment

problems among socioeconomically disadvantaged

young people ages 16 to 21 by teaching job skills,

providing incentives to employees, and placing

individuals in jobs (148). They also include demonstration projects such as the Summer Training and

Education Program (STEP), which served adolescents in five cities, and the Teen Outreach Program

(TOP) in St. Louis (see table 10-9).

Job Corps and Youth Incentive Entitlement Pilot

Projects-Federal and other programs designed to

increase the employability of young people from

low socioeconomic and minority backgrounds have

been in existence for a number of years. Only

recently has their potential for adolescent pregnancy

prevention been explored. This development follows increasing awareness that a lack of economic

opportunities may influence the likelihood that an

adolescent will become (or will make someone)

pregnant. Most employment and job training programs have not included any explicit instruction in

sex education or family planning,

Presumably because many youth employment

programs have focused on young males and on

employment, information has not been collected on

the impact of traditional youth employment programs on adolescents’ fertility behavior. One notable exception is a 1978 evaluation of the federally

supported Job Corps program (148). That evaluation

found that participation in the Job Corps seemed to

delay family formation and reduce the incidence of

out-of-wedlock childbearing among participants (210).

To OTA’s knowledge, more recent evidence concerning the impact of participation in the Job Corps

on adolescents’ childbearing is not available.

One more recent investigation considered the

impact on adolescent fertility of the federally funded

Youth Incentive Entitlement Pilot Projects. These

pilot projects provided jobs to economically disadvantaged high school students who remained in

school and maintained adequate levels of school

performance (158). The results of the investigation,

while not conclusive, seemed to indicate that adolescent females were more likely to delay childbearing

(at least until the age of 18) in the communities

where the projects were located than were adolescent females in the comparison sites.

summer Training and Education Program (STEP)--

STEP is a 15-month program developed to keep

disadvantaged 14- and 15-year-olds from dropping

out of school and becoming adolescent parents

(185c). With summer income as an incentive,

14- and 15-year-olds who are eligible for the Federal

summer Youth Employment and Training Program

(SYETP) 82 enroll in STEP for two consecutive

summers of remedial instruction in reading and

math, life skills instruction (stressing responsible

social and sexual attitudes and behavior), and work

experience combined with supportive services during the academic year (see table 10-9). Supportive

services offered during the academic year include

individual counseling, group activities, workshops,

and meetings with parents (21,22).

Developed and managed by Public/Private Ventures, a private nonprofit corporation in Philadelphia, STEP was first implemented in a three-city

pilot program in the summer of 1984 (185c).

Following that successful pilot, Public/Private Ventures began a national demonstration of STEP in five

cities (Boston, Fresno, San Diego, Seattle, and

Portland, Oregon). Half the eligible youth interested

in participating were randomly assigned to STEP or

to a control group who participated in SYETP. In

each of the five sites, three cohorts of about 320

youth each are participating in the program and

research, so there are about 4,800 youth in the

demonstration (185 b). Cohort I entered the program

in 1985, Cohort II in 1986, and Cohort III in 1987.

The operational phase of the program ended in

August 1988 with Cohort III’s second summer of

services, but the long-term research phase of the

demonstration (which includes the collection of

Whe Federal Surnmer Youth Employment and Training Program (SYETP) is a U.S. Department of Labor program authorized under Title II-B of

the Job Training Partnership Act. It offers 7 to 8 weeks of summer employment and remedial assistance to low-income teenagers. For further discussion

see the section on Federal policies and programs pertaining to adolescent pregnancy and parenting below.
Table 10-9—Evaluations of Youth Employment Demonstration Programsa

Program Program Evaluation

studyb

characteristics participants characteristics Findings

Branch, Milliner, Bloom,

et al., 1985;

Branch, MiIliner, and

Bumbaugh, 1986;

Sipe, Grossman,

and Milliner, 1988

Philliber, 1985; PhilIiber and Allen,

1990; Philliber and

Allen, no date

Summer Training and Education Program (STEP): Over a 15-month

period, offers 2 consecutive summers of remedial education, life

skills instruction, and work experience plus various support services (e.g., counseling) during the

school year.c

Teen Outreach Program (TOP): An

after-school program offered during the academic year with two

major components: 1 ) a twiceweekly discussion group led by

trained facilitators, covering topics such as family relationships,

peer pressure, sexuality, and focusing on teaching group members to set life goals and develop

plans for reaching those goals;

and 2) volunteer service placement with community agencies

to provide participants with work

experience and opportunities to

practice job-related skills learned

in discussion groups. Students

may earn credit toward graduation for participation in TOP.

14- to 15-year-olds from low-income

families in five cities who are at

risk of dropping out of school and

becoming adolescent parents. In

each of 5 sites, three cohorts

(1985, 1986, and 1987) of about

320 youths each are participating, for a total of 4,800 youth in

the demonstration.

National sample of junior and senior

high school students who enrolled voluntarily in response to

announcements or who were identified as being at risk or potentially at risk for school dropout or

pregnancy and enrolled by counselors or others. In 1984-85, there

were 148 students at 7 sites, in

1985-86444 students at 16 sites;

in 1986-87, 632 students at 35

sites; in 1987-88,782 students at

44 sites; and in 1988-89, 1,028

students at 60 sites. In 1988-89,

over 75 percent of TOP participants were female; average age

15 (range was 11 to 21). In

1988-89, about 40 percent of

TOP participants were black, 40

percent were white; and 13 percent were Hispanic; the rest were

mostly Asians or Native Americans. About 41 percent came

from nonintact families; socioecEligible youth were randomly assigned to STEP or to a control

group (remedial education and

summer work experience only).d

Findings are based on metropolitan achievement test scores, STEP

questionnaire responses, school

records, and past program interviews.

Years 1-4: TOP participants were

compared with students in variously matched comparison

groups.f The evaluations monitored four outcome variables for

TOP students and their comparisons: school suspension, failure

of courses in school, dropping

out of school, and pregnancies.

Year 5 (1980-90): Same as in

years 1-4, but additional outcome variables were measured.g

At 5 TOP replication sites, students were randomly assigned to

either TOP (79 students) or to a

control group (89 students).

onomic status varied.

In the short term, STEP stemmed

participants’ academic losses and

increased their knowledge of contraception. Conclusive statements

regarding STEP’s long-term impacts on dropout rates and fertilityrelated behavior must await completion of the study.e

Years 1-devaluations found positive

results among TOP participants.

Year 5 evaluation found similar

results in the national Sample.h

At the 5 random assignment sites,

TOP participants had significantly

lower school suspension arrest,

and were more likely to get an

award. Other differences were

not statistically significant. Findings from year 6 of the evaluation

will not be available until after

1992.

a~i~ table ~h- evaluations of y~~h employment demonstration programs and therefore does not include the Job ~rps program Or Other large-scale yodh employment programs .SpOnSOred

by the U.S. Department of Labor. Those other programs are discussed in the text.

bFull ~tat”m~ are l~ted at the end of this chapter.

CDunng the .sUmmer, STEP Partiapants sped half their time in remediation and life s~lls clas~s and half their time in work experience. All yodh are paid minimum wage fOr their

participation with funds from the Federal Summer Youth Employment and Training Program (SYETP), which is funded by the U.S. Department of Labor.

d~ntroi group ~bj~~ were offer~ rem~ial edu~tion and a summer through SYETP. They d~ not receive life skills inst~ction or supportive servkes during the S&OOl year.

e~e Operational ph~ of research ended in August 1988, but researchers will follow the youth through 1992.

fE~h TOp site r=mit~ a Iml Compariwn group at the beginning of the school year, preferably using t~e random assignment procedures (16%). In .%X1’W Sitx Where

random assignment was not possible, student partiapants identified comparison students for themselves, naming young peopfe who might have filled out intake forms “about like

you did.” In 1988-89, TOP participants in the national sample were significantly more likely to be female than comparison students (76 percent v. 67.5 percsnt) and were significantly

less likely to have been pregnant (4.5 percent v. 7.8 percent).

gThe 1988-89 evaluation gathered data not only on the four variables considered in the previous 4 years but also on arrests, stipping school, use of alcohol or marijuana, having sexual intercourse,

using contraceptive when sexually active, joining after-school activities, getting an award, getting on the honor role, and educational aspirations.

hAfter ~~gmu~ ~ar=te~ti= and &eline levels Of o~mm= weremntroll~ for, parti~pation in Top was found to ~relatively related to getting pregnant or causing pregnancy, Suspension,

getting arrested, family courses, and skipping school. It was positively related to using contraception when sexually active, getting awards, getting on the honor role, raising college aspirations, and

staying m school.

SOURCE: Off”w of Technology Assessment, 1991.
Chapter 10-Pregnancy and Parenting: Prevention and Services . II-393

school records data and data from personal records)

will not be completed until 1993.

preliminary findings issued in thesummer of

1988 were based on four groups of data for each

cohort: pre- and post-summer metropolitan achievement test scores, STEP questionnaire responses,

school records and postprogram interviews (185c).

These preliminary findings indicate that STEP was

most effective in stemming participants’ academic

losses over the summer and in sharply increasing

their knowledge of contraception. The preliminary

results are consistent with the hypothesis that STEP

reduces dropout behavior but are based on small

numbers and are not statistically significant. Consistent effects on STEP participants’ fertility-related

behavior were not found in preliminary results.

Nevertheless, final conclusions about STEP’s longterm effects on dropout and fertility behavior must

await the completion of the research.

Teen Outreach Program (TOP)—TOP is an

after-school program designed to prevent early

pregnancy, to encourage regular attendance in

school, and generally to promote life options among

junior and senior high school students at risk of

school dropout or pregnancy (163a). The program

was begun in 1978 as a collaborative effort between

the Danforth Foundation and the St. Louis public

school system. In 1983, funding was provided by the

Charles Stewart Mott Foundation to begin a 3-year

national replication of TOP. In 1987, a second 3-year

national replication began under the direction of the

Association of Junior Leagues International and the

American Association of School Administrators.

TOP consists of two major components: 1) small

group discussions about life planning, relationships,

peer pressure, sexuality, and parenting and 2)

volunteer service experience (163a). A twiceweekly discussion group is led by a trained facilitator,83 who uses a variety of strategies (e.g., group

exercises, role-playing, and homework) to teach

group members how to set realistic life goals and

develop plans for reaching those goals. Weekly

volunteer service placement for the last threequarters of the academic year provides TOP participants with real work experience and an opportunity

to practice job-related skills learned in the discussion groups. Volunteer placements for participants

are identified by the trained facilitators, who also

supervise the placement process.

The number of TOP sites increased from 7 in the

1984-85 school year to 24 in 1985-86 to 35 in

1986-87 to 44 in 1987-88 to 60 in 1988-89, to an

estimated 87 in 1989-90 (163a). TOP evaluations in

the first 4 years monitored four outcomes: school

suspension, failure of courses in school, dropping

out of school, and pregnancies. The evaluation data

were fairly consistently positive (164a), The range in

the types of students enrolled at the different TOP

replication sites and the variability in the comparison groups at the different sites make interpreting

the results of these evaluations difficult. Students at

some sites volunteered entirely on their own to

participate in TOP; at other sites, students were

enrolled in the program by counselors or others.

Some evaluators asked student participants to identify their own matched comparisons by naming

someone who would be likely to fill out intake forms

“about like you did. ” Other evaluators recruited

comparison students as a group from other classes

(164).

The 1989-90 evaluation of TOP monitored the

four outcomes noted above plus several others,

including having sexual intercourse and using contraception when sexually active. In this evaluation,

five of the TOP replication sites existing at that time

were able to conduct a true experiment by randomly

assigning at-risk students to either TOP or a control

group (163a,164). The results of the 1989-90 evaluation appear somewhat less promising than results

suggested by aggregate data from the previous 4

years. In all randomized and nonrandomized sites

combined, evaluators found significant differences

between TOP participants and comparison students

in four indicators: school suspension rates, school

failure rates, school dropout rates, and pregnancy

rates. At the five sites with randomization, evaluators found that TOP participants had lower school

suspension and failure rates than control group

students but did not have lower dropout or pregnancy rates. It is important to note, however, that the

five sites with randomization included only 79 TOP

participants and 89 controls. This small number of

students across five different sites makes it difficult

to detect differences in such low frequency events as

pregnancy.

83AH tie facilitator for TOP are specially trained secondary school teachers.
II-394 ● Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Summary of the Effectiveness of Programs

That Seek To Develop Adolescents’ Life Options--

Definitive conclusions about the effectiveness of life

options programs are difficult to draw in part

because such programs are more difficult to evaluate

than programs with a narrower focus and in part

because some evaluations are still underway. Nonetheless, some of these programs do seem to show

promise. Life planning and decisionmaking interventions that do not provide work experience are

probably less successful than those that do provide

such experience. One youth employment program,

the Job Corps, seemed to delay family formation and

reduce out-of-wedlock childbearing among participants, but the evaluation of that program was

performed in 1978. An evaluation of the federally

funded Youth Incentive Entitlement Projects found

that adolescent females in the communities where

the projects were located were more likely to delay

childbearing than females in comparison sites.

Preliminary findings from an evaluation of the

Summer Training and Education Program (STEP)

indicate that the program reduces 14- to 15-year-old

participants’ academic losses over thesummer and

increases their knowledge of contraception, but the

evaluation of that program has not been completed,

and it is too early to draw conclusions about STEP’s

long-term impact on dropout or fertility behavior.

An evaluation of the Teen Outreach Program (TOP)

suggests that this program is somewhat promising in

terms of reducing pregnancies and school problems,

but methodological problems in the evaluation make

it difficult to draw definitive conclusions about its

effectiveness in reducing pregnancies. Role model

and mentoring projects that emphasize responsible

sexual behavior are a recent innovation, and data on

their effects on adolescents’ sexual behavior are only

beginning to be collected.

Economic Incentive Programs

A controversial and experimental approach to

preventing second pregnancies among low-income

adolescents who have already been pregnant before

the age of 16 was developed by the Rocky Mountain

Planned Parenthood program (101). This program,

called Dollar-a-Day, uses money to attract adolescent females to attend a voluntary weekly meeting

led by professional counselors. Dr. Jeff Dolgan, then

director for the Denver Children’s Home, proposed

this program after working with adolescents who got

pregnant and showed little motivation to prevent

future pregnancies. He asked the adolescents what it

would take to get them to come to a voluntary

program, and their response was that it would take

money. Every week, adolescents who attend Dollara-Day weekly meetings are given 7$1 bills for not

becoming pregnant. The assumption being made is

that adolescents who attend these meetings will

receive support and peer pressure not to become

pregnant from other adolescents. By helping delay

further pregnancies, the program claims to “buy

time” for high-risk adolescents, allowing them to

mature emotionally and to finish or return to school.

It is hoped that participants will discover that

parenthood is not the solution to their problems.

Although no formal evaluation was done, records

on pregnancy rates for program participants have

been kept. Of the 56 adolescents who completed the

program, 9 girls (17 percent) have become pregnant.

Program designers compare these percentages with

national statistics on repeat pregnancies, which the

Alan Guttmacher Institute estimates to be between

37 and 50 percent (148). The program proponents

claim that the program is successful and that the

weekly groups and not the money are responsible for

averted births. Their evaluation lacks an experimental control group, however, and it appears that they

include pregnancy statistics only on those adolescents who graduate from the program and do not

account for the pregnancy rates of those adolescents

who drop out of the program. A similar program, the

Cash Awards for Teens Who Stay Program, is being

administered in Florida (185).

Conclusions About the Effectiveness of Programs

To Prevent Adolescent Pregnancy

The prevention of adolescent pregnancy would

result in fewer births to U.S. adolescents and would

also result in fewer abortions (148). Unfortunately,

however, a political consensus in this country about

how to prevent adolescent pregnancy has not been—

and may never be--reached.84 As Dryfoos notes in

her recent comparative review of prevention programs for delinquency, substance abuse, and pregnancy, “Clearly, when sex enters the scene, the

situation becomes complicated” (47a).

MTO some extmt, MS lackof co~ensus is reflwted in Federal programs such as Title X and Title XX of the Public Health Semice Act. These progmms

are discussed later in this chapter.
Chapter 10-Pregnancy and Parenting: Prevention and Services ● //-395

Dryfoos notes a schism between political “liberals’ and ‘ ‘conservatives’ on the issue of adolescent

pregnancy prevention (47a). Many conservatives

take the position that government support for sex

education and contraception weakens family ties

and encourages promiscuity and that government

initiatives should encourage adolescents to abstain

from sexual intercourse. Many liberals agree that

encouraging adolescents to delay sexual intercourse

until full adulthood would be preferable, but are

alarmed by the consequences of unprotected adolescent sexuality (i.e., pregnancy, AIDS, STDs) and

believe that society’s approach should go beyond

relying on the abstinence message alone. Scholars

are generally frightened away from the topic of

adolescent sexuality, and as one result, there is little

scientifically valid evaluation of pregnancy prevention programs; the paucity of methodologically

sound research makes drawing definitive conclusions about what works difficult (47a,107a,148).

The National Academy of Sciences’ Panel on

Adolescent Pregnancy and Childbearing concluded

in 1987 that ‘‘prevention of adolescent pregnancy

should have the highest priority’ (see box 10-C for

the panel’s six general conclusions). While noting

the lack of rigorous evaluative efforts, the panel felt

there was an adequate basis at that time for making

recommendations about strategies to prevent adolescent pregnancy (148). The three general strategies

that the panel felt could lead to a reduction in the rate

of adolescent pregnancies were as follows:

1) enhance the life options of disadvantaged

adolescents,

2) delay the initiation of sexual activity, and

3) encourage contraceptive use by sexually active teenagers (148).

“Diligent contraceptive use” by adolescents was

considered to be the most effective of these pregnancy prevention interventions, but no program

element alone was considered to be sufficient, and

specific approaches for implementing the three

strategies were provided (148). Central to all the

strategies embraced by the National Academy of

Sciences panel was “the need for teenagers themselves to embrace values that lead to responsible,

healthy, and productive lives, including the avoidance of unplanned and untimely parenting, and to be

steadfast in their belief that they can achieve their

goals” (148). Parents, other family members, and

community and societal norms were seen as playing

a key role in helping young people acquire and

maintain those values.85

Following her more recent review of pregnancy

prevention interventions, Dryfoos drew conclusions

similar to those of the National Academy of Sciences’ Panel on Adolescent Pregnancy and Childbearing, with emphases on early intervention (no

later than the middle school years), the use of

multiple approaches, and confidential access to

contraceptives (47a). As Dryfoos notes:

No one program component will be sufficient. In

every community, young people should have access

to a package of services that include both capacitybuilding 86 and life-option87 components (47a).

Similarly, in a review of the effectiveness of

sexuality education programs, Kirby concluded that

such programs must do more than increase knowledge:

Programs must help adolescents personalize that

information, improve their decisionmaking and communication skills, increase their motivation either to

avoid sex or to use birth control, change their

perception of peer group norms regarding having sex

and using condoms, and therefore reduce their

risk-taking behavior (107a).

Further, Kirby noted that sex education programs

will probably be more effective if they involve

adolescents in both shaping the programs and

promoting the programs’ goals, and incorporate

community-wide strategies that are both multifaceted and mutually reinforcing (e.g., 215) (107a).

Kirby’s review did not examine the effectiveness of

actually providing contraceptives to adolescents,

although his conclusion that their use should be

encouraged suggests support for providing contraceptives to sexually active adolescents (107a).

Wt my seem tO some that the use of contraceptives would be contrary to adolescents’ adoption of ‘v~ues, ” but if the goal is pregnancy prevention

(and avoidance of other negative consequences of unprotected sexual intercourse), the use of contraception by those adolescents who are sexually active

can be seerI as responsible and health-promoting.

86capac1ty-bull&ng &ludes fiptig ~owledge about human sexuality and contraceptive use ad developing decisio~~g s~~s.

87Lfie Option comPnents include developing adolescents’ ~~)Iafio~ not to cut short heir &VelOprnen~ ~ajectory by prematurely becoming

pregnant and/or parents and helping adolescents to develop the skills to fulfill their (sometimes new-found) life ambitions.
II-396 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 10-C—The Six General Conclusions of the National Academy of Sciences’ Panel

on Adolescent Pregnancy and Childbearing

On the basis of 2 years of review, analysis, and debate, the National Academy of Sciences Panel on Adolescent

Pregnancy and Childbearing reached six general conclusions that underlie all of its specific conclusions and

recommendations for policies and programs:

1. Prevention of adolescent pregnancy should have the highest priority. In both human and monetary

terms, it is less costly to prevent pregnancy than to cope with its consequences; and it is less expensive to prevent

a repeat pregnancy than to treat the compounded problems.

2. Sexually active teenagers, both boys and girls, need the ability to avoid pregnancy and the motivation

to do so. Early, regular, and effective contraceptive use results in fewer unintended pregnancies. Delaying the

initiation of sexual activity will also reduce the incidence of pregnancy, but we currently know very little about how

to effectively discourage unmarried teenagers from initiating intercourse. Most young people do become sexually

active during their teenage years. Therefore, making contraceptive methods available and accessible to those who

are sexually active and encouraging them to diligently use these methods is the surest strategy for pregnancy

prevention.

3. Society must avoid treating adolescent pregnancy as a problem peculiar to teenage girls. Our concept

of the high-risk population must include boys. Their attitudes, motivations, and behavior are as central to the

problems as those of their female partners, and they must also be central to the solutions.

4. There is no single approach or quick fix to solving all the problems of early unintended pregnancy

and childbearing. We will continue to need a comprehensive array of policies and programs targeted to the special

characteristics of communities and to the circumstances of teenagers from different social, cultural, and economic

backgrounds and of different ages. Because adolescents are not a monolithic group, they do not all experience sexual

activity, pregnancy, and childbearing in the same way. Our broad goal is the same for all young people: that they

develop the necessary capabilities to make and carry out responsible decisions about their sexual and fertility

behavior. The strategies for achieving these goals and the specific interventions to carry them out, however, should

be sensitive to differences in values, attitudes, and experiences among individuals and groups.

5. If tradeoffs are to be made in addressing the special needs of one group over another, priority should

be given to those for whom the consequences of an early unintended pregnancy and birth are likely to be most

severe: young adolescents and those from the most socially and economically disadvantaged backgrounds.

In many ways, those at highest risk are hardest to serve, yet they are also the groups that have been shown to benefit

most.

6. Responsibility for addressing the problems of adolescent pregnancy and childbearing should be

shared among individuals families, voluntary organizations, communities, and governments. In the United

States, we place a high priority on ensuring the rights of individuals to hold different values and the rights of families

to raise their children according to their own beliefs. Therefore, public policies should affirm the role and

responsibility of families to teach human values. Federal and State governments and community institutions should

supplement rather than detract from that role.

SOURCE: National Academy of Sciences, National Research Council, Commission on Behavioral and Social Sciences and Education,

Committee on Child Development Research and Public Policy, Panel on Adolescent Pregnancy and Childbearing, Risking the Future:

Aa’olescentkwaiity, Pregnancy, and Childbearing, Volume I, C.I). Hayes (cd.) (Washin@oQ DC: National Academy Press, 1987).

Thus, a consensus is growing among scholars seek to improve knowledge and foster healthwho have examined the pregnancy prevention litera- promoting, responsible attitudes; life-skills deciture that there is no ‘‘magic bullet’ for preventing

adolescent pregnancy, Rather, a realistic approach

that acknowledges that adolescents should be protected from the risks of unprotected sexual intercourse and at the same time strongly encouraged to

delay the initiation of sexual intercourse seems

essential. Short-term with a limited focus "programs”—

e.g., didactic sexuality education interventions that

sionmaking interventions that teach adolescents

how to deal with pressure to have sex or unprotected

sex; and parent-child communication programs--do

not appear to be able on their own to do very much

about reducing the high incidence of adolescent

pregnancy, although each of these program types

shows some positive effects. One promising pregnancy prevention intervention was the South Caro-
Chapter 10-Pregnancy and Parenting: Prevention and Services ● II-397

lina program that involved the provision of information and contraceptives, and involved parents, teachers, as well as adolescents as participants. This

model did not include job and life skills training;

other studies suggest that job and life skills training

may be able to increase adolescents’ motivation to

avoid early pregnancy and childbearing.

The evidence on risk factors discussed above

suggests that, as noted by the National Academy of

Sciences panel, different adolescents will have

different needs, depending on their age, gender,

socioeconomic status, cultural background, and

community of residence. Although more scientifically valid research is sorely needed, enough evidence exists to guide communities and national

policymakers in their search for approaches that can

lower adolescent pregnancy rates. Clearly, the figures presented earlier in this chapter (on increasing

sexual experience rates among adolescents; apparent

inconsistent use of contraceptives; persistently high

adolescent pregnancy and birth rates; and clearly

increasing levels of out-of-wedlock births) make an

excellent case for ending the largely timid approach

of the present. Finally, it may be important to go

beyond ‘‘programs.’ Rather than simply being

replicated in isolation, each of the successful interventions can be used to inform a general approach to

working with adolescents.

Programs Designed To Prevent Negative

Outcomes of Adolescent Pregnancy

and Parenthood

Approximately one million U.S. adolescents become pregnant each year. Interventions to reduce the

likelihood of negative outcomes of adolescent pregnancy and childbearing for the young female, her

offspring, or her partner take four general approaches:

● providing pregnant adolescents with alternatives to parenthood by offering abortion or

adoption services;

●

●

●

ensuring that pregnant adolescents have adequate prenatal and other maternity care services88

;

offering pregnant and parenting adolescents

specific types of services that might help them

(e.g., educational services or job training and

employment services or social support services

or housing, child care, or transportation)89; and

providing pregnant or parenting adolescents

with health and a wide range of other services

in a comprehensive service program.

These approaches are discussed further below.

Programs That Offer Alternatives to Parenthood

Programs That Offer Abortions---For females

who become pregnant and do not wish to become

parents voluntary pregnancy termination by induced

abortion became a nationally legal option following

the U.S. Supreme Court’s 1973 decision in Roe v.

Wade [410 U.S. 113 (1973)].90 Although this

alternative is charged with controversy, especially

for adolescents who are legal minors, in recent years

it has been widely used by substantial numbers of

adolescents who become pregnant, as was discussed

earlier.

Legal abortions in the United States are performed

in hospitals (as inpatient and outpatient procedures),

in abortion and other clinics, and in private physicians’ offices (79). The long-term trend as been

away from the use of hospitals toward the use of

abortion clinics and other nonhospital abortion

providers (79). According to Henshaw and his

colleagues at the Alan Guttmacher Institute, 86

percent of abortions in the United States in 1988

were performed in nonhospital facilities, including

freestanding abortion clinics (64 percent of all

abortions), other clinics such as surgicenters and

family planning clinics (18 percent), and private

doctors’ offices (4 percent) (81 b). The remainder (10

percent) were performed on either an inpatient or an

88~emt~ ~mc ad h~~ ~miw~ ~tended t. &nefit ~~fi and young Cfildren were discuss~ at leng@ in OTA’S 1988 !WpOII ~ea~fhy Children:

Investing in the Future ( 199), so the primary focus in the discussion that follows will be on semices intended primarily to benefit pregnant and parenting

adolescents.

89~ogms deslwed t. e~ce he soc~, emotio~, ad cognitive &VelOprnent of c~dren bom to adolescent mo~ers (e.g., pareIl@ education

programs) may have some benefits for the adolescents themselves. Because they are designed to benefit the children+ however, such programs will not

be discussed in detail here.

~For a discussion of IJ.S. Supreme Court decisions dealing with abortiont see ch. 17, “Consent and Confidentiality in Adolescent Heatth Care

Decisionmakmg,” in Vol. III.
II-398 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

outpatient basis in hospitals (8lb).91 Most facilities

that perform abortions also provide proabortion

sessions to provide information about the procedure

and answer patients’ questions, as well as contraceptive services and a postabortion checkup (78).

Several factors may limit adolescents’ access to

abortion, among them lack of abortion providers (or

knowledge about abortion providers) in the community, parental consent and notification requirements,

and cost. Abortion services are currently unavailable

in many areas of the United States (79). Abortion

services are most available in States on the East and

West coasts (88). Abortion services are concentrated

in metropolitan areas and are often not found in rural

communities and small towns; in 1985, only 32,000

(2 percent) of the total number of abortions nationwide were performed outside of metropolitan areas

(79). Another point is that fewer than half of all U.S.

abortion providers perform abortions past the 12th

week of pregnancy (79). A disproportionate number

of women seeking second-trimester abortions are

adolescents, and these adolescents may have particular difficulty obtaining abortions (79).

Several empirical studies concerning the impact

of parental consent and notification requirements

indicate that such requirements do create barriers to

adolescents’ access to and utilization of abortion

services (e.g., 18a,18b,193c).92 A number of States

have passed laws requiring abortion facilities to

obtain consent from one or both parents for legal

minors who wish to obtain an abortion.93 Furthermore, as discussed elsewhere in this Report, the

Supreme Court’s ruling in the 1989 case Webster v.

Reproductive Health Services [109 S. Ct. 3040

(1989)] appears to give States greater leeway in

restricting access to abortions and at the same time

cast doubt on the future of Roe v. Wade and other

Supreme Court decisions dealing with abortion. To

the extent that Webster and future rulings increase

States’ ability to restrict abortion generally, they

may reduce minors’ access to abortion--even

though the decisions do not directly address the

question of parental consent. Also it should be noted

that even if the laws do not require parental consent

or notification, health care providers may as a matter

of policy or practice refuse to provide services to

minors without parental consent or notification. One

reason for such a policy might be to ensure payment.

According to the Alan Guttmacher Institute, 22

percent of all abortion clinics in 1981 required

parental consent for most minors under most circumstances, especially for those under the age of 15 (78).

As of mid-1986, charges for a first-trimester

nonhospital abortion ranged from $75 to $900 (79).

For adolescents from low-income families, adolescents who lack health insurance, and adolescents

whose health insurance does not cover abortions

except in the narrowest of circumstances, the cost of

an abortion maybe a barrier to access. At least eight

States (Idaho, Kentucky, Minnesota, Missouri, Nebraska, North Dakota, Pennsylvania, and Rhode

Island) have mandated some restrictions on private

health insurance for abortions (76a) .94 Federal funding of abortions through Medicaid has been prohibited since 1977 (8 la), and only a minority of State

have used their own moneys to fund abortions for

low-income women (79).

In 1988, DHHS issued new regulations under

Title X of the Public Health Service Act prohibiting

Title X family planning clinics from providing

abortion counseling or abortion referrals to pregnant

women. To the extent that the regulation is enforced,

it is likely to have an adverse effect on adolescents’

access to abortions.95

Programs That Offer Adoption Services—

Some adolescent females carry their pregnancies to

term because they do not have access to abortion

services, do not consider abortion an acceptable

alternative, or become aware of their pregnancy

beyond the point at which they can have an abortion,

and feel they are not prepared for parenthood. For

glfior t. 1983, hospi~s Were more likely than facilities to provide later stage abortions, but a 1983 U.S. Supreme Court ruling det-ined tiat Sfates

may not require hospitals to perform early second-trimester abortions [(City of Akron v. Akron Centerfor Reproductive Heafth, 462 U.S. 416 (1973)].

This ruling, combined with the fact that clinic-based abortions are substantially less expensive than those performed in hospitals, has led to growth in

the number of clinics providing abortions and a simultaneous decline in the number of hospitals performing this service (79,81 b).

%ther studies are noted in ch. 17, “Consent and confidentiality in Adolescent Health Care Decisionmaking,” in Vol. III.

gqFor f~er disc~sion of Stite s~~tes de~ing with aborfion and the impact of parental consent and notilcation R@eIIIeIItS or iiCCeSS to SeNiCeS,

see ch. 17, ‘‘Consent and Confidentiality in Adolescent Health Care Decisionmakm“ g,” in vol. III.

~For ~er dis~ssioq see ch. 16, “Financial Access to Hdth Services, ” in VO1. ~.

95cmnt ~tations on me use of Fede~ Medic~d, Title X, ~d Tide ~f~ds to pay for abofions, abofion referrals, ~d abortion counseling

are discussed below in the section of this chapter entitled ‘‘Federal Programs and Policies Pertaining to Adolescent Pregnancy and Parenting. ”
Chapter 10-Pregnancy and Parenting: Prevention and Services ● //-399

these adolescents, services to help plan for adoption

or assist in the process of having the child adopted

may be important.

Although several studies of adoption decisions

and the decisionmaking process have been conducted in recent years (12,133), relatively little

information is available on the extent and nature of

services provided for adolescents considering adoption (88). Adoption services may include education

and counseling for the adolescent, identification and

selection of adoptive families, and legal services

related to carrying out the adoption decision (148).

When such services are provided in a residential

program, they are usually part of a comprehensive

package (146). Typically, however, multiple agencies, including public and private adoption agencies,

are involved in providing the range of services

needed by adolescents considering giving a baby up

for adoption.

According to the National Academy of Sciences,

less than 10 percent of all U.S. adolescents who

become pregnant choose adoption (148). In a 1986

survey of services to pregnant and parenting adolescents offered by member agencies of the Child

Welfare League of America (CWLA), 63 percent of

the 121 agencies surveyed indicated that they made

adoptive placement available to their female adolescent clients (21 1). In contrast, almost all (97 percent)

of the CWLA agencies who responded to a similar

survey in 1969 offered adoptive placement services

(186). Fairly few of the agencies surveyed in the

1986 survey indicated that adoption services were in

demand among their clients; only 26 percent of the

agencies named adoption in listing the five services

they provided which were most often used by young

women (there were no similar data from the 1969

study).

One Federal program that supports adoption as an

alternative to abortion among adolescents is the

Adolescent Family Life (AFL) program authorized

under Title XX of the Public Health Service Act.

Federal assistance for adoption is also provided

under Title IV-E of the Social Security Act.96

Programs That Offer Maternity Care or

Family Planning Services

Programs That Offer Maternity Care-As

noted earlier, the standards of maternity care developed by the American College of Obstetricians and

Gynecologists recommended that every pregnant

woman have a comprehensive program of prenatal

care beginning as early in the first trimester of

pregnancy as possible (9a,148). A recognition that

pregnant adolescents, especially low-income and

minority adolescents, may be at high risk of receiving inadequate prenatal care, and therefore at risk of

poor pregnancy outcomes, has led to various efforts

intended to increase the quality and amount of

prenatal care that pregnant adolescents receive.

Programs to help high-risk adolescents obtain

adequate prenatal care have been initiated by public

health departments, university hospitals, freestanding clinics, youth service agencies, school-linked

health centers (SLHCS),97 and by private physicians

(148). These providers offer services that include

pregnancy testing and counseling; testing for STDs;

regular medical examinations to monitor the course

of the pregnancy; health and nutrition education and

referral for nutrition services (e.g. those provided

through the U.S. Department of Agriculture’s Special Supplemental Food Program for Women, Infants, and Children); and delivery and postpartum

care services. Many programs have included intensive outreach components and provide transportation to clinic sites in areas where public transportation is inadequate or unavailable (147). Others have

offered counseling, referral, and educational services through home visits by professional health care

providers or trained paraprofessionals, combined

with clinic visits for medical care. The services may

be provided in a separate program or may be

included as part of a comprehensive package of

services to pregnant and parenting adolescents

(150a).

One of the factors influencing adolescents’ use of

prenatal and other maternity care is the availability

of health insurance coverage. Private health insurance provides maternity care coverage for women at

all income levels. Since the enactment by Congress

of the Pregnancy Discrimination Act of 1978 (Public

%~e Tltie ~~~rogm is di~~u~~ed later ~ ~s chapter along wi~ o~er Feder~ progr~s related to ado]ewent pregnancy ~d parenting.

mFor discussion of services offered by SLHCS, see ch. 15, ‘‘Major Issues Pertaining to the Delivery of Health and Related Services to Adolescents, ’

in vol. m.
11-400. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Law 95-555), almost all employment-based health

plans covering 15 or more employees provide

maternity care benefits (76b). Because of a loophole

in the regulations issued under that act, however,

about one-third of privately insured adolescents are

not covered for maternity benefits by their parents’

employment based health plan.98

Medicaid is the major public financing program

for pregnant women who are poor. The Omnibus

Budget Reconciliation Act of 1989 (Public Law

101-239) required that, as of April 1, 1990, States

provide Medicaid coverage to all pregnant women

and children up to age 6 with family incomes up to

133 percent of the poverty level. Even women who

are eligible for Medicaid, however, may encounter

barriers (e.g., low Medicaid participation rates

among physicians due to low reimbursement rates or

onerous administrative procedures) to the timely

receipt of care.99

Two major financing alternatives to health insurance coverage for maternity care are the Maternal

and Child Health Block Grant Program authorized

by Title V of the Social Security Act and community

and migrant health centers (199). As discussed later

in this chapter, little is known about who receives

what services under the Title V maternal and child

health block grant. Community health centers provide “primary health services” to residents of

medically underserved areas, about half of whom

lack health insurance.l00

Programs That Offer Family Planning Services To Prevent Repeat Pregnancies-Females

who have a first pregnancy during their adolescent

years are at high risk of having repeat pregnancies.

As noted earlier, Furstenberg and colleagues found

that adolescent mothers who gave birth to additional

children in the years immediately after the birth of

their first child did not achieve as well vocationally

as the mothers who had controlled their fertility

(68a). Making family planning services available to

young mothers following the birth of their frost child

may help to delay a second pregnancy for up to a

year; few long-term effects on pregnancy rates have

been demonstrated (86).

Programs That Offer Specific Types of Services to

Pregnant Adolescents and Adolescent Mothers

School-Based Programs-Because of the strong

relationship between the educational attainment of

young mothers and their economic self-sufficiency,

many programs serving pregnant adolescents or

adolescent mothers have focused on the adolescents’

educational needs. Title IX of the Education Amendments of 1972 prohibits discrimination in education

against teens because of their pregnancy/childbearing/

marital status (88). In the late 1970s and early 1980s,

teens who gave birth were less likely to leave school

than in the late 1960s and early 1970s (88).

Regular school routines, regulations, and facilities are seldom able to accommodate all of the

special needs of pregnant adolescents or adolescent

mothers (e.g., their need for flexible schedules, child

care, and specialized health education, and in some

cases, parent training). In order to help meet these

needs, at least some school systems have established

alternative schools for pregnant adolescents and

adolescent mothers (148). Some of these alternative

schools are located within existing secondary

schools, facilities, and others are in facilities of their

own. Most of the alternative schools are selfcontained. Alternative school programs typically

offer pregnant and parenting adolescents individually paced academic instruction. In addition, many

programs provide special instruction in sex education, health and hygiene, nutrition education, parenting skills training, life planning, life skills training,

and job training (148). Most of them also provide

onsite child care. Alternative schools for pregnant

and parenting adolescent mothers frequently help

link their students to other programs both within the

school system and in the larger community (e.g.,

family planning, income supports, housing).

School-based interventions for pregnant adolescents and adolescent mothers vary widely in intensity, duration, and scope. Intensive, comprehensive

educational programs offered both during and after

pregnancy may be able to increase the likelihood

that pregnant adolescents will stay in school and that

adolescent mothers will complete high school (230).

gsFor f~er discussio~ see ch. 16, “Financial Access to Health Services, ’ b VOI. ~.

%%eproblemof low Medicaid participation by obstetricians is discussed in ch. 16, “FinancialAccess to Health Semices,” in Vol. HI. This and other

barriers to the timely receipt of maternity care by poor women eligible for Medicaid were discussed at greater length in OTA’s 1988 report Heahhy

Chifdren: Investing in the Future (199).

l~or discussion of we Tide V Mated ~d c~d He~~ Block G~t~o~ ~d ccImrnun@ h~th centers, see the section on Federal programs

related to adolescent pregnancy and parenting below.
Chapter 10-Pregnancy and Parenting: Prevention and Services . //-401

Unfortunately, well-controlled studies of the impact

of alternative school programs on adolescent mothers’ educational attainment do not exist (1 15,172).

There is some evidence, however, that alternative

school programs are able to increase participants’

educational aspirations, enhance their knowledge of

positive health practices and parenting skills, and

improve health-related outcomes for both mothers

and their infants (121).

It is important to note that school-based programs

for pregnant and parenting adolescents serve only

adolescents who remain in school after they become

pregnant; few programs conduct active outreach to

identify adolescents who are no longer in school

when they become pregnant, and some do not follow

up on adolescents who drop out during the course of

their pregnancies (172). Thus, school-based programs for pregnant and parenting adolescents may

be serving only the best informed, most highly

motivated adolescents. There is also some concern

that in areas where school officials lack commitment

to or actively resist alternative programs, such

programs may serve to exclude pregnant and parenting adolescents from regular school settings and

may not provide them with an education that is

comparable with that of their nonparenting peers

(2,230).

Employment and Job Training Programs---As

noted earlier, early parenthood may adversely affect

adolescents’ job opportunities and ability to achieve

economic self-sufficiency. For that reason, increasing attention has been paid to the needs of pregnant

and parenting adolescents for job training and job

placement services, especially for older adolescents.

In some comprehensive care programs for pregnant

and parenting adolescents, however, including employment as a goal has been controversial because of

the concerns that an emphasis on employment as a

goal may lower the educational attainment of

younger adolescents who have not yet completed

high school (148).

As discussed elsewhere in this Report, the U.S.

Department of Labor supports training and employment programs for economically disadvantaged

youth ages 16 and over under the 1982 Job Training

Partnership Act. This act authorizes the Job Corps

and various other programs affecting adolescents.l01

Few of the large federally supported youth employment programs have been sensitive to the special

needs of pregnant and parenting adolescents (e.g.,

their need for child care) (148). Such programs have

not had much effect on young mothers’ employment

status or earning levels. Even programs that have

targeted adolescent parents seem to have shown

little impact on participants’ employment rates (26),

although some programs have been able to increase

participants’ work preparedness and actual work

experience (148).

A program called Teenage Parent Demonstration, sponsored by the Office of Family Assistance

in the Family Support Administration of DHHS, is

currently operating in Illinois and New Jersey in

three different sites (131). This program serves

urban, low-income, largely minority adolescent

parents who are receiving AFDC benefits, with the

goal of reducing long-term welfare dependency

among them. Case managers assist program participants in identifying and fulfilling educational or

employment-related experiences, and they provide

referral services to community resources. The program also offers assistance with child care and

transportation to help adolescents adhere to their

plans. In an attempt to enhance the long-term ability

of fathers to make support payments, efforts are

being made to establish paternity soon after the birth

of the baby, and the fathers of the participant’s

children are eligible to receive employment-related

training. The Teenage Parent Demonstration is

being evaluated for the effects of program participation on the adolescent parents’ prospects for selfsufficiency by Mathematical Policy Research Inc.,

which will obtain State and county agency records,

program records data, and followup interviews and

basic skills tests with experimental and control

groups. The program is still being implemented, so

data are not yet available.

Programs That Provide Social and Emotional

Support—In the 1986 survey of services to pregnant and parenting adolescents offered by member

agencies of the CWLA, individual counseling was

mentioned by almost four-fifths (79 percent) of the

responding agencies as a ‘‘most often used’ service

by pregnant and parenting adolescents (both males

and females) (21 1). To some extent, this finding may

IOIA 1978 ~v~~tion~f ~eJ~b c~~~ program~view~ earlier~ ~s chapterfo~d ~tp~cipation~~e program ~med to delay ftildy fOITIMtiOn

and reduce the incidence of out-of-wedlock childbearing among participants (2 10). For further discussion of the Job Corps and other youth training and

employment programs administered by the U.S. Department of Labor, see ch. 19, “The Role of Federal Agencies in Adolescent Health,” in Vol. III.
11-402. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

reflect the nature of the agencies surveyed (which

were mostly child welfare and family service

agencies, both public and private), but it also

suggests that the provision of social support services

may be an important component of interventions for

pregnant and parenting adolescents.l02

In addition to providing counseling, several programs link pregnant adolescents and adolescent

mothers with adult or peer mentors or role models.

These programs frequently target young women

who are no longer living with their families of origin.

Many have made use of community women volunteers or older adolescent mothers who provide

advocacy for needed services, practical assistance,

and reinforcement of positive messages related to

prenatal and postnatal care, continuing in school,

and effective contraceptive use. Such services may

be offered as part of a larger program (170) or may

exist as a separate intervention (155).

Unfortunately, interventions that focus on providing social and emotional support to pregnant and

parenting adolescents have not been evaluated

separately for their impact on such outcomes as

educational attainment, job status, subsequent childbearing, or health status of mothers or infants (148).

It is reasonable to expect, however, that the quality

of the training and supervision that role models and

mentors themselves receive will affect the ability of

mentoring efforts to influence desired program

outcomes, as will the quality of the mentoring

relationship (148). In one comprehensive intervention for pregnant and parenting adolescents (Project

Redirection, described below), the mentoring component affected program attrition, with those who

were dissatisfied with their community mentors

citing this as a reason for their dissatisfaction with

the program (170). Thus, while it maybe important

to offer social support to pregnant adolescents and

adolescent parents, particularly those who are alienated from their own families, further information is

needed about the potential for role modeling and

mentoring approaches to provide this service.

Programs That Provide Housing, Child Care,

or Transportation Services-Although many pregnant and parenting adolescents are able to live with

their families of origin or with their partners’

families, and others have the resources to establish

independent living, finding adequate housing is a

problem for a significant minority of pregnant and

parenting adolescents, especially those who are

tiers (24). Residential programs for both pregnant

adolescents and adolescent mothers, after experiencing a decline during the past 3 decades, have

apparently been increasing in number in recent

years, but the number is still small. According to

William Pierce, president of the National Committee

for Adoption, in 1980 there were only 99 homes for

pregnant adolescents, but in 1989 there were about

140 homes serving about 2,600 adolescents (75).

Some of these homes have been sponsored by

antiabortion groups in response to criticisms that

young women were being admonished to continue

their pregnancies and choose adoption without being

given resources to enable them to carry healthy

pregnancies to term (75). Others, such as the

Florence Crittenton agencies, have had a longstanding emphasis on preparing young mothers and

their children for independent living and have

tended not to support adoption (132).

Some residential programs for unwed pregnant

adolescents exist primarily to offer housing and

auxiliary services until a young woman gives birth;

33 percent of the CWLA agencies surveyed in 1986

offered prebirth residential or group home care in

1986 (21 1). Other programs continue to provide

housing and other services after the birth of the child,

although such services are less common; only 18

percent of CWLA agencies offered postbirth residential care in 1986 (21 1).

Adequate child care, especially infant care, is

another service that is crucial for adolescent mothers

who are enrolled in school, involved in job training,

or working to support themselves (23,36). The

inability to obtain child care is the single most

commonly cited reason young mothers give for not

returning to school following the birth of their child

(49,2 16). However, some school-based programs for

adolescent mothers do provide child care on-site,

and some adolescents are able to make private child

care arrangements, usually with family members.

Less than half (47 percent) of the CWLA agencies

surveyed in 1986 stated that they provided child care

(211).

102~s idea iS Su~~~fled by me results of tie men Fa~er Collaboration (discussed later), which indicated &t counseling WW the Shgle XIIOSt Utihd

semice by the adolescent fathers involved in the project (177).
Chapter 10-Pregnancy and Parenting: Prevention and Services ● II-403

Transportation, especially to school or child care

facilities, and especially in communities with limited (or no) public transportation, is also essential for

many parenting adolescents. In most communities,

school buses are not able to carry infants and

toddlers for safety reasons (35), Thus, specially

equipped vans or buses may be needed to transport

adolescent mothers enrolled in school or employment programs. However, transportation services

are not commonly offered to pregnant and parenting

adolescents; a study published in 1984 found that

only 29 percent of the pregnant teens and 14 percent

of the teen mothers involved in programs funded by

the Office of Adolescent Pregnancy Prevention in

the Office of Population Affairs of DHHS benefited

from transportation assistance (26). Although approximately three-fifths of the CWLA agencies

surveyed in 1986 stated that they offered transportation services, less than one-fifth saw this assistance

as necessary; perhaps as a result, transportation was

a frequently used service by clients in less than 10

percent of the CWLA agencies (21 1).

Although support services such as housing, child

care, and transportation are frequently cited as

essential adjuncts to the success of many interventions for pregnant and parenting adolescents (24,35),

little information is available on their impact on

program goals and outcomes. Nevertheless, there are

some data that do support assertions regarding the

importance of including support components in

comprehensive service programs. A study of Office

of Adolescent Pregnancy Prevention programs, for

example, found that receipt of child care reduced the

likelihood of a repeat pregnancy by 1 full year

among adolescents who were pregnant at entry into

the programs; adolescents receiving child care who

were already mothers at entry were more likely than

those who did not receive child care to have

completed more schooling or to be employed 1 year

later (26). The same study found that pregnant

adolescents who received transportation assistance

through Office of Adolescent Pregnancy Prevention

projects were more likely to be still enrolled in

school at the time they delivered than were other

participants who did not receive transportation

services (26). A 1987 study of programs for pregnant

and parenting adolescents supported by the California Department of Education found that when

transportation services were cut, program attendance declined (27). Thus, although the data are

limited, they strongly suggest that such support

services may be integral to the ultimate success of

interventions for pregnant and parenting adolescents.

Programs That Offer Comprehensive Services to

Pregnant Adolescents and Adolescent Mothers

Over the past decade, there has been growing

awareness that most pregnant and parenting adolescents are not well-served by a fragmented service

delivery system designed to deal separately with

needs for health care, educational services, economic assistance, and psychosocial support services. Consequently, efforts have been made to

establish comprehensive programs able to provide

pregnant and parenting adolescents with multiple

services either during pregnancy or through the first

year or two of parenthood.

Comprehensive programs for pregnant or parenting adolescent females typically provide education,

health care, employment, and social services. The

services may either be provided by one agency or

provided through several different agencies with

formal or informal agreements, often using a case

management approach (24).

The Teenage Pregnancy and Parenting Program

(TAPP) in San Francisco is one example of the

comprehensive services model. This program, which

is coordinated by the Family Service Agency of San

Francisco and the San Francisco Unified School

District, involves over 30 agencies in providing

health, education, and social services to pregnant

adolescents. Staff from a number of different agencies are located at TAPP sites, and TAPP staff serve

as liaisons in other agencies that see large numbers

of pregnant and parenting adolescents (e.g., a

hospital-based clinic, a maternity home, an SLHC).

Each pregnant adolescent client is assigned a “continuous counselor’ who provides case management;

an alternative school, child care, and health care

services are provided on-site at TAPP, and transportation assistance for the public transit system is

available to clients (191). An evaluation of TAPP

found successful outcomes in terms of school

attendance and avoidance of repeat pregnancies

(23a,47a).

Another example of the comprehensive services

model is Project Redirection, which was established

to help low-income young mothers and pregnant

adolescents who had not completed school (217).

Project Redirection was initially implemented in
II-404 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Photo credit: Katherine Criss, New York, NY

The report One-stop Shopping: The Road to Healthy Mothers and Children, by the bipartisan National Commission To Prevent

Infant Mortality, noted the current level of fragmentation among services for pregnant and parenting women, including adolescents.

It found that the current consensus is that a comprehensive range of services should be provided, optimally in a single setting.

four sites nationwide with funding from the Ford

Foundation and the U.S. Department of Labor.

These four sites provided low-income young mothers and pregnant adolescents with educational and

employment counseling, parenting education and

life skills training, transportation, child care, and

referral to health services. Because of its initial

success in terms of welfare reductions, employment,

and improved parenting skills, Project Redirection

was expanded to an additional seven sites (169).

Each program participant was assigned to a female

community volunteer, who provided social support,

practical assistance, and linkage between the program and the participant (170).

Project Redirection, which emphasized education

and the development of job skills, had little effect on

participants’ pregnancy rates, contraceptive use, or

repeat pregnancy rates, but it decreased the number

of abortions among program participants 103 and

increased participants’ rates of school retention and

completion, levels of employment, and parenting

ability; it also improved the cognitive skills of

participants’ children (169) and reduced the number

of behavioral problems among children (67,170).

Further, these advantages were maintained 5 years

after enrollment in the Project Redirection pro-&am

(67,169,170).

However, the final report on Project Redirection

notes that, despite impressive gains for many

individuals, the program should not be considered a

panacea (169). At the close of the project, the

majority of participating adolescent mothers had

still not received their diplomas or passed the tests

of general educational development (GED); were not

working despite their desire to do so; had received

AFDC at some point during the previous 12 months;

and were living in poverty (169). One observation

made by the researchers was that the participants’

serious educational needs were probably not adequately met by the program, because educational

services were not tailored to the participants’ needs

and because they were delivered off-site (169).

Clearly, educational deficits can have a great deal to

do with employability and poverty levels.

IOs~e f~repo~ on~ojwt Re&ction notes be possible interaction between the program’s success with parenting education and relative ‘ftthl?’

with pregnancy and birth rates (169). According to Polit and her colleagues, “An environment that encouraged nurturing and vigilant maternal behavior,

in which babies were given a lot of love and attention+ could well have dampened interest in terminating [or otherwise reducing] unintended pregnancies’

(169). The lesson to be drawq according to the researchers, is not that the parenting edueation component of the program should be discarded or

minimized (it apparently was responsible for the beneficial effects on the children of participating mothers), but that the family planning aspects (which

were actually delivered off-site and implemented in a “fairly low-key” fashion) should be strengthened (169).
Chapter l&Pregnancy and Parenting: Prevention and Services .11-405

Drawing on the lessons of Project Redirection,

Manpower Demonstration Research Corporation

designed New Chance, a program for adolescent

mothers begun in 1989 (126a). New Chance emphasizes integration of services, onsite provision of

services, longer duration of services, greater intensity of services, greater obligations on the part of

enrollees to participate regularly, comprehensiveness (educational development, employability development, personal and social development, health

services, and services for participants’ children), and

an experimental evaluation design (126a), New

Chance will not target adolescents younger than 17

(126a).

According to the National Academy of Sciences’

Panel on Adolescent Pregnancy and Childbearing,

the available evidence suggests that it may be

important for comprehensive service programs for

pregnant and parenting adolescents to take into

account the age of the adolescents they serve, since

the needs of younger adolescents and adolescents

who remain in their families of origin may differ

from the needs of older adolescents who are no

longer in school or who are living independently

(148). Also, as noted by Polit and her colleagues,

because many comprehensive programs rely on

other agencies to provide some of the services

needed by their adolescent clients, the impact of

these programs is likely to depend heavily on the

availability and quality of brokered services. Indeed,

one study of comprehensive care programs for

pregnant and parenting adolescents concluded that

most organizations offering these programs were not

able to meet their goals because of a lack of

resources, community support, problems in interagency collaboration, or a lack of adequate mechanisms for coordinating services to pregnant and

parenting adolescents (218). Hofferth concluded

that the comprehensive services model holds promise for improving outcomes for pregnant and parenting adolescents, but it appears that services must be

truly comprehensive, client-focused, and intensive

to be effective (86).

Programs for Adolescent Fathers

Along with the increasing recognition of the

importance of involving young men in pregnancy

prevention efforts has come greater interest in

including adolescent and young adult fathers in the

provision of services. Some concerns about the

adolescent and young adult fathers of children born

Make a baby-make a lifetime commitment.

Photo credit: The North Carolina Coalition on Adolescent Pregnancy

Adolescent females have traditionally been the target

group for special services for adolescent parents and their

children. Over the last decade, however, several

comprehensive service programs for adolescent fathers

have been established. The programs for fathers are

generally intended to improve adolescent fathers’ ability to

support their children and to improve their ability

to be good parents.

to adolescent mothers have centered less on the

welfare of the fathers, however, than on the fathers’

limited ability to behave “responsibly” toward the

family they have helped to create (i.e., by providing

financial support) and have tended to focus on issues

of establishing paternity and child support (l).

Adolescent and young adult fathers have been

included in many youth employment and job training programs, but such programs typically have paid

little attention to their status as parents and make

little effort to adapt program services to their

parental roles (148).

Over the last decade, however, several comprehensive service programs for adolescent fathers have

been established. These comprehensive service pro-
11-406. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

grams for adolescent fathers operate through a

variety of organizations (e.g., existing adolescent

pregnancy programs for young women, schools,

community service agencies). The programs are

generally intended to improve adolescent fathers’

ability to support their children and to improve their

parenting skills, and provide a variety of services,

including education (dropout prevention, remedial

education, or GED classes), employment and employability services (e.g., job training, job counseling, and vocational education), individual counseling, parenting skills training, and legal representation and advocacy for paternity establishment and

child support issues (la,99).

The Teen Father Collaboration, a national demonstration project initiated and supported by the

Ford Foundation, has been a model for comprehensive service programs designed for adolescent fathers (and the only adolescent fathers’ project with

systematic evaluation data) (116). Eight sites were

selected to extend existing service programs for

adolescent mothers to include adolescent fathers.

Outreach strategies, types of services offered, and

locations of service provision varied from site to

site; local agencies were not expected to implement

and test any particular model of service delivery, nor

were any adolescent fathers placed in a comparison

group receiving no or different services (178).

Instead, each agency had to struggle to understand

and meet the needs of its own local population of

adolescent fathers. Evaluation of the results of the

project were also limited by the facts that the

adolescent fathers who took part were entirely

self-selected, and that there was a high attrition rate

(178); thus, any findings should be viewed cautiously. An evaluation component found that, overall, nearly half of the adolescent fathers not enrolled

in school at the beginning of the project (and for

whom outcome data were available) returned to

school or began a GED program subsequent to their

participation; over 60 percent of the adolescent

fathers who had been unemployed at the start of the

project were able to get a job and provide financial

support (as well as in-kind contributions and emotional support) to their partners and children, and

over 80 percent of participating fathers had daily

contact with their children (178).

Public/Private Ventures has begun a program

similar in some respects to the Teen Father Collaboration called the Young Unwed Fathers Project

(169b). The purpose of the project is to help local

agencies respond to the mandate of the Family

Support Act of 1988 (Public Law 100-485) that,

effective October 1990, welfare agencies require

adolescent fathers to contribute to the support of

their children (169b). As Public/Private Ventures

notes, the Family Support Act’s mandate is only one

part of the story: ‘‘Enabling the young men to fulfil

their obligations is the job of other agencies in the

community" (169b).

The Young Unwed Fathers Project is designed to

demonstrate how the needed agency connections can

be made, and how the enabling services can be

delivered effectively (169b). Six communities were

selected to test a variety of paths toward providing

unwed adolescent fathers with training and jobs at a

wage level equal to meeting family responsibilities,

and education for and support in the fathering role.

The young men in each program will be enrolled for

up to 1 year, with followup counseling and support

for an additional 6 months. The demonstration

project’s research questions include: “Which program strategies, involving which agencies, best

attract, retain, and produce positive effects on the

young men? What are the effects? And is cost a

factor in the program components that produce

outcome variations?” (169b).

Conclusions About the Effectiveness of Programs

To Prevent Negative Outcomes of Adolescent

Pregnancy and Parenthood

Although national statistics on adolescent births

do not readily provide information on the socioeconomic status of the adolescents (e.g., 207b), other

information clearly indicates that becoming a mother

places an adolescent and her child in a precarious

situation in terms of immediate socioeconomic

status and both the mother’s and child’s future

(70,148,195a). One of the most definitive lessons to

be learned from interventions that have attempted to

improve the lives of adolescent mothers and their

children is that such mothers and children typically

have need for an extraordinary range of support and

services. These services can include income support,

health services, further education, employability

training, job skills, transportation, housing, parenting education, social support, and child care (e.g.,

169). It is for just this reason that many have

suggested that, when thinking of interventions

dealing with adolescent pregnancy and childbearing,

pregnancy prevention be made the highest priority

(148).
Chapter 10-Pregnancy and Parenting: Prevention and Services . //-407

Adolescent fathers are a less visible part of the

picture and have received less programmatic attention than adolescent mothers. Available data suggest

that they too often have serious needs for a range of

remedial services (e.g., 195a).

That there are now several model programs for the

provision of a comprehensive range of services to

pregnant and parenting adolescents and their children (e.g., 47a,150a,169a) should not disguise the

fact that it is more than likely that many pregnant and

parenting adolescents will face serious barriers to

getting the services they need (150a). Typically,

model and demonstration programs are only that:

models for what could be, rather than illustrations of

strategies that serve all or most of those in need.

In its review of services for pregnant and parenting women and their children, the bipartisan National Commission To Prevent Infant Mortality

found that many needy pregnant women and their

children face numerous “roadblocks’ to receiving

care (see box 10-D). As an example of what can

befall a particular woman, the commission provided

the following case study (150a):

In January 1988, Jolene wasn’t feeling well and

wanted a pregnancy test, However, because the local

public health clinic only offered tests on certain days

of the week which were inconvenient for her, she

went to a local Planned Parenthood. After learning

she was pregnant, Jolene began seeking out services.

Her first stop was at the Food Stamp office. While

there, she learned about AFDC benefits and was

referred to another service center to apply for them

and for Medicaid.

She next went to the community Women’s Center

for prenatal care, only to be told to return in two

weeks for an eligibility determination appointment.

When she did, she was referred to the Central Clinic

downtown to apply for WIC services and to University Hospital to establish hospitalization eligibility.

She was finally given an appointment for three

weeks later at the Women’s Center, and was told to

go back to the downtown Central Clinic for an HIV

test.

After giving birth, Jolene returned for family

planning services, but found that they were only

provided 2 days per week. All told, Jolene made nine

trips in 6 weeks to begin care and receive Medicaid

eligibility.

This case study does not address multiple other

needs that a ‘‘Jolene’ may have had: for housing,

child care, education, parent skills training, job

training, employment, and transportation (see box

Box 10-D—Roadblocks to the Provision

and Coordination of Care for Pregnant

and Parenting Women and Children:

Findings of the National Commission

To Prevent Infant Mortality

According to the National Commission To Prevent Infant Mortality, there are numerous roadblocks to the provision of care for pregnant and

parenting women and their children.

Roadblocks to the provision of care:

● Lack of Medicaid coverage;

● Insufficient physicians, certified nursemidwives, or nurse practitioners in the clinic or

the community-especially true of rural and

inner-city areas;

. Physicians who refuse to accept Medicaid, or

who have dropped their obstetrical practice

because of the high cost of malpractice insurance;

● Lack of treatment programs for substanceabusing pregnant women and mothers;

. Lack of transportation;

. Lack of child care;

. Inconvenient service hours;

. Language and cultural barriers;

● Fragmentation of programs and services such

as Medicaid, the Special Supplemental Food

Program for Women, Infants, and Children

(WIC), housing assistance, and other programs.

Roadblocks to the coordination of care:

● The fact that Federal, State, and local governments typically respond to one health or social

crisis at a time;

● Increases in the numbers of programs and the

size of government, resulting in “vertical

fragmentation”;

. Fragmentation between administrating agencies and service providers (so-called “horizontal fragmentation”);

. Multiple funding streams;

● Different definitions, terminology, and factors

for determiningg eligibility and benefits.

SOURCE: National Commiss ion lb l%evenl Infant Mortality,

One-Stop Shopping: The Road to Healthy Mothers

und Chil&en (Washington DC: April 1991).

10-A earlier in this chapter). Neither does it address

the needs of the father of “Jolene’s” baby.

A major point made by the National Commission

To Prevent Infant Mortality and other observers is

that programs should be designed around the needs
11-408. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

and characteristics of the clients, rather than around

the habits and traditional orientations of the providers (150a).

OTA suggests that, in addition to the barriers

listed in box 10-D, a reason that comprehensive,

integrated services may not have been implemented

is that they appear to be expensive. It is encouraging

that organizations such as Public/Private Ventures

are beginning to include examination of program

costs in some of their demonstration projects (169b).

In order to advance the case for comprehensive,

integrated services for pregnant and parenting adolescents, it maybe necessary to demonstrate (if such

is the case) that such programs are cost-effective in

comparison to most currently available alternatives.

Major Federal Programs and Policies

Pertaining to Adolescent Pregnancy

and Parenting

A number of Federal health, educational, and

human services programs offer services that may

either help prevent adolescent pregnancy or may

affect the outcome of adolescent pregnancy. These

include the Title X Family Planning Program and the

Title XX Adolescent Family Life (AFL) Program

under the Public Health Service Act (see table

10-10). Title X and Title XX are discussed further

below.

Also discussed briefly below are various other

health benefit, income support, education, training,

and food and nutrition programs that are relevant to

adolescents who are at risk of pregnancy or are

pregnant or parenting (160).l04 In many cases, there

are few data on the use of these other programs by

adolescents. 105 A recent review concluded that there

are essentially no Federal programs specifically

designed to ameliorate the long-term consequences

of adolescent pregnancy and childbearing (196).

The Title X Family Planning Services

and Research Program

Title X of the Public Health Service Act was

established by the Family Planning Services and

Population Research Act of 1970 (Public Law

91-572). At the Federal level, it is administered by

the Office of Population Affairs in DHHS. As shown

in table 10-10, Title X provides Federal grants to

public and nonprofit entities that operate family

planning clinics for predominantly low-income women

(including adolescents) in need of subsidized family

planning services; it also supports family planning

research, trainining and information and educational

activities. The Title X program is the major source

of Federal funding ($130 million appropriation in

fiscal year 1990) for public and private nonprofit

family planning clinics that offer contraceptive and

other services (e.g., screening for STDs, pregnancy

testing and counseling, and sometimes prenatal care)

to predominantly low-income clients.l06 Furthermore, it is the only Federal program designed

specifically to provide family planning services.

During the 1970s, the appropriation for the Title

X program increased steadily, peaking in 1981 at at

$161 million. Since 1982, the appropriation has not

exceeded $140 million. Furthermore, the Title X

family planning program has not been formally

reauthorized by Congress since the end of fiscal year

1985. Instead, it has been reauthorized through the

appropriations process via continuing resolutions

(196,197). In 1988, Congress appropriated $138.3

million for Title X, and in 1990, it appropriated $130

million. For fiscal year 1991, the administration

requested $139 million for the family planning

program (197). As in previous years, the budget

request assumed enactment of the administration’s

proposal to recast the Title X into an authority for

block grants for State family planning programs

(197).

Title X Family Planning Clinics-Title X grantees (including public and private nonprofit entities

such as county health departments, Planned Parenthood affiliates, and hospital outpatient departments)

operate some 4,000 family planning clinics across

the country. In fiscal year 1989, clinics that received

Title X funds served more than 4.3 million clients

(predominantly low-income females), including 1.4

l@$For Wr disc~sion of these programs, see J.G. DryfoOS, Addesce?frs at Risk (47a).

105 See ch. 19, “me Role of Federal Agencies in Adol=@nt Health, “ in Vol. III for a general discussion of Federal programs related to adolescent

health.

lo6Fede~ ~~ for f~y p-~N1ces ~so comes p*y from ~ee o~er so~es: the SNial services block grant (Title XX of the Social

Security Act), Medicaid (Title XIX of the Social Security Act), and the maternal and child health block grant (Title V of the Social Seeurity Act) (74c).

These progmrns are discussed below.
Table 10-1 O-Overview of Title X and Title XX of the Public Health Service Acta

Total adolescents

Program Purpose Priorities Funding level served in a year

Title X of the Public

Health Service Act

(Family Planning

Services and Research Act of 1970)

Title XX of the Public

Health Service Act

(Adolescent Family Life Program)

To provide grants for entities that

operate approximately 4,000 pubIic or private nonprofit family planning clinics across the country.

Also to fund training for personnel to improve the delivery of

family planning services; to promote service delivery improvement through research on family

planning and population issues;

and to develop and distribute

information on family planning.

To provide grants for: 1) demonstration projects that seek to prevent

adolescent pregnancy by encouraging adolescents to abstain from

premarital sexual activity,c and 2)

demonstration projects that provide care services for pregnant

or parenting adolescents.d Also

to support research on the societal causes and consequences of

adolescent pregnancy, and childrearing to support evaluative

research to identify effective services; and to disseminate results

of research projects.

Clinics that receive Title X money are

supposed to offer a broad range

of family planning methods and

services. b Priority for clinic services is given to low-income clients. In fiscal year 1987, national

priority areas for service grants

were family involvement of Title

X adolescent clients, infertility

services, natural family planning

services, male involvement, sexually transmitted diseases, AIDS,

adolescent abstinence from sexual intercourse, and regionally

identified areas of concern.

One-third of Title XX funds goes to

demonstration projects for adolescent pregnancy prevention that

primarily encourage sexual abstinence; two-thirds goes to demonstration

projects that provide innovative

approaches to the delivery of

care services for pregnant and

parenting adolescents. Priority is

given to grant applicants who

serve areas with a high incidence of adolescent pregnancy,

serve areas with a hiqh pro-

,.

portion of Iow-income families.

$130 million appropriation in fiscal

year 1990. Since about one-third

of the Title X clients are adolescents, about one-third of this

($43 million) funding is used for

adolescents.

$9.5 million annual appropriations

for 1990 through 1992. All Title

XX funding is for adolescents

under age 19.

Of the estimated 4.3 million predominantly female clients served annually by Title X clinics, about

one-third (1.4 million) of whom

are adolescents ages 15 through

19.

Pregnancy prevention projects in 1 982:

54,000 females and 48,000 males.

Projects that provide care services to pregnant or parenting

adolescents in 1986: 10,728 females and 3,387 male partners.

a~tie x and Title xx of the pu~ic Health Service Act are both administered by the Office of population Affairs within the U.S. Department of Health and Human %tVbS (DHHS).

bFamily planning serv~es provid~ by Title x ~inics include a broad range of ~ntraceptive methods, screening for sexually transmitted diseases (STDS), infertility services, and natural family

planning. The use of Title X funds for abort’km as a method of family planning has been prohibited by statute and regulations since the enactment of the Title X program. For its first 17 years, Title

X program was administered under regulations that required employees of clinics receiving Title X money to provide nondirective counseling (about abortion as well as childbirth) to women who

requested information about managing an unintended pregnancy. In 1988, however, DHHS issued regulations that prohibited employees of Title X clinics from providing counseling and referrals

for abortion services. That regulation was challenged, but a May 1991 ruling by the U.S. Supreme Court upheld it (Rustv. Sullivan, 111 S. Ct. 1759 (1991)).

~itle XX projects are prohibited by the Ttie XX law from providing family planning services other than counseling and referral unless such services are not otherwise available in the cxmmunity.

Title XX projects are statutorily prohibited f rom providing abortions, abortion counseling, and abortion referrals.

dUnderTitle xx, care serv~=for pregnant or parenting adoles~nts include pregnancy testing and maternity counseling, adoption counseling and referrals, primary and preventive health services

including prenatal and postnatal care, nutrition information and counseling, referral for screening and treatment of STDS, referral to pediatric care, family life education, educational and

vocational services, referrals to maternity services, mental health services and referrals, child care to enable the parent to go to school or work, consumer education and homemaking, and

family planning services.

SOURCE: Office of Technology Assessment, 1991.
11-410. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

million adolescent females ages 15 to 19 (47a,196).107

Title X clinics are rarely visited by young males

unless they are accompanying a female partner

(148).

Title X clinics offer a broad range of family

planning methods (including contraceptives that

have to be delivered by a clinic or a private

physician) and services. In 1983, for example, 99

percent of family plannin g agencies offered pregnancy testing, 92 percent offered pregnancy counseling, 95 percent offered testing for STDs, 70 percent

offered community education; 71 percent offered

treatment for STDs; 60 percent offered infertility

counseling; 50 percent had programs for parents; 47

percent had special staff for helping teenagers; 46

percent offered prenatal care; 44 percent had teen

outreach; 39 percent had programs for adolescent

mothers; 31 percent offered genetic counseling; and

20 percent had programs for young men (148,193a).

The services that are most commonly provided to

adolescents at an initial visit to a family planning

clinic include information concerning various methods of contraception (e.g., their use, effectiveness,

and potential risks), counseling in the choice of an

appropriate method; a medical evaluation involving

a pelvic examination, breast examination, blood

pressure check, blood test, and a Pap smear (148,193b).

About two-thirds of first visits involve a pregnancy

test and urinalysis to test for possible contraindications to the use of some contraceptive method. In

addition, about two-thirds of all first visits include

testing for STDs (193b).108

Family planning clinics are generally more willing than private physicians are to provide contraceptive services to unmarried adolescents under age 18

without parental consent or notification (148).109

The provision of contraceptives to adolescents by

Title X clinics has been controversial,l10 but the

courts have thus far held that adolescents may obtain

Title X family planning services without parental

consent or notification ( 196).111 Thus, although Title

X grantees are statutorily required to encourage

family involvement for adolescent patients, Title X

clinics can provide contraceptive services to adolescents without parental consent or notification,l12

Because the Title X program is supposed to serve

low-income women in need of subsidized family

planning services, the services provided by Title X

clinics are generally offered at lower fees than are

charged by private physicians (148,161). Clinics

that receive Title X funds must provide family

planning services free of charge to individuals

whose incomes do not exceed 100 percent of the

Federal poverty guidelines. For individuals whose

income is between 100 percent to 250 percent of the

poverty level, fees are determined on a sliding

payment schedule. Adolescents seeking family planIOT~e nm~r of adolescents using family planning clinics increased dramatically between 1969 and 1983, from 214,000 to 1.6 fiion (148). me

proportion of adolescent clinic patients also increased rapidly in the early years of the Title X prograrq but since 1979, the percentage has been stable

at about 33 percent (148).

log~omtion on tie prev~ence of HIV infection and STDS among U.S. adolescents is presented ~ ch. 9, ‘‘AIDS and Sexually Transmitted Diseases:

Prevention and Services, ” in this volume.

l~~y51cim5 ~ State5 mat do not ~ve expficit consent laws for minors have been feud 5i@fk@ly less ~elY to se~e unmarried teenagers on their

own authority (148, 161 ). In States without explicit consent laws for minors, adolescents may have better access to contraceptive services through family

planning clinics than through private physicians (148). As noted inch. 17, ‘‘Consent and Confidentiality in Adolescent Health Care Decisionmaking,’

in Vol. III, a little under half of the States and the District of Columbia have statutes that specillcrdly authorize minors to give their own consent for what

are variously described as contraceptives, birth control services, or services for the prevention of pregnancy. In the other States, there are no laws

specifically authorizing minors to give consent or the laws are ambiguous.

11% 1983, DHHS attempted unsuccessfully to implement regulations requiring tit ftilypl@ g clinics receiving Title Xfunds notify parents when

contraceptives were prescribed for their unemancipated adolescent children. The regulations were challenged, however, and ultimately, two Federal

courts enjoined DHHS from implementing them. For further discussion, see ch. 17, “Consent and Confidentiality in Adolescent Health Care

Decisionmakm“ g,” in vol. III.

11 I see ch. 17, ‘ ‘Consent ~d Conildentitity in Adolescent Health Care Decisionrnaking, ‘‘ in Vol. III for a review of Federal and State law pertaining

to parental consent and notifkation in situations involving family planning services and other health services related to sexual activities (e.g., STD

treatment, pregnancy-related health sewices).

112A s~dy published k 1980 fowd tit newly two-thirds of adolescents seeking contraceptive services from orgtied f~Y P1 arming providers

thought their parents knew they were doing so, but a signitlcant minority said their parents were not aware they were using the services (148,193c).

Among the adolescents whose parents did not know, a large proportion said they would not come to a family pl arming clinic if parentat notifk-ation were

required.
Chapter l&Pregnancy and Parenting: Prevention and Services .11-411

ning services without parental consent are generally

assumed to be medically indigent (47a).

The use of Title X funds for abortion ‘as a method

of family plannin g’ has been prohibited by statute

(sec. 1008) and by regulations since the enactment

of the Title X program (55a,197). Prior to 1988,

DHHS had interpreted this directive as having no

bearing on speech and information between a

pregnant woman and her physician or counselor at a

clinic receiving Title XX funds. Thus, Title X clinics

were able to provide abortion counseling and

referrals for many years.

In 1988, however, DHHS issued new Title X

regulations prohibiting clinics that receive Title X

funds from providing abortion counseling or referrals to pregnant women (53 FR 2921). Section 59.8

of the 1988 regulations specifies that ‘‘once a client

served by a Title X project is diagnosed as pregnant,

she must be referred for appropriate prenatal and/or

social services by furnishing a list of available

providers that promote the welfare of the mother and

unborn child. If a pregnant client asks for information about abortion or its availability, the Title X

clinic counselor is to reply that ‘‘the project does not

consider abortion an appropriate method of family

planning. ” Section 59.9 of the 1988 regulations

requires a Title X project to be ‘‘organized so that it

is physically and financially separate’ from ‘‘prohibited activities. ” Finally, Section 59.10 of the

regulations prohibits Title X clinics from engaging

in activities that ‘‘encourage, promote, or advocate

abortion. ” The prohibition reaches all activities or

information that ‘‘assist’ a woman in obtaining

abortion or that make the abortion option more

‘‘accessible.

A number of State governments and private

organizations initiated court action to prevent implementation of these Title X regulations (9b,197), but

the regulations were upheld on statutory and constitutional grounds by the U.S. Supreme Court in a

May 1991 ruling [Rust v. Sullivan, 111 S. Ct. 1759

(1991)]. If in response some large-scale providers of

family planning services no longer accept Title X

funds, adolescents’ access to contraception and

abortion could be seriously limited. As this volume

of this Report was being prepared for publication,

the U.S. Congress was considering various amendments to Public Law 91-572. If passed and signed by

the President, some of these amendments would

codify that Congress did not mean to exclude

abortion counseling as part of its 1970 prohibition on

providing abortions in Title X clinics. Passage of

such an amendment would help ensure that adolescents (as well as other individuals) could continue to

get access to abortions as needed and as legally

available to them.113

Research and Other Activities Supported by

Title X Funds--In addition to providing grants for

family planning clinics, Title X funds training for

personnel to improve the delivery of family planning

services; promotes service delivery improvement

through research; and develops and disseminates

information on family planning (197). Title X grants

for research related to family planning, training of

personnel for family planning clinics, and the

development and dissemination of information on

family planning are handled directly by the Office of

Population Affairs. Topics of research include

problems of human fertility and infertility, development of effective methods for fertility regulation,

evaluation of contraceptive methods, and research in

the changes in population structure (202).

Some observers have suggested that these efforts

may not be adequate to meet current needs. In 1990,

the National Academy of Sciences’ Committee on

Contraceptive Development criticized the United

States for a recent lack of leadership in the development of contraceptive technologies (130). The

National Academy of Sciences’ committee also said

that additional attention to the factors that would

“promote contraceptive use among individuals not

seeking to become pregnant is also important

(130).

The Title XX Adolescent Family Life Program

The Adolescent Family Life (AFL) program

under Title XX of the Public Health Service Act was

enacted as part of the Omnibus Budget Reconciliation Act of 1981 and is administered by the Office of

Population Affairs within DHHS. As shown in table

10-10, the Title XX AFL program awards Federal

grants for two types of demonstration projects: 1)

projects that seek to prevent adolescent pregnancy

(primarily by encouraging abstinence from sexual

113As noted above, and in ch. 17, “Consent and Cotildentiality in Adolescent Health Care Decisionrnaking, ” in Vol. III, legal restrictions on

adolescents’ independent access to abortion include certain State requirements for parental consent and notification. Federal constitutional law

concerning the permissible scope of State regulation of abortion as interpreted by the U.S. Supreme Court appears to be in flux.
(1-412 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

activity), and 2) projects that provide health and

social services (including adoption) for pregnant or

parenting adolescents. In addition, the Title XX AFL

program supports research on the causes and consequences of adolescent pregnancy and parenting

(196,202).

From the time of its inception, the Title XX AFL

program has been funded with appropriations that

have not exceeded $15 million per year (e.g., $14.9

million in fiscal year 1984, $14.7 million in 1985,

$14.5 million in 1986, $14.0 million in 1987, $9.5

million in 1988, and $9.5 million in 1989) (202). The

AFL program’s formal authorization expired in

1985. Since then, the program has been reauthorized

through the appropriations process via continuing

resolutions. In fiscal year 1990, Congress appropriated $9.5 million for the AFL program.

About one-third of Title= AFL funding goes to

demonstration projects for adolescent pregnancy

prevention. AFL adolescent pregnancy prevention

projects seek to find the means, within the context of

the family, to reach male and female adolescents

before they become sexually active in order to

promote abstinence from premarital sexual relations

(196). These projects emphasize the importance of

abstaining from sexual intercourse except in the

context of marriage, parent-child communication,

and the development of skills to resist peer pressure.

Most of the other two-thirds of Title XX AFL

funding goes to demonstration projects that provide

care for adolescents who are pregnant or parenting.

AFL adolescent care projects provide, directly or by

referral, health and social services that include

pregnancy testing and maternity counseling; adoption counseling; primary and preventive health care;

nutritional information; screening for venereal diseases; education and vocational services; and mental

health services (196). Title XX projects are not

permitted to offer adolescents contraceptive services

unless they are not otherwise available in the

community and cannot provide abortions, abortion

counseling, or abortion referrals. Adolescents must

be under age 19 to participate in AFL demonstration

projects, and they are generally required to have

parental consent (196).

As of 1989, the AFL program was administering

88 demonstration projects around the country (196).

In 1982, AFL pregnancy prevention projects served

102,000 adolescents under age 19 (48,000 males and

over 54,000 females). In 1986, AFL care projects

served approximately 15,000 pregnant and parenting adolescents (10,728 females, 3,387 males); these

projects also served 6,274 family members and

5,689 infants of adolescent mothers.

These data say nothing about the impact of AFL

projects on either the prevention of adolescent

pregnancies or the amelioration of the negative

effects of adolescent pregnancies. All the AFL

projects are required to include an evaluation

component. However, few AFL projects to date have

included experimental or even adequate quasiexperimental designs which would enable firm

conclusions to be drawn about the impact of these

programs (220a).

In a 1991 review of evaluations of AFL-funded

pregnancy prevention curriculum programs, White

and White concluded that there is a need for

comprehensive examination of such programs to be

made available in academic publications (220a). The

evaluations they were able to locate came from a

variety of sources, including testimonials by project

directors. White and White noted that many of the

evaluations lacked important details about methodological procedures; many may not have been objective (220a). White and White noted that ‘the lack of

available information inhibits researchers in their

attempts to design further program evaluations,

causes speculation about the efficacy of the programs, and prohibits informed policy recommendations” (220a). They suggested that Federal funding

for evaluation research on the programs be increased

(220a). Increasing the funding for evaluation research would be no small feat within the existing

Title XX budget of less than $10 million. But if

rigorous evaluations are not increased and improved

methodologically, important questions about the

effectiveness of federally funded pregnancy prevention programs will not be able to be answered.

Other Federal Programs Pertaining to

Adolescent Pregnancy and Parenting

Although it has been noted that there are no

Federal programs specifically designed to ameliorate the long-term consequences of adolescent pregnancy and childbearing (196), there are several

policies and programs that may be helpful to

pregnant and parenting adolescents. The fact that

these and other Federal programs were not well

coordinated provided some of the impetus for the
Chapter 10---Pregnancy and Parenting: Prevention and Services . II-413

recently announced reorganization of several DHHS

programs for children and families (202b). As

discussed below, it is not yet clear how effective this

Federal reorganization will be in terms of service

delivery at the local level or in terms of the needs of

adolescents specifically. Further, the reorganization

affects only selected programs in DHHS and does

not specifically include housing, education, or labor

programs; nor does it include Medicaid.

Various Federal programs apart from Title X and

Title XX of the Public Health Service Act offer

services that are relevant to the problems confronted

by adolescents who are at risk of pregnancy or who

are already pregnant or parenting (196).1

14

. Medicaid—Medicaid (Title XIX of the Social

Security Act) is a federally aided, Stateadministered program that was established in

1965 to provide medical assistance for very

low-income people meeting specific income

and family structure requirements. 115 Some—

though not all-poor adolescents are covered

by Medicaid. At the Federal level, Medicaid is

administered by the Health Care Financing

Administration in DHHS.

In order to receive Federal Medicaid funds,

States are required to offer a specific minimum

benefit package that includes, among other

things, hospital inpatient and outpatient services, physician services, nurse midwife services, and family planning services. Thus, Medicaid is a source of Federal financing of family

planning services and supplies for low-income

adolescents, who meet the program’s eligibility

requirements. 116 Many adolescents living in

poverty are not eligible for Medicaid, so not all

poor adolescents can get family plannin g services through Medicaid. As noted elsewhere in

this Report, in fiscal year 1988, Medicaid spent

an estimated $16 million on family planning

services for the 4.583 million adolescents ages

10 through 18 who were enrolled in the

program ($3 million or $1 per capita for the

2.657 million adolescents ages 10 to 14 and $10

million or $7 per capita for the 1.928 million

adolescents ages 15 to 18.1

17 Medicaid reimbursement for contraceptive services provided

to adolescents is accepted by the vast majority

of family planning clinics (90 percent in 1983),

but a significant percentage (53 percent in

1983) of the private physicians who could give

adolescent patients contraceptives will not

accept Medicaid reimbursement (148).1 18

In addition to being a source of funding for

contraceptive services, Medicaid is a source of

Federal financing for pregnancy-related care

for low-income women and pediatric care for

children. The Omnibus Budget Reconciliation

Act of 1989 (Public Law 101-239) required

States to extend Medicaid eligibility to all

pregnant women and children up to age 6 with

family incomes up to 133 percent of the Federal

poverty level.119 An important policy issue

which the recent extension of Medicaid eligibility did not address, however, is the effect of

declining Medicaid participation rates among

specialists in obstetrics/gynecology and pediatrics on Medicaid enrollees’ access to care.120

I liIt tiso should be noted that Title IX of the Education Amendments (1972) prohibits dk elimination in education because of pregnancy, childbearing,

or marital status (148). Consequently, all school systems receiving Federal funds must allow pregnant adolescents to remain in school throughout

pregnancy and to return after the birth of their child (148).

1 15 E11gibi11ty for Medl~aid ~s gen~al]y been l~ed to p~cipation ~ the A~C c~h we~~e pro~~.~ eligibility hinges IIOt Ody on whether

family income and resources fall within the State’s AFDC limits but also, with few exceptions, on whether the family has a “deprivation factor” (i.e.,

at least one parent is dead, disabled, continually absent from the home, or as of October 1990, in two-parent families where the principal bread winner

is unemployed). For a discussion of Medicaid eligibility requirements, coverage, payment policies, etc., as they peflain to adolescents, see ch. 16,

“Financial Access to Heatth Services, ’ in Vol. III.

116~ flsc~ Yw 1985, Feder~ f~ds consti~ted 84 percent of public expendit~es on con~aceptive sewices ad supplies. Folly pl@ g services

grants under Title X of the Public Health Semice Act accounted for 34 percenc Medicaid reimbursements accounted for 34 percent; social services block

grant funds accounted for 10 percenq and muternal and chi/d health bZock grun( funds accounted for 6 percent (74c).

1 ITSee Mblc 16.g inch. 16, “Financial Access to Health SeWICeL ‘‘in Vol. III For a breakdown of Medicaid expenditures on adolescents ages 10 through

18 by type of service.

118~ fiscal Yem 19g3, $108 ~llllon of Medic~d funds were used to reimb~se org~~tio~ ~d pfivate physicians for contraceptive Sc3_ViCf3S fOr all

ages (148).

119poor adolescents’ acwss t. Medicaid w~ ch~ged by the omnibus Budget R&OnCiliatiOn Act of 1990 (fiblicIAW 101-508), which required that

beginning July 1, 1991, children born after Sept. 30, 1983, with family incomes up to 100 percent of the Federal poverty level, arc to be phased in to

the Medicaid program. This change will not, therefore, affect the current generation of adolescents.

l~OMedlcald Pmiclpatlon mtc~ and [he effect of Medicaid payment policies on access tO CiWe ~d the availability of qualified providers ‘e ‘iscussd

further in ch. 16, ‘‘Financial Access to Health Services, ” in Vol. III.
//-414 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

●

The use of Federal Medicaid funds to subsidize poor women’s abortions has been statutorily prohibited since the implementation of the

Hyde Amendment in 1977 (74c). Hyde Amendments have been attached to the annual appropriations bills for DHHS and the U.S. Department of Labor every year since 1977. Federal

Medicaid funds can be used for abortions only

in the tiny number of cases in which a woman’s

life is threatened if a pregnancy is carried to

term. 121

Maternal and Child Health Block Grant Program, under Title V of the Social Security

Act—As discussed elsewhere in this Report,

the Title V Maternal and Child Health Services

Block Grant Program, is administered at the

Federal level by the Bureau of Maternal and

Child Health of the Health Resources and

Services Administration within the Public

Health Service of DHHS.122 Federal maternal

and child health block grants are awarded to the

States, which in turn provide grants directly to

public and private providers of maternal and

child health care services. The goal is to

“assure access to quality maternal and child

health services, especially for those with low

incomes and living in areas with limited

availability of health services. ’ Title V is also

used to provide funds for special projects of

regional and national significance (SPRANS)

that contribute to maternal, infant, and child

health. In fiscal year 1988, the appropriation for

the Title V program was $52.6 million. Eightyfive percent ($444.3 million) was allocated to

State health agencies to help them promote,

improve, and deliver maternal and child health

services, and 15 percent ($82.3 million) was set

aside for SPRANS. Title V funds may, but do

not have to be, used for family planning services.

States have wide latitude in establishing the

types of maternal and child health services—

e.g., family planning services, prenatal, delivery, and postpartum care for low-income mothers, well-child care-that are provided and the

●

distribution of funds to support those services

(74c). Expenditures for specific services under

the maternal and child health block grant

program are nearly impossible to identify,

largely because the Federal Government does

not require the collection or reporting of

pertinent data (199). The problem is exacerbated by the fact that there are no requirements

regarding minimum services or eligibility (199).

As a consequence, very little is known about

who receives what types of services under the

maternal and child health block grant. It is

virtually impossible to determine the amount of

Title V funding for services to adolescents or

their children or the adequacy of services they

receive.

Community and migrant health centers—The

community health center program is one of the

largest categorical grant programs, providing

maternal and child health care, as well as other

services, to residents of medically undersexed

areas (199). In fiscal year 1985, community

health centers received $383 million in Federal

funding (199). Nearly half of community health

center users are without health insurance (199).

As discussed elsewhere in this Report, funds

are provided to community and migrant health

centers by the Health Resources and Services

Administration’s Bureau of Health Care Delivery and Assistance. In 1989, 814,000 adolescents received care in community and migrant

health centers, including 117,000 females ages

10 to 14 who received family planning services.123 In 1988, community and migrant health

centers rated teen pregnancy, infant mortality,

and comprehensive perinatal care programs as

their top priorities (135 b). In fiscal year 1988,

the Bureau of Health Care Delivery and Assistance awarded $20 million in grants to fund

comprehensive perinatal care programs to provide primary health care services to lowincome pregnant women and infants at 206

community and migrant health centers. These

comprehensive perinatal care programs proIZIA nm~r of States use their own monies to provide publicly funded abortions for poor women (74c).

122More ~omtionon ~eTifle V ~te~~d c~dhe~~ block gr~tprogr~ is provided kch. 18, “ISSUm h the Delivery of Services tO Sdt?Ctd

Groups of Adolescents, ’ and inch. 19, “The Role of Federal Agencies in Adolescent Heal@” in Vol. III. Under the proposed reorganization of certain

programs in DHHS, administration of the maternal and child health block grant would be moved to the new Administration on Children and Families

(202b,222a).

lzscornparable data Orl adolescents ages 15 and over who received fami~ P1 arming services are not available. As noted in ch. 19, “The Role of Federal

Agencies in Adolescent Health+’ in Vol III, the collection of data on the use of community and migrant health centers by adolescents ages 15 and above

was discontinued about 8 years age.
Chapter 10----Pregnancy and Parenting: Prevention and Services . II-415

vialed case-managed, coordinated perinatal services to 6 percent of all U.S. pregnant adolescents under the age of 20 and 29 percent of

pregnant adolescents 15 years of age and under

(207d).

● Social Services Block Grant Program, under

Title XX of the Social Security Act—As discussed elsewhere in this Report, the Title XX

Social Services Block Grant Program, which is

administered by the Office of Human Development Services in DHHS, provides block grants

to States for social services. 124 States are given

wide discretion in determining what services

will be provided, who will be eligible for

services, and how the funds will be distributed

in the State. Some States use social services

block grants for family planning services and

for foster care and adoption services and

health-related services, but there is little information on how many adolescents or children

born to adolescents are affected.

● Aid to Families With Dependent Children

(AFDC) program—As discussed elsewhere in

this Report, the AFDC program is a cash

assistance program for needy families with

children that is administered by the States

within broad Federal guidelines. 125 At the

Federal level, it is administered by the Family

Support Administration of DHHS. Families

started by women under age 20 account for the

majority of families on welfare, but adolescent

parents constitute a small portion of the AFDC

population at any given point. In fiscal year

1987, 121,000 adolescents (85 percent of whom

were females) received AFDC benefits as

heads of household (201 b). Congress enacted

major welfare reform in the Family Support Act

of 1988 (Public Law 100-485). To give families

receiving AFDC an opportunity to become

self-sufficient, the Family Support Act required

all States to implement a comprehensive education, job training, and work experience program

known as the Job Opportunity and Basic Skills

(JOBS) program by October 1, 1990 (150b).

With few exceptions, all AFDC mothers ages

16 through 19 years of age must participate in

the JOBS program or face the prospect of a cut

in their AFDC benefit.126 States must provide

adolescent JOB participants with child care,

transportation, and any other support services

(e.g., parent education, counseling, peer support groups) that they deem necessary for an

adolescent parent to participate in the JOBS

program. If States lack the resources to provide

the necessary support services or if there is no

JOBS program in the area, AFDC mothers ages

16 to 19 cannot be required to participate in

JOBS. 127

If well implemented, the JOBS program

could have a substantial positive impact on

adolescent parents. According to the National

Health Policy Forum, the Family Support Act

effect on adolescent parents and their children

to date is not yet known, in part because DHHS

reporting rules initially did not require the

collection of very detailed program information

(150b).128 In April 1991, the Center for Law

and Social Policy conducted a survey of the

States to fill the information gap and learn

about adolescent parent participation in JOBS.

That survey found that there were about 25,000

adolescent parents participating in JOBS in the

24 States that reported adolescent parent data

(150b). About two-thirds of these 25,000 adolescents were in five States (Ohio, Florida,

Illinois, Connecticut, and Oklahoma). The 24

States varied widely in the extent to which they

were serving all of their AFDC adolescent

parents (e.g., Oregon was estimated to be

serving 69 percent of its adolescent mothers,

Ohio serving 60 percent, and 10 other States

were serving between 30 and 54 percent, while

Massachusetts was serving about 13 percent

and California was serving about 2 percent)

124More infom(lon on the Tiflc xx SWial Senices Block Grant Progam is provided inch. 1 g, “Issues in tie Defivery of Services to Selected fhOUpS

of Adolescents, and in ch. 19, “The Role of Federal Agencies in Adolescent Health,” in Vol. III.

IZsFor further discussion of the AFDC program s= ch. 18, “Issues in the Delivery of Services to Selected Groups of Adolescents,’ and ch. 19, “The

Role of Federal Agencies in Adolescent Health, ” in Vol. III.

lzbAdolescents ages 16 ~d over me exempt if hey we el~er ill or incapaci~t@ we needed at home ~cause heir child is ill or incapacimted, We in

school full time, or are in their second or third trimester of pregnancy (150 b).

127Auord1ng t. the N~tion~ Hcal~ pollcy Fe-, this is a sizable loophole in tie Family Support Act’s requkements for adolescent pill%CipatiOn h

the JOBS program (150b).

128 New D~S repofi~g ~les ~111 &,come effec(lve ~ October 1991 and will require detailed pro~~ ~o~ation but will not require infOITIlatiOn

on the types of supportive services that States are providing ( 150b).
II-416 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

●

●

(150b). The Center for Law and Social Policy’s

survey also found that educational placements

of JOBS adolescent mothers were generally far

more common than job training or work

placements, although some States (e.g., Iowa,

Missouri, Ohio, and Oklahoma) had substantial

numbers in job training. Only eight States

could report how many JOBS parents were

receiving child care subsidized under JOBS,

and these data showed substantial variation

among the States (150b).

Child Support Enforcement Program—As discussed elsewhere in this Report, the Child

Support Enforcement Program was established

in 1975 under Title IV-D of the Social Security

Act. This program is aimed at helping States

locate absent fathers, establish their paternity,

and enforce their child support obligations. At

the Federal level, the Family Support Administration provides assistance to States to help

them operate programs that offer services to

individuals and families to help them collect

child support from absent parents.129 T h e

number of single adolescent mothers rearing

children affected by this program and the nature

of the program’s effects on adolescent parents

or their children are unknown.

Food and nutritional assistance programs such

as the Special Supplemental Food Program for

Women, Infants, and Children (WIC) and the

Food Stamp Program—As discussed elsewhere in this Report, the U.S. Department of

Agriculture’s Food and Nutrition Service administers several programs that provide food

assistance to low-income individuals and families, including the Food Stamp program, WIC,

and various child nutrition programs.130 Under

the WIC program, participants receive vouchers for food such as milk, cheese, fruit juices,

eggs, dry beans, iron-fortified cereal, and infant

formula (88). Pregnant, breastfeeding, or postpartum adolescents make up an estimated 2.8

percent of WIC participants (200a). An evaluation of the prenatal part of WIC in Massachu-

●

●

setts found that the program improved pregnancy outcomes among all participants, but

especially among teens and unmarried women

(88,117a). To OTA’s knowledge, there is no

comparable information on the percentage of

Food Stamp program participants who are

breastfeeding, or postpartum adolescents or

their children. There is also no information on

the extent to which existing food and nutritional assistance programs meet the needs of

adolescents who are pregnant or parenting and

their children.

Employment programs for economically disadvantaged youth—As discussed elsewhere in

this Report, the U.S. Department of Labor,

through its Employment and Training Administration, supports training and employment

programs for economically disadvantaged youth

under the 1982 Job Training Partnership Act.

Titles II-A and II-B authorize block grants to

the States. In 1989, $715.1 million in Title II-A

funds was earmarked to support training services for economically disadvantaged adolescents, and $709.4 million in Title II-B funds

was designated for support of the Summer

Youth Employment and Training Program for

adolescents. *31 Title IV authorizes federally

administered programs such as the Job Corps,

a joint venture between the U.S. Department of

Labor, private corporations, and nonprofit organizations that provides employment and

training in primarily residential centers for

disadvantaged adolescents and young adults

ages 16 to 21.132 In program year 1989, there

were 100,000 participants in the Job Corps.

Other programs-A variety of Federal programs discussed elsewhere in this Report may

assist pregnant or parenting adolescents by, for

example, providing child care assistance (e.g.,

the Head Start Program, Child Care Food

program, comprehensive child development

centers); housing assistance (e.g., low-income

public housing, leased housing assistance);

funding for projects for substance-abusing

lzg~e child Support Enforcement Program is discussed b ch. 18, ‘‘Issues in the Delivery of Services to Selected Groups of Adolescents, ” and ch.

19, “The Role of Federal Agencies in Adolescent Health, ” in Vol. Ill.

l~ese Progws are discussed iII ch. 19, “The Role of Federal Agencies in Adolescent Healt&” in Vol. III.

13 I’l”he Fede~ Swer Youth EmplO~ent adTr*fiogr~ provides more ~650,()(N) low-kcome teenagers thrOU@OUt the. COUIl@y Wif.h

7 to 8 weeks of employment during the summer. Funding from this program was used to support the Summer Training and Education (STEP) Program

discussed earlier in this chapter.

lszForaddltio~ ~omtiona~utthese ~d other progr~satistered by tie I_J.S. Department of Labor, S(X ch. 19, ‘ ‘The Role of Federal Agencies

in Adolescent Heal@’ in Vol. HI.
Chapter l&Pregnancy and Parenting: Prevention and Services . II-417

pregnant and postpartum women (e.g., alcohol,

drug abuse, and mental health block grants to

States); finding for community and migrant

health centers that provide primary health care

and other services to medically underserved

populations; and other services,

As noted elsewhere in this Report, there are few

data on the utilization of many of these Federal

programs by adolescents, on expenditures for adolescents, or on the adequacy of available services in

terms of meeting adolescents’ needs. Furthermore, a

U.S. General Accounting Office report issued in July

1986 said little is known about the effectiveness of

services provided for adolescents under these programs (195b,196). Numerous other health, education, labor, employment and social service agencies

may have contact with adolescents at risk of

pregnancy, or already parenting, or have the potential to serve them. Although the array of programs

may present a vast set of potential means of

assistance for sexually active, pregnant, or parenting

adolescents, there are substantial barriers to the

effective use of such programs and services by

adolescents (see, e.g., 150a).133 In addition, some

services needed by adolescents may not be available

either generally or in a specific adolescent community (169).

The lack of coordination among programs relevant or potentially relevant to adolescents at the

Federal level is discussed in Volume III of this

report, Strategies to improve coordination at the

Federal and local levels have been described by the

National Commission To Prevent Infant Mortality

( 150a). Furthermore, in April 1991, DHHS announced a reorganization of some programs in a new

Administration for Children and Families (202b).

The reorganization would combine all programs of

the Family Support Administration and the Office of

Human Development Services, and the Title V

maternal and child health block grant program

administered by the Health Resources and Services

Administration (202 b). One purpose of the new

administration would be to bring together Federal

initiatives affecting pregnant and parenting adolescents. Because specific features of the reorganization were still being debated as this volume was

being prepared, OTA could not evaluate the potential effectiveness of this reorganization in delivering

coordinated, comprehensive services to pregnant

and parenting adolescents. Congress may want to

investigate the effects of the reorganization specifically on programs for pregnant and parenting

adolescents in the future.

Conclusions and Policy Implications

The United States has higher adolescent pregnancy rates, birth rates, and abortion rates than a

number of other industrialized countries. Of the

roughly one million U.S. adolescents who become

pregnant each year, about half a million give birth.

In 1988, there were 488,941 births to U.S. females

under age 20 (478,353 to females ages 15 to 19 and

10,588 to females under age 15). The overall birth

rate among U.S. adolescents has leveled off since the

mid- 1970s, but birth rates among black adolescents

have been increasing rather steadily since 1984.

Furthermore, the birth rate among unmarried U.S.

adolescents has been skyrocketing. Whereas onefifth of births to U.S. females under age 20 in 1970

were births to single mothers, about two-thirds of

births to U.S. females under age 20 in 1988 were

births to single mothers (312,499 births to single

females ages 15 to 19 and 9,907 births to single

females under age 15).

These trends related to adolescent pregnancy and

childbearing are disturbing in light of meager

Federal involvement in workable pregnancy prevention efforts and efforts to assist pregnant and

parenting adolescents. For a decade, U.S. executive

branch policy has emphasized the teaching of

abstinence over any other approach to the prevention

of pregnancy. While seeking to delay sexual involvement may be appropriate and effective for

some adolescents who are not yet sexually active,

there is no evidence that the promotion of abstinence

alone is an appropriate or effective approach to

pregnancy prevention for the large group of adolescents who are already sexually active. On average,

65 percent of U.S. males ages 15 to 19 and 53 percent

of U.S. females ages 15 to 19 report that they have

had sexual intercourse.

Policy and program changes are needed to prevent

adolescent pregnancy and to improve the lives of

adolescent parents and their children. In making

these changes, efforts should be made to involve

adolescent males as well as females. OTA’s review

of the literature on adolescent pregnancy prevention
11-418. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

suggests conclusions similar to those of the National

Academy of Sciences’ Panel on Adolescent Pregnancy and Childbearing and other analyses (47a,107a).

There is no “magic bullet” for the prevention of

adolescent pregnancy. Rather, young adolescents

who are not already sexually active should be

encouraged to delay sexual activity, and sexually

active adolescents should be provided with both the

capacity (e.g., contraceptives, information) and motivation (e.g., life skills training, the hope of

obtaining jobs) to avoid too-early pregnancy and

childbearing. Promising models for the provision of

contraceptives (e.g., SLHCs) and enhancing motivation exist; both additional support and more rigorous

evaluation of these models are needed. Also needed

is support for research on contraceptive technology

development, as well as investigation into the

reasons for the high contraceptive failure rates

among adolescents.

Although preventing too-early childbearing among

U.S. adolescents is clearly preferable, careful evaluations of efforts such as Project Redirection suggest

that investing in improving the lives of adolescent

mothers and their children has clear benefits. Such

programs ought to be extended to additional numbers of adolescent parents.

Abortion is a legal alternative to parenthood for

pregnant adolescents, but not an option that a

pregnant adolescent makes lightly. For adolescents

who may choose abortion, there are geographic and

financial limitations on access to abortions, as well

as legal ones. Many births to adolescents are

unwanted.134 If the Federal Government is not going

to act more decisively to prevent pregnancies among

U.S. adolescents or to make life for adolescent

parents and their children less onerous, it could act

to make abortion more available.

Finally, males-both adolescent and older males—

seem to have been largely forgotten in discussions of

adolescent pregnancy and parenting. New efforts to

increase child support enforcement among unwed

and otherwise absent fathers may eventually be

effective in inculcating a sense of responsibility and

obligation in sexually active males, but greater

access to contraception and increased motivation to

avoid unprotected sexual intercourse are probably

also necessary.

. %

t1

Photo reedit: March of Dimes Birth Defects Foundation

Specific options for congressional consideration

pertaining to adolescent pregnancy and parenting are

listed in Volume I.

Chapter 10 References

1.

la.

2.

3.

4.

5.

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Chapter l&Pregnancy and Parenting: Prevention and Services . //-419

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1987.
PREVENTION AND SERVICES

RELATED TO MENTAL

HEALTH PROBLEMS
Chapter 11

MENTAL HEALTH PROBLEMS:

PREVENTION AND SERVICES

Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

Background on Adolescent Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

Prevalence of Mental Health Problems Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

Prevalence of Diagnosable Mental Disorders Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

Prevalence of Subjective Distress Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 436

Prevalence of Suicide, Suicide Attempts, and Suicidal Ideation Among Adolescents . . . . . . . . . . . . . . . . 437

Consequences of Selected Severe Mental Health Problems in Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . 439

Consequences for Individual Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439

Consequences for Adolescents’ Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440

Consequences for Society. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441

Mental Health Promotion and the Prevention of Mental Health Problems in Adolescents . . . . . . . . . . . . . . . . 441

Promoting Adolescent Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442

The Concept of Mental Health Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442

Selected Mental Health Promotion Programs and Their Effectiveness ..,. . . . . . . . . . . . . . . . . . . . . . . . . 443

Problems in Mental Health Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445

Preventing Adolescent Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .446

Factors Associated With Suicide Risk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446

Primary Prevention of Adolescent Suicide . . . . . . . . . . .,,.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .448

Secondary Prevention of Adolescent Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451

Services for the Treatment of Mental Health Problems of Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453

Perspectives on the Current Mental Health Treatment System for Adolescents . . . . . . . . . . . . . . . . . . . . . . . 453

Utilization of Mental Health Treatment by Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454

Sources and Limitations of Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .454

Estimates of Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456

Further Examination of Patterns of Utilization Using NIMH Survey Data . . . . . . . . . . . . . . . . . . . . . . . . 457

Effectiveness of the Mental Health Treatment System for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462

Effectiveness of Inpatient Psychiatric Services and Residential Treatment Centers . . . . . . . . . . . . . . . . . 462

Effectiveness of Day Treatment .,...,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464

Effectiveness of Therapeutic Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .465

Access to Mental Health Treatment Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466

Availability of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466

Affordability of Services . . . . . . . . ..,,... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Approachability of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468

Mental Health Treatment Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .469

Coordination Between the Mental Health System and Other Systems of Care . . . . . . . . . . . . . . . . . . . . . . . 469

The General Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470

The Juvenile Justice System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470

The Child Welfare System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471

The Public School System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471

Barriers to Coordination Between the Mental Health System and Other Systems . . . . . . . . . . . . . . . . . . 472

Selected Models of Innovative Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
Home-Based Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473

Therapeutic Foster Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474

Therapeutic Group Homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . 474

Models for the Provision of Comprehensive, Coordinated Mental Health Services . . . . . . . . . . . . . . . . . . . 475

Ventura County Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475

Alaska Youth Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476

Kaleidoscope Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476

Major Federal Policies and Programs Pertaining to Adolescent Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . 477

Financing of Mental Health Treatment for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478

Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478

Alcohol, Drug Abuse, and Mental Health Block Grant . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 478

Coordination of Mental Health Services for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .479

Child and Adolescent Service System program of NIMH . . . . . . . . . . . . . . . . . . . . ................... 479

The State Comprehensive Mental Health Services Plan Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479

The Education for All Handicapped Children Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479

Research on Adolescent Mental Health Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480

The Promotion of Mental Health and Prevention of Mental Health Problems Among Adolescents . . . . . . 481

The Delivery of Mental Health Treatment Services to Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482

Developing Local Systems for the Delivery of Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 483

Financing the Delivery of Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .483

Use of Institutional Mental Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ........484

Training for Mental Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484

Research on Services for Adolescents With Mental Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485

Summary of Federal Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487

Chapter 11 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488

Boxes

Box Page

11-A. Examples of DSM-III-R Mental Disorders That Affect Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434

1 l-B. Mental Health Service Organizations Surveyed by the National Institute of Mental Health:

Definitions . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,. 455

11-C. An Adolescent Mental Health Crisis Situation Described by a Mental Health Professional . . . . . . . . . 468

1 l-D. The National Mental Health Association’s Recommendations To Limit the Use of

Inpatient Mental Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485

Figures

Figure Page

11-1. U.S. Suicide Rates by Sex, Race, and Age, 1986 . .,.. ,,,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......447

11-2. Suicide Deaths Among U.S. Adolescents Ages 10 to 14 and 15 to 19, by Method of Suicide,

Sex, and Race, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . 449

11-3. Distribution of Admissions of Individuals Under Age 18 to Inpatient Psychiatric Services, by Type,

United States, 1975, 1980, and 1986, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459

11-4. Inpatient Admissions to Specialty Mental Health Organizations Among U.S. Children and

Adolescents Under Age 18, by Race and Ethnicity, 1975, 1980, and 1986 . . . . . . . . . . . . . . . . ....... 460

11-5. Outpatient Admissions to Speciality Mental Health Organizations Among U.S. Children and

Adolescents Under Age 18, by Race and Ethnicity, 1975 and 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461

Tab/es

Table Page

11-1. Prevalence Rates of DSM-III Diagnoses in Nonclinic Samples: Studies Using Methods Suitable for

Nonclinician Interviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .435

11-2. Suicide Deaths per 100,000 Among U.S. Adolescents Ages 10 to 14 and 15 to 19,1979-87.........438

11-3. Admissions of U.S. Adolescents Ages 10 to 18 to Specialty Mental Health Care in Organized Settings,

by Level of Care, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457

11-4. Distribution of Admissions of U.S. Adolescents Ages 10 to 14 and 15 to 17 to All Inpatient Psychiatric

. . . . . . .

Services, by Diagnosis and Age, 1975 and 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458

11-5. Distribution of Outpatient Admissions of U.S. Adolescents Ages 10 to 14 and 15 to 17 in

Mental Health Organizations, by Source of Payment, 1975 and 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459

11-6. Rough Estimate of Direct Expenditures for Mental Health Services for U.S. Adolescents

Ages 10 to 18, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........469
Chapter 11

MENTAL HEALTH PROBLEMS: PREVENTION AND SERVICES

Introduction

A popular view of adolescent mental health is that

adolescence is inevitably a time of “storm and

stress” (158a). Inner turmoil and doubt, as well as

conflict with family members and the larger society,

are commonly assumed to be normal signs of

psychological development in adolescence.

While adolescence is clearly a time of significant

physiological, cognitive, and social changes, serious

emotional disturbance is not inevitably the result of

attempting to cope with the changes of adolescence

(148). Research over the past two decades has

demonstrated little support for the idea that emotional problems are a hallmark of adolescence.

Nonetheless, the available data do indicate that a

substantial proportion of the adolescent population

suffers from psychological problems serious enough

to warrant mental health treatment.

This chapter provides an overview of adolescent

mental health problems and illustrates issues related

to prevention with analyses in two areas: 1) efforts

related to the promotion of mental health and 2)

efforts related to the prevention of suicide. It also

examines the mental health treatment system. The

chapter ends with a review of major Federal

programs and policies pertaining to adolescent

mental health and conclusions and policy implications.

Background on Adolescent

Mental Health

A widely accepted system for classifying mental

disorders of children, adolescents, and adults is the

Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (revised) of the American Psychiatric

Association—also referred to as DSM-III-R (6).

Although there is criticism of its lack of a developmental perspective (74,45) and controversy over the

applicability of adult diagnoses for disorders of

childhood and adolescence (l), this widely used

classification system provides clinicians and researchers with a common language for identifying

mental disorders, Use of the DSM-III-R classification system in epidemiologic and clinical research

also enhances the comparability of results from

different investigations.

Examples of DSM-III-R mental disorders that

affect adolescents are shown in box 1 l-A. Some of

these disorders are usually first diagnosed in childhood, and others are most commonly seen in adults.l

Recent studies that have looked specifically at the

prevalence of mental health problems among adolescents are discussed below. Also discussed at length

are suicide and suicide attempts, which, though not

DSM-III-R mental disorders, are behavior indicators

of mental health problems. Finally, this section

considers briefly the consequences of severe mental

health problems for adolescents, for their families,

and for society.

Prevalence of Mental Health Problems

Among Adolescents

Prevalence of Diagnosable Mental Disorders

Among Adolescents

In its 1986 report on children’s mental health,

OTA concluded that at least 12 percent of the

population under the age of 18 (approximately 7.5

million of the 63 million children and adolescents in

the United States) suffered from some type of

diagnosable mental disorder (202). This finding was

supported by a 1989 Institute of Medicine review

suggested that the 12 percent figure was probably a

conservative estimate of the prevalence mental

disorders among children and adolescents (139).

The overall prevalence of diagnosable mental disorders among individuals under age 20 may actually

be higher than 12 percent—i.e., closer to 20 percent,

or one child in five (51) (see table 1 l-l). In an

examination of five recent epidemiologic investigations (9,23,52, 149,22 1), Costello found overall prevalence rates of diagnosable mental disorders ranging

from 17.6 percent to approximately 25 percent in

samples including adolescents (51 ). Kashani found

a prevalence rate of 18.7 percent in a small study of

]Even ~ough ~roblcm~ ~clat~ t. psychoactive substace use me also included in tie DSM.~-R c~ssification of men~ disorders, the volume of

literature on adolescent substance abuse treatment and prevention is sufficiently large to warrant separate discussion. Thus, substance abuse problems

and their treatment in adolescence are included in ch. 12, ‘‘Alcohol, Tobacco, and Drug Abuse: Prevention and Services, in this volume.

-II-433-
II-434 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 11-A—Examples of DSM-III-R Mental Disorders That Affect Adolescents1

Disruptive Behavior Disorders-The three primary behavior disorders of concern during adolescence are

attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder.

Attention deficit hyperactivity disorder is a diagnosis made when adolescents have difficulty organizing their

schoolwork or cooperating in group activities because of hyperactivity and inattentiveness. The onset of attention

deficit disorder is typically before the age of 4, and the disorder often persists into adolescence.

Oppositional defiant disorder is a diagnosis made on the basis of a pattern of hostile and defiant behavior.

Adolescents with oppositional defiant disorder are often argumentative, resentful, and easily annoyed by others, but

not physically aggressive or prone to violate social norms.

Conduct disorder is a more serious diagnosis, although it also is made on the basis of a pattern of hostile and

defiant behavior. Conduct disorder involves a pattern of behavior (lasting at least 6 months) in which the young

person violates others’ rights as well as age-appropriate social norms and displays at least 3 of 13 specified

behavioral symptoms (e.g., truancy, lying, stealing, fighting).

Eating Disorders-Eating disorders in adolescence primarily include anorexia nervosa and bulimia.

Anorexia nervosa is the severe and prolonged refusal to eat, with severe weight loss and an intense fear of becoming

obese. Bulimia involves episodic and excessive eating binges unrelated to feelings of hunger. It is usually followed

by self-induced vomiting or the use of laxatives. Death is less likely for bulimics than for anorexics, but physical

health problems are common for both groups.

Mood (Affective) Disorders-Diagnoses of depressive disorder are made when individuals suffer from

prolonged and severely disabling depression, as distinguished from the temporary and normal moods of

unhappiness. Feelings of worthlessness, hopelessness, or irritability and thoughts of death or suicide are common.

There is some evidence that antisocial behavior, aggressiveness, or substance abuse may hide or mask clinical

depression but this notion remains controversial.

Bipolar or manic-depressive disorder involves extreme swings in mood between severe depression and intense

elation. During the manic phase, hyperactivity and a decreased need for sleep are common, as are an inflated sense

of self-esteem and a lack of recognition that the behavior is not normal. These manic periods alternate with periods

of depression, sometimes immediately following each other and sometimes with a period of normal moods between

the manic and depressive phases.

Anxiety Disorders--Anxiety disorders are disorders in which excessive anxiety is the primary symptom.

Separation anxiety disorder involves irrational fears or panic about being separated from those to whom one is

attached, usually the parent(s). Physical complaints may accompany the disorder. While separation anxiety disorder

is more common among children, it may continue into adolescence.

Individuals suffering from avoidant disorder become anxious in the presence of unfamiliar people and socially

withdraw, causing severe impairment in their social functioning. Overanxious disorder involves generalized anxiety

about future events or one’s performance in a variety of situations such as exams or social activities.

Adjustment Disorder-Adjustment disorder develops in reaction to a stressful event or series of events (e.g.,

parental divorce, illness or death, moving). The disorder impairs ability to function in school or on the job, because

the individual cannot cope with problems in an appropriate way and may become emotionally incapacitated by stress.

Schizophrenia-schizophrenia is a severe and disabling mental illness that involves disturbances in

emotional expression, behavior, or thought patterns. Although the illness occurs most commonly in adults, it

frequently has its onset in the later teen years. Also, many people who become schizophrenic as adults show

precursory symptoms of the disorder during their adolescent years. Among the essential features of schizophrenia

are the presence of psychotic symptoms, which may include delusions, hallucinations, or catatonia.

Suicide and Suicidal Ideation--Suicide and suicidal ideation are not diagnostic categories included in

DSM-III-R but are behavioral symptoms of underlying problems, many, but not all, of which may relate to the

mental health status of an individual. Suicide is the taking of one’s own life. Suicidal ideation involves

preoccupation with thoughts about committing suicide and may be a precursor to the act itself.

lsub~~u ~~w prob]ems, &lu@g ~cohol ad ~g de~nd~cy, me o~r DSM-~-R disorders that affect adolescents, but they are

not included in this box. For further information, see ch. 12, “Alcoho4 ‘Ibbacco, and Drug Abuse: Prevention and Services, ” in this volume.

SOURCE: Adapted from American Psychiatric Association Diugnowic and Statistical Manual of MentaZ Disorders, 3rd cd., revised

(Washington, DC: 1987).
Table n-l-Prevalence Rates of DSM-III Diagnoses in Nonclinic Samples: Studies Using Methods Suitable for Nonclinician Interviews

National Health Interview

Survey, 1988

Studya Anderson et al., 1987 Bird et al., 1989 Velez et al., 1989 Costello et al., 1988 Offord et al., 1987 Kashani et al., 1987 (Zilland Schoenbom, 1990)

Country New Zealand Puerto Rico Us. Us. Us. Us. Us.

Informants Child (Interview) Parent (Checklist)

Parent (Checklist) Child (Interview) Child (Interview) Child (Interview) Parent (Interview) Child (Checklist) Parent (Interview)

Teacher (Checklist) Parent (Interview) Parent (Interview) Parent (Interview) Teacher (Checklist) Child (Interview)

Sample

N = NAb Ages 6-11

N = 782 Age 11 N = 777 Ages 4-16 N = 776 Ages 11-20 N = 789 Ages 7-11 N = 2,679 Ages 4-16 N = 150 Ages 14-16 and ages 12-17

Specific diagnosis

Attention deficit disorder

(+ Hyperactivity) . . . . . . . . . . . . 6.7% 10.1% 4.3% 2.2% 6.2% 2.7%

Oppositional disorder, . . . . . . . . . .

—

9.7 6.6 6.6 NA 6.0

Conduct disorders . . . . . . . . . . . . . .

—

: : : 1.5 5.4 2.6 5,5 8.7

Separation anxiety . . . . . . . . . . . . . .

—

3.5 4.8 5.4 4.1 NA

(All anxiety disorders) –

overanxious disorder, . . . . . . . . . . 2.9 NA 2.7 1.6 NA —

(“Emotional disorder”)

Simple phobia . . . . . . . . . . . . . . . . . 2,4 2.3 NA 9.2 NA NA

Depression, dyethymia . . . . . . . . . .

—

1.8 5.9 1.7 2.0 NA 8.0 —

(Major depression)

Enuresis (bedwetting) . . . . . . . . . . NA 4.8 NA 4.4 NA 0.7 —

Total with one or mom

diagnoses . . . . . . . . . . . . . . . . . . 17.6% 18.0% * 3.4% 20.6% 22.0% * 3.4% 18.10/0 18.7% 6-11: 12.7%

12-17: 18.5%’

NA E Not available.

aFull reference ~tations are listed at the end of this chapter.

bln total, parents of 17,110 children ages 3 t. 17 were inte~ewed in the 1988 National Health Interview Survey. The proportion of children or adolesmnts a9es 6 to ~ 1 and 1217 is not r=dily

available; however, the estimates shown were deemed reliable by NCHS.

~he number shown is the percentage of children of that age who “ever has an emotional or behavioral problem that lasted 3 months or more or required psychological help”

(235).

SOURCE: Office of Technology Assessment, 1991.
II-436 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

15014- to 16-year-olds (106), and the 1988 National

Health Interview Survey (NHIS) conducted by the

National Center for Health Statistics in the U.S.

Department of Health and Human Services (DHHS)

found a lifetime prevalence rate for 6- to 11-yearolds of 12.7 percent, and a lifetime prevalence rate

for 12- to 17-year-olds of 18.5 percent (235). Thus,

international, national, and local studies find similar

overall rates of mental health problems among

adolescents. 2

In two studies reviewed by Costello that focused

on adolescents (9, 221), the most common disorders

were the disruptive behavior disorders of attention

deficit disorder, oppositional defiant disorder, conduct disorder,3 and the anxiety disorder known as

separation anxiety disorder (51). A third study

among adolescents found a higher rate of depression

than the other investigations (106). The most notable

variations from study to study were those relating to

the rates of specific diagnoses—accounted for, in

part, by different measures and differences in the

samples. In addition, the studies reviewed by Costello, and the NHIS study, found differences in

demographic risk factors for overall prevalence of

emotional and behavioral problems. Older children

were generally more likely than younger children to

have a mental health problem; males were generally

more likely than females to have a mental health

problem; and those of low socioeconomic status

were consistently more likely than those of high

socioeconomic status to have a mental health

problem. 4 Costello did not report on racial or ethnic

differences, but NHIS found that white, nonHispanic parents were more likely to report the

existence of an emotional or behavioral problem

than were black or Hispanic parents (235).5 Further,

NHIS reported a higher lifetime prevalence of

emotional and behavioral problems among those

12-to 17-year-olds: 1) in urban areas6 (19.1 percent)

than in rural areas7 (16.5 percent); and 2) living with

families headed by a biological mother and a

stepfather (29. 1 percent), biological mother alone

(2.5 percent), and “all other” family structures (25.8

percent), than by a biological mother and father

(1 1.6 percent) (235).

Prevalence of Subjective Distress

Among Adolescents

As discussed in chapters 2,3, and 4 of this Report,

there are several aspects of adolescence that may

cause emotional distress among adolescents. Adolescents are rarely asked about such subjective

distress, and the relationship of subjective distress to

diagnosable mental disorders is not known.8 Subjective distress is an important issue because access to

formal sources of mental health treatment may

depend on the existence of a diagnosable mental

zIt should be noted that tie National Healti Interview Survey (NHIS) differed from the other, more local, surveys in some reSpezt.S. It involved Ot@’

parents as respondents, it was in large part an estimate of lifetime prevalence, and the results pertain to a global rating, rather than to specific problems

or disorders. SpecKlcally, estimates of the prevalence of mental health problems were based on the responses of parents of children 3 to 17 to the following

1988 NHIS Child Health supplement questions: First, all parents were asked, “Has [your child] ever had an emotional or behmioral problem that lasted

3 months or more?” Parents who had not reported that their child had had such a problem were asked, “Has [your child] ever seen a psychiatrist,

psychologist, doctor, or counselor about any emotional, mental, or behavioral problem?” Those who responded negatively to this question were asked,

“During the past 12 months, have you felt or has anyone suggested, that ~our child] needed help for any emotional, mental, or behavioral problem?”

If the parent answered affmatively to either of the latter questions, the chdd was counted as having had an emotional or behavioral conditioq even if

the parent had answered the initial question about such conditions in the negative (235).

3some behaviors tit mi@t lead to a dia~osis of conduct disorder may ~SCI result h m adolescent’s being considered delinquent. For further

discussio~ see ch. 13, “Delinquency: Prevention and Services, ” in this volume.

‘k20stello did not report quantitative results from the five studies she reviewed. In the NHIS study, the following percentages by family income were

reported for 12- to 17-year-olds: 22.5 percent in families with incomes of less than $10,000; 19.3 percent in families with incomes between $10,000 and

$24,999; 19.6 percent tifamilies with incomes between $25,000 and $39,999; and 17.6 percent in families with incomes of $40,000 or more (235). Thus,

while there were differences, they were not very substantial. If mother’s education were to be used as an indicator of socioeconomic status, tbe picture

is more compkated; 18.5 percent of 12- to 17-year-olds whose mothers had less than 12 years of education were reported to have had an emotional or

behavioral problem some time in their lives, compared to 16.7 percent whose mothers had 12 years of education, and 20.1 percent whose mothers had

more than 12 years of education (235).

5For 12-t. 17-yeU-olds, tie folIow~g percentages of p~ents repofied tie efistence of problems la.stig 3 months or mOre, OrrtXpllfig pSyChOIO@Cd

help, sometime during the child’s life: 19.5 percent of white parents v. 15.1 percent of black parents; 18.9 percent of non-Hispanic parents v. 14.8 of

Hispanic parents.

burb~ a.reas were defined as Metropolitan Statistical Areas (235).

TRur~ ~em were defined as areas other t.haII Metropolitan Statistic Areas (235).

8As is fiplicit ~ ~x 11-A ~d ~ble 11-1, DSM-~-R diagnoses for adolescents are somewhat weighted toward mental health problems d~t result

in impairment obvious to an observer (e.g., oppositional defiant disorder, conduct disorder, attention deficit disorder, separation anxiety disorder). As

noted abeve, investigators tend’to find that these disorders are the most common among adolescents. Thus, the mental health problems of adolescents

have often been referred to in summary fashion as “behavior disorders” a characterization that has been criticized recently (155 b).
Chapter 11—Mental Health Problems: Prevention and Services . //-437

disorder (202). Two studies that did ask adolescents

about their levels of distress are the National

Adolescent Student Health Survey (8) and the

Adolescent Health Survey conducted by the University of Minnesota (see 204).

The National Adolescent Student Health Survey

of 8th and 10th graders found that, on average, 45

percent of respondents found coping with stressful

situations at home and school ‘‘hard” (29.8 percent)

or ‘‘very hard’ (15.6 percent), 61 percent felt sad

and hopeless in the past month either ‘ ‘sometimes’

(36.9 percent) or ‘‘often’ (24 percent); 36 percent

felt that they had nothing to look forward to in the

past month either “sometimes” (23,0 percent) or

“often” (13.2 percent) (8). On all items, females

were more likely to report distress than were males

(8).

The University of Minnesota survey found that,

on average across grade levels, up to 28 percent of

7th through 12th graders reported experiencing

“extreme stresses and strains’ up to 25 percent

reported that they were dissatisfied with their

personal lives; up to 23 percent reported that life was

uninteresting; up to 26 percent reported that they

were tired or worn out; and 19 percent reported that

they were not feeling emotionally secure-all in the

month before the survey (see 204). These survey

results are more or less consistent with those of Offer

and his colleagues, who have consistently found that

about 1 out of 5 adolescents find adolescence

extremely difficult (148).

If one compares adolescents’ reports and reports

of parents, one finds that adolescents may report

more—and different—symptoms than do their parents. It is often difficult to detect these differences

because psychiatric epidemiologists often combine

the reports of parents and adolescents to come to a

single estimate of prevalence (51). Kashani found

that there were differences between parents and

adolescents in overall prevalence of mental disorders (106a). In addition, parents were more likely to

report symptoms of oppositional defiant disorder

among their 17-year-olds; the 17-year-olds themselves were more likely to report symptoms pertaining to all other disorders measured (conduct disorder, anxiety disorders, depression, enuresis, and

substance abuse) than symptoms of oppositional

defiant disorder (106a).

The Minnesota survey distinguished among metropolitan and rural Minnesota adolescents, and also

conducted a survey of American Indian and Alaska

Native adolescents (see 204). Of the Minnesota

adolescents, urban females reported the highest

prevalence of subjective distress on three out of five

items. Rural males were, however, most likely to

endorse the item, “life was uninteresting. ” Preliminary results of the surveys among American Indian

and Alaska Native adolescents found that American

Indian and Alaska Native adolescents were much

more likely to endorse the statements that ‘‘life was

uninteresting” (45 percent of males and 41 percent

of females), that they were not feeling emotionally

secure (43 percent for both males and females), and

somewhat more likely to report that they were

feeling tired and worn out (23 percent of males and

31 percent of females) (see 204).

Thus, both the level of subjective distress and the

level of symptoms of diagnosable disorders reported

by adolescents are quite high. As a general matter,

diagnosable disorders are more common among

male adolescents (5 1,235), but subjective distress is

more common among female adolescents (8,204).

Prevalence of Suicide, Suicide Attempts, and

Suicidal Ideation Among Adolescents

As noted in box 1 l-A, suicide and suicidal

ideation are not diagnostic categories included in

DSM-III-R. Rather they are behavioral symptoms of

underlying problems, many, but not all, of which

may relate to the mental health status of an

individual.9

Despite its seriousness, suicide appears to be a

relatively uncommon cause of mortality in U.S.

adolescents, accounting for about 10 percent of all

deaths to U.S. adolescents. In 1986, for example,

there were 2,146 cases of suicide reported among

U.S. adolescents ages 10 to 19 (220). In contrast,

there were 11,231 cases of accidental death in

1986-accounting for 54 percent of all deaths for

adolescents in that year.10 Nonetheless, suicide still

~cspite its inclusion in this chapter on mental health, some observers suggest that suicide maybe caused by a variety of factors other than mental

illness (e.g., fma.ncial pressures, social protest loneliness). Suicide has been included in the discussion of mental health issues beeause mental health

status is a major contributing factor in many suicides and suicide prevention and treatment interventions are often located within programs for mental

health service delivery.

l~see ch, 5, < ‘Accidental Injuries: Prevention and SeNiCeS, ‘‘ in this volume for a discussion of morbidity among adolescents due to accidental injuries.
II-438 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table n-2-Suicide Deaths per 100,000 Among U.S. Adolescents Ages 10 to 14 and 15 to 19, 1979-87

Suicide deaths/100,000 population

Ages 10 to 14 Ages 15 to 19

Total Male Female White Black Other Total Male Female White Black Other

1979 . . . . 0.81 1.09 0.59 0.91 0.26 1.21 8.35 13.32 3.2 8.92 4.38 12.13

1980 . . . . 0.76 1.21 0.29 0.86 0.33 0 8.51 13.82 3.02 9.29 3.59 11.02

1981 . . . . 0.89 1.23 0.54 1.01 0.22 0.79 8.63 13.56 3.54 9.45 3.53 11.28

1982 . . . . 1.09 1.71 0.44 1.13 0.81 1.29 8.7 14.07 3.15 9.58 3,86 8.26

1983 . . . . 1.09 1.58 0.57 1.1 1.0 1.23 8.7 13.98 3.24 9.4 4.15 12.32 ~

1984 . . . . 1.28 1.91 0.63 1.38 0.71 1.51 9.01 14.26 3.54 9.92 3.8 10.12

1985 . . . . 1.61 2.31 0.87 1.76 0.83 1.62 9.97 15.98 3.73 10.81 4.86 12.07

1986 . . . . 1.5 2.3 0.66 1.58 0.96 2.05 10.18 16.36 3.76 11.28 4.59 8.36

1987 .,.. 1.5 2.3 0.6 1.6 1.0 0 10.3 16.2 4.2 11.2 5.8 0.7

SOURCE: U.S. Congress, Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Services, Public Health Serviee, Centers

for Disease Control, National Center for Health Statistics, unpublished data on suicide deaths among adolescents, Hyattsville, MD, 1990.

fluctuates between being the second or third leading

cause of death among U.S. adolescents, largely

because of the relatively sound physical health of

this age group.ll

According to the National Center for Health

Statistics in DHHS, the suicide rate among U.S.

adolescents ages 15 to 19 has doubled since the late

1960s, from 5.0 suicides per 100,000 in 1968 to 10.3

suicides per 100,000 in 1987 (219a,220). The

suicide rate among adolescents ages 10 to 14 has

always been much lower than that for 15- to

19-year-olds, but has almost tripled since 1968, from

a rate of 0.6 per 100,000 in 1968 to 1.5 suicides per

100,000 in 1987 (219a,220). Suicide rates for U.S.

adolescents in the years 1979 to 1987 are shown in

table 11-2.

Official suicide statistics are likely to significantly underrepresent the actual incidence of suicide. Holinger and Offer suggest that the numbers of

reported suicides among adolescents may very well

be two to three times lower than the actual figures

(101).

Factors that seem to influence the reporting of

death by suicide include the following: 1) variations

in medical criteria used to determine cause of death

in different jurisdictions, 2) a tendency to discount

intentional self-destruction as a cause of death

among the young, and 3) practical considerations

such as potential loss of insurance benefits and

family or community concerns about the stigma

attached to suicide (57,96,102). Another factor that

may influence the reporting of suicides, especially

suicides among children and adolescents, may be the

desire to protect families from the distress resulting

from a finding of suicide (96,206).

Finally, some suicides may not be recognized as

such. Young men in particular may be seen as

reckless or impulsive rather than suicidal, especially

if their deaths result from falls, drowning, or drug

overdoses (158). On the basis of investigations of

fatal motor vehicle accidents, some researchers

estimate that as many as 10 percent of deaths among

adolescents involved in single-vehicle accidents are

suicides (75, 182,233). Conversely, accidental

deaths may sometimes be erroneously classified as

suicides (175,153). Currently available postmortem

methods for determiningg suicide are inadequate to

determine the extent to which completed suicides

among the young are underreported (35,67).

Although the documented increase in completed

suicides would suggest a concomitant increase in

suicide attempts, little information is available on

trends in nonfatal suicidal behavior (96). There is no

national reporting system for suicide attempts. Many

writers assert that there has been a marked increase

in suicide attempts among adolescents in recent

years (e.g., 57), although studies that have found

increasing rates of suicide attempts among young

people have not separated those below the age of 20

from young adults over 20 (110,226,230). One

investigation of the proportion of people under age

21 among suicide attempters admitted to a New

Haven hospital, however, found an increase between

1 l~olesmnts do ~ve physic~ he~ti problems that require medical interventio~ however. For a review of epidemiologic and other dw on tie

prevalence of physical health problems of adolescents, see ch. 6, “Chronic Physicat Illnesses: Prevention and Services, ” in this volume. FOI a review

of the primary health care services system for adolescents, see ch. 15, “Major Issues in the Delivery of ~ary and Comprehensive Health Services

to Adolescents, ’ in Vol. III.
Chapter n-Mental Health Problems: Prevention and Services . //-439

1970 and 1975 (230), while a second study in a

Boston hospital found no increase in intentiona l

adolescent drug overdoses between 1964 and 1974

(147). The latter study may simply reflect stable

rates of intentional drug overdose. It is not known if

suicide attempts by other means were also stabl e

during this time period .

Berman and Cohen-Sandler have pointed out tha t

there is little consistency across studies in the criteria

used for classifying suicidal behavior or even

suicide attempts (22). Only 4 of the 38 studies they

reviewed contained operational definitions of suicidal behavior in the sample being studied.

Further, data on attempted suicides are based

largely on clinical samples of adolescents admitted

to hospitals following suicide attempts. Studies

based on clinical samples obviously overlook those

suicide attempters who do not come into contact

with hospitals. One study found that the number of

cases of suicide attempts identified through sources

other than hospitals (e.g., jails, private health care

providers, social service agencies) was more than

double the number identified through hospitals

(231). There may also be substantial numbers of

adolescent suicide attempters who do not receive

treatment. One study found that only 12 percent of

the suicide attempters responding to a school-based

survey received medical attention following their

suicide attempt (179).

Even school-based samples suffer from methodological limitations. Information on suicide attempts

from adolescents in a single community (or even a

single high school) cannot be generalized to provide

accurate estimates of regional or national attempt

rates, and school-based samples will necessarily be

unrepresentative of the significant numbers of young

people who have dropped out of school.12 Also, the

relationship between self-reported attempts and the

actual rate of suicide attempts in a population is

unknown.

Despite these limitations, local and national

school-based studies in offer some insight into the

prevalence of suicide attempts among adolescents.

In Oregon, 6.2 percent of a sample of high school

students reported attempting suicide (1 1). The 1986-

87 Minnesota Adolescent Health Survey found that

7 percent of the males and 14 percent of the females

in grades 7 through 12 of that State’s public schools

reported having attempted suicide at least once (12),

while 14.2 percent of a nationwide sample of 8th and

10th grade students reported suicide attempts in a

survey by the American School Health Association

(8). The differences in estimates maybe attributable

to variations in the questions or actual differences in

the populations represented by each sample.

Prior suicide attempts are predictive of completed

suicide among adolescents, but the vast majority of

adolescents who attempt or threaten suicide do not

actually go on to kill themselves (76,81,137).

Consequences of Selected Severe Mental

Health Problems in Adolescence

Mental health problems in adolescence range in

seriousness from relatively minor behavioral issues

to severely disabling mental illnesses that can be life

threatening. Sometimes the comparatively less severe problems, if left untreated, produce long-lasting

consequences for social adjustment, self-image,

interpersonal relationships, or other factors influencing the quality of life. At other times these less

severe mental health problems may not warrant

professional intervention. Experience and the maturation process may prove a sufficient remedy (202).

Unfortunately, little is known about the short- and

long-term consequences of the apparently less severe adolescent mental health problems.

For mental health diagnoses of the more dysfunctional and persistent variety, the consequences are

frequently profound for the affected adolescent, the

adolescent’s family, and society at large. The

consequences of serious mental health problems are

the focus of the discussion that follows, because

something more than passive tolerance is necessary

to avoid the potentially devastating results of such

disorders.

Consequences for Individual Adolescents

Adolescents with serious mental health problems

may be stigmatized by their peers because of odd

behaviors, labeled in school as troublemakers, and

become alienated from their personal support systems (particularly the family) as a consequence of

expressed hostility, inability to communicate effectively, or other factors (83). They may become

socially isolated and self-abasing. Their academic

performance frequently suffers, and they may ex12.s= Ch, 4, “schools and Discretionary Time, ‘‘ in this volume for information on the numbers of dropouts.
II-440. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

hibit underachievement in other areas as well. The

lack of ability to hold a job or interact in other

environmental settings can further exacerbate a

debilitating mental condition. Encounters with the

juvenile justice system may result from antisocial or

disruptive behaviors. For some disorders, substance

abuse may become a feature of self-medication or

comorbidity.

13 Violence toward others or selfinflicted injury or death may follow a descending

cycle of pain and depression.14

Although there is little research on the relationship between childhood mental disorders and adult

mental illnesses, some adult disorders do seem to be

preceded by mental health problems in adolescence.

In a review of research on the long-term prognosis

for adolescents identified as having conduct disorders, Kazdin found that adolescents with conduct

disorders had an increased likelihood of later mental

health problems, psychiatric hospitalization, and

alcohol and drug abuse (107). Kandel and Davies

found that the long-term effects of adolescent

depression manifest themselves in a reduced ability

to establish intimate relationships in young adulthood, with increased use of minor prescription

tranquilizers (for women), and with more deviant

activities and accidents as young adults (104a). Data

from the National Institute of Mental Health (NIMH)

in DHHS indicate that several major adult mental

disorders, including anxiety disorders and some

types of depressive and substance abuse disorders,

commonly begin during the late adolescent years

(44).

Consequences for Adolescents’ Families

Families are the primary caregivers for most

adolescents with mental health problems. As caregivers, families are expected to provide food,

shelter, and a loving, supportive environment for

their adolescent members. But this familial and

social expectation is imposed without significant

supportive services or respite programs to alleviate

the burden it often represents (84,133).

Thus, families seeking to cope with serious

mental health problems in adolescents can experience enormous stress (16,43,94). Typically, mental

health problems in adolescents are initially discounted by families as ‘‘normal’ teenage rebellion

or ‘‘quirkiness. ’ But as symptoms persist, families

are frequently forced into behavior patterns that may

be destructive of the family unit as a whole.

Mental Health Effects for Parents and Siblings--

Parents of adolescents with serious mental health

problems may begin to blame themselves or their

spouse for failure to provide appropriate discipline

or nurturance. Widespread societal ignorance about

mental disorders and their causes may reinforce this

idea of parental responsibility. Some family therapies also continue to ascribe a causal relationship

between faulty parenting and mental disorder in

children (93,133). Over time, disputes between

parents may yield to estrangement or permanent

alienation from one another. Frustration, anxiety,

and feelings of hopelessness may accompany life

with an adolescent with mental health problems.

Unable to cope rationally with their environment,

parents may sometimes retreat into substance abuse

or violence to relieve unremitted tensions (43,133).

Siblings may encounter similar feelings of guilt

and frustration. Some may become overly protective

of their mentally disordered brother or sister. Others

may withdraw and ignore their ill relative. Many

siblings experience fear that they may also have

mental health problems in the future. Resentment is

common, as family attention focuses--of necessity—

almost exclusively upon the adolescent with problems (43).

Financial Costs for Families-Families bear the

financial costs of adolescent mental health problems

in several ways:

14

2.

They may pay direct out-of-pocket expenses

for professional mental health services which

may or may not be reimbursed by insurance.

Health insurance coverage for mental health

services is frequently more limited than coverage for other health services, with higher

copayments and deductibles or lifetime or

annual benefit restrictions. 15 Benefit structures

may also favor a medical model of treatment,

driving service utilization in a particular direction that may be more expensive (43).

Parents may lose work days because they are .

needed to supervise, intervene, or participate

—

lsfjub~t~ce abuse problems ~ adolescerl~ are discus~ inch. 12, “Alcohol, Tobacco, and Drug Abuse: ~eventiOn tind Services, ’ in ~s vol~e.

ld~e problem of violenu is discussed in ch. 13, “Delinquency: Prevention and Services, ” in this volume.

15 For tier ~omtion on he~~ ~swace covemge of mental heal~ services, see ch. 16, “Fficial Access to Health Services, ’ h VO1. ~.
Chapter 11—Mental Health Problems: Prevention and Services .11-441

in their adolescent’s educational, therapeutic,

or other activities.

3. Families may incur losses from property damaged by the aggressive behavior of an adolescent with a mental health problem or from

financial resources spent to cover irresponsible

expenditures or provide special assistance to

the adolescent in distress. For example, an

adolescent with a mental health problem may

be aggressive and kick a hole in a wall, break

furniture, or wreck the family vehicle (accidentally or intentionally). Or, an adolescent

with a credit card may make excessive purchases beyond his or her means, and the family

resources may be used to cover the expenditures. Or, a runaway adolescent with bipolar

(manic-depressive) disorder may incur expenses associated with return travel when he or

she seeks to return home.

4. Siblings may forgo college assistance or other

financial benefits as the family struggles to

meet mounting costs and allocate limited

resources.

Social Costs for Families—Families of adolescents with mental disorders frequently encounter

social ostracism. Longtime friendships may be

ruined. Certain activities may become off-limits for

fear that the adolescent with a disorder may become

disruptive or embarrassing. In some families, a siege

mentality may develop, and the entire family unit

may become isolated and introverted (43).

Consequences for Society

The costs of adolescent mental health problems

for society are of two general types: direct costs

related to mental health treatment and indirect costs

(e.g., losses in productivity, burden on public

services). None of these costs have been quantified

with a high degree of confidence.

Using the best evidence and method available,

OTA estimates that the total cost of mental health

treatment for adolescents in 1986 may have been

$3.5 billion (see below, ‘‘Mental Health Treatment

Costs’ for details).l6

Quantifying the indirect costs of adolescent mental health problems is even more difficult than

quantifying direct costs. Indirect costs include such

diverse factors as lost productivity (for both the

adolescent and frequently for the family caregiver);

increased burdens upon the educational, welfare,

police and juvenile justice systems; disorder-related

damage to property due to accident or aggression;

and impact on hopelessness (139). Perhaps one of

the greatest indirect costs is the forgone talent and

potential contribution to society of an adolescent

whose education is interrupted and never becomes

what he or she might have been—whether physician

or artist, poet or plumber--or worse, whose premature death through suicide deprives society of an

unknown future benefit. Value-laden as they are,

such costs cannot be estimated, but they are nonetheless significant.

Mental Health Promotion and

the Prevention of Mental Health

Problems in Adolescents

Mental health promotion and the prevention of

mental health problems have been widely espoused

as means of averting the devastating costs of

adolescent mental health problems on afflicted

individuals, families, and society. Furthermore, a

broad professional field has developed around these

mental health promotion and preventive endeavors.

Such endeavors include the following:

●

●

●

mental health promotion programs to promote

positive mental health in the general population;

primary prevention efforts intended to avoid the

onset of specific mental health problems; and

secondary prevention efforts intended to keep

high-risk populations from developing mental

health difficulties and to delay the course of a

disorder or prevent its recurrence.

This section illustrates the field by focusing on two

areas that may be thought of as opposite ends of the

spectrum of mental health. It begins by describing

programs designed to promote positive mental

health (not necessarily prevent specific disorders)

among adolescents. Then, it describes programs

designed to prevent adolescent suicide, both among

the general population of adolescents (i.e., primary

prevention) and among high-risk groups, such as

those who have attempted suicide (i.e., secondary

prevention). Issues relating to evaluating the effectiveness of all mental health promotion and prevention efforts are also discussed.

[6 D1rcct ~[)sls for ~czitmcnt of mcnt~ illnesses across ~11 ~gc gI-Oups bvc been estimated at $35 billion ( 139).

:17 I )), , ] I ! (/1,
II-442 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Promoting Adolescent Mental Health

It seems almost unnecessary to argue that the

promotion of positive mental health among adolescents is a worthwhile endeavor. But the notion that

a young person’s mental health status can be

protected or improved by preventive interventions

has been the source of considerable professional and

social controversy (e.g., 152b,169). Despite the

controversy, there is mounting evidence that adolescents can receive supportive services that affect their

mental health in a positive way. This section

explores some of those approaches and identifies

potential problems associated with the promotion of

mental health.

The Concept of Mental Health Promotion

While behavioral scientists have not embraced a

precise common definition of positive mental

health, 17 certain general characteristics are consistent themes in various definitions:

●

●

●

●

●

●

●

a sense of overall subjective well-being, despite

periodic variations in mood,

a belief that the self is competent and effective

in areas that are personally important to the

individual,

the ability to get along with others in mutually

satisfying ways,

psychological and behavioral flexibility in

dealing with stress,

a sense of personal autonomy and control,

commitment to personal goals that are valued in

one’s social environment, and

a repertoire of behavioral skills needed to solve

interpersonal problems and problems of daily

living in a competent way (47).

In the discussion to follow, positive mental health

is not viewed as the antithesis of mental illness.18

Rather than being simply the absence of mental

disturbance, positive mental health is a concept

based on the psychological and emotional competence of an individual to function effectively in his

or her environment. While the absence of psychopathology is a necessary condition for positive

mental health status, it is not sufficient to ensure the

presence of adaptive behaviors or feelings of wellbeing (2,3). Mental health promotion activities are

intended to meet that need.

Mental health promotion seeks to foster a healthy

mental equilibrium and maintain emotional stability

rather than to restore the effective functioning of an

individual with a major mental illness (63). As a

result, mental health promotion programs have

developed along lines that differ from those of

traditional medical models for treating psychopathology.

As Catalano and Dooley have pointed out, a

mental health problem may be avoided by either of

two means: eliminating the problem after onset or

intervening before onset (42). Positive mental health

promotion focuses on the latter approach by concentrating on the healthy population and perhaps those

with subclinical manifestations of disorders.

Sound mental health status in adolescents maybe

fragile and difficult to maintain, given the tremendous physical and emotional changes that occur

during this period of life. Individual variables, such

as genetic predispositions, biological factors, social

and cultural differences, and personality characteristics, can affect both the subjective well-being and the

behavioral competence of adolescents. Changing

family and peer relationships further complicate the

picture. Positive mental health promotion focuses on

keeping the well-adjusted adolescent able to function in psychologically healthy ways.

Thus, interventions have been devised to strengthen

adolescents’ autonomy and ability to cope with

stresses, while promoting their self-esteem and

appropriate peer relationships. Because of the importance of the educational system in developing

academic and interpersonal skills and its convenience as a social unit, schools have served as the

primary context for many of the programs to

promote positive mental health in adolescents (25).19

Community mental health centers also have served

Iyone point of controversy is the degree to which an individual should embrace social conventions or behave in socially acceptable ways. Within my

pluralistic community, there may be numerous subcultures with competing values. It may be that an individual can function in a way that is congruent

with the noms of a particular subculture (e.g., a street gang) and be considered mentally healthy in that context alone, while the same behavior suggests

mental health problems from the perspective of society-at-large. This debate on social values is not enjoined in the following discussion.

18S= ~h. ‘7, “~t Is Adolescent He~th?” in this vol~e for a more extensive discussion of tiem-g of adolescent health and the various

deftitions which have been developed. Throughout this ReporL OTA uses a broad defiition of health that includes the absence of physical or mental

pathology but also encompasses behavioral, environmental, and subjective considerations.

I~e role of schoo~ ~ adolescents’ lives is discussti in ch. 4, “Schools and Discretionary Time,” ~ ~s volume.
Chapter 11--Mental Health Problems: Prevention and Services ● II-443

as program sites in some areas of the country. Less

frequently, but still affording largely untapped

opportunities, health care settings like health maintenance organizations and family group practices

can serve as program delivery sites. The following

section examines selected mental health promotion

strategies and programs and provides information

about their effectiveness.

Selected Mental Health Promotion Programs

and Their Effectiveness

The most widely used mental health promotion

programs have attempted to enhance individuals’

social competence and life skills by strengthening

their adaptive abilities, reducing stressors, and

creating mental-health-promoting environments. These

mental health promotion programs are of three

types:

. broad-based mental health promotion programs

that are delivered as part of a school curriculum,

. programs to help adolescents with a specific

risk factor (e.g., parental divorce), and

. programs to prevent a specified problem.

Each of these types is discussed below. The first type

is the purest form of mental health promotion. The

second and third categories overlap with primary

prevention programs because of their targeted nature, even though they use positive mental health

program techniques and provide generic mental

health benefits beyond their avowed focus.20

Broad-Based Mental Health Promotion Programs-Mental health promotion programs that are

broad-based and generic are typically implemented

as part of a public school curriculum. The aim of

these programs has been the development of a set of

basic problem-solving and coping skills that can be

applied to different types of stressful events. Such

programs tend to be designed for delivery to all

segments of a particular population (e.g., a particular

adolescent age group).

Yale-New Haven/Social-Problem-Solving Project (YNH-SPS), the Improving-Social-Awarenessl

Social-Problem- Solving Project (ISA-SPS), and

the Comprehensive Stress Management Program for Children Project—YNH-SPS (224),

ISA-SPS (59), and the Comprehensive Stress

Management program for Children (1 19) are

programs designed to teach children without

apparent mental health problems social competence, decisionrnaking, and stress management

skills. Thus, these programs are generally

known as ‘socia.competence-promotion’ models. The programs are typically implemented in

schools as part of the regular school curriculum. They may involve 8 to 20 sessions

conducted by teachers or counselors with

special mental health training. Weissberg and

others have developed a 6-step response sequence in which YNH-SPS students are asked

to: 1) stop, calm down, and think before they

act; 2) state the problem and how they feel

about it; 3) set positive goals; 4) think of

alternative solutions; 5) think of the consequences of each solution; and 6) implement the

solution which seems most appropriate (224).

Other models have 4-step (15), 8-step (59), or

1 l-step (88) sequences, reflecting differing

views about the appropriate number of sequences to be learned by students at different

age levels.

Empowerment Models—A number of different

mental health promotion models are based on

the concept that adolescents are already basically competent but are impeded from being

effective in their environment by social structures or lack of resources. The perceived deficit

is that of power to influence the course of one’s

activities.

Thus, empowerment models attempt to provide individuals with opportunities to control

their own lives. Professionals are engaged not

mFeher and Fe~er used a different typology to describe the variety of positive mental health promotion pm-tied thrO@out tie co~q (63).

In their analysis, mental health promotion programs were identified as being: 1) person-focused; 2) transaction-focused; or 3) environmentally focused.

Person-focusedprograrn.r include programs that provide informatio~ assertiveness trainin g, coping skills, interpersonal sociat problem-solving skills,

behavioral skill-building, and reduction of psychological vulnerability. Transaction-focused program include programs that rely on peer support and

self-help networks, but also include projects to help children through major life crises or to build abilities for future use (ala Head Start or High Scopdype

initiatives). Parent-focused programs like Parent Effectiveness Training belong to this genre, as do educational readiness programs which attempt to

match students’ educational deficits to remedial supports. Environmentally focused programs include efforts to provide social and economic supports

for homeless childre% nutrition programs, home-based education supplementation programs, and efforts to modify the structure of educational

institutions.

Paroles and colleagues suggested yet another typology for mental health prevention programs, categorizing some programs as universal iruervenfions

intended for alI members of a particular population indicated interventions targeted to individwds with clinical or preclinical problems; and selected

infervenrions, which focus on high-risk groups (152 b).
II-444 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

to solve problems before they occur, but to

work cooperatively with others to facilitate

self-directed solutions. In the educational arena,

the Maryland Department of Education’s Instructional Leadership Project is an example

(135). This program uses a collaborative approach involving students and teachers in

instructional decisions.

Programs To Help Adolescents Experiencing a

Specific Risk Factor—Mental health promotion

programs to assist adolescents in coping with a

specified risk factor (e.g., stressful events like

parental divorce, school transitions), chronic problems in the social environment, or community

problems (e.g., gang violence) are directed toward

those portions of the population with epidemiologically established risk factors for mental health

problems .21

Adolescence may be a stressful time of life. But

the sources of adolescent stress appear to vary by age

and may thus lend themselves to differing stressreduction strategies. One study looked at three

adolescent age groups and found that family stresses

dominated the concerns of 12- to 14-year-olds; peer

stresses were uppermost among 15- to 17-year-olds;

and academic stresses preoccupied the older adolescents (222). The investigators concluded, “If prevention programs are to be effective in helping

youngsters manage stress, they will need to account

for the types of stress that are significant for the age

group targeted by the program” (222).

● Children of Divorce Intervention Project—The

Children of Divorce Intervention Project follows the specified risk model of mental health

promotion (154). This project is a 16-session,

school-based intervention for 4th through 6th

grade children whose parents are divorcing.

The program focuses on five main goals: 1)

fostering a supportive group environment, 2)

facilitating the identification and expression of

divorce-related feelings, 3) promoting an understanding of divorce-related concepts and

clarifying misconceptions, 4) teaching problemsolving skills, and 5) enhancing positive perceptions of self and family (5,154).

Programs To Prevent a Specified Problem—

Some mental health promotion programs intended to

prevent a specified problem (substance abuse, adolescent pregnancy, or aggressive/antisocial behavior) are focused on high-risk groups, and others are

primarily targeted toward individuals who have

clinical or preclinical problems. The focus on

identifiable problems places programs of this type

more appropriately under the broader label of

primary prevention than of health promotion, although some programs stress generic mental health

maintenance skills that could be taught to a wider

audience in a variety of settings.

. Life Skills Training (LST)--The LST approach

to the prevention of substance abuse is an

example of a program that focuses on a

particular problem but teaches skills that have

broad applicability (26,29). Although it was

initially conceived to deal with the harmful

consequences of substance use, LST has a

broader application because it improves life

skills in general and encourages self-directed

behavioral change techniques that can be useful

in many situations. LST teaches interpersonal

skills, mechanisms for coping with anxiety, and

promotes independent decisionmaking A booster

program for 8th and 10th graders has also been

designed. A detailed teacher’s manual gives a

complete description of the content and activities of each session. These step-by-step lesson

plans permit regular classroom teachers to

implement LST after attending a training workshop (29).

● School Transitional Environment Project—

The School Transitional Environment Project

is a program that was designed to reduce the

problems experienced by children entering

large junior and senior high schools from

relatively small feeder elementary schools.

Entering students were assigned to a core

curriculum with 60 to 80 students. They

primarily interacted with their “core” peers in

different classes throughout the day, thereby

reducing the number of new classmates they

needed to meet. Efforts were made to minimize

the students’ fear and confusion by providing

some stability in the school day. Teachers

served as administrative links between the

school, home, and student, providing counseling and support as necessary (66).

zlFor a discussion of envlromen~l fisk factors for menti health problems in children and adolescents, see OTA’S 1986 background paper Children’s

Mental Health: Problems and Services (202).
Chapter II—Mental Health Problems: Prevention and Services . II-445

Effectiveness of Mental Health Promotion Programs-A review of the literature indicates that

broad-based mental health promotion programs

implemented in schools have demonstrated some

success in enhancing the coping skills of adolescents

and the ability of adolescents to function in social

settings. At this point, though, the link between these

gains at specific developmental stages and the

long-term maintenance of generally healthy mental

status remains unclear.

An evaluation of the YNH-SPS [Yale-New Haven/

Social Problem-Solving Project] found that program

participants improved their ability to use effective

and planned solutions to problems relative to

untrained controls (225). Program participants had

increased involvement with their peers, improved

academic performance, better impulse control, and

decreased self-reports of misbehavior.

An evaluation of the ISA-SPS [Improving-SocialAwareness/Social-Problem-Solving Project] found

that children who had completed the program, in

comparison to a control group of nonparticipants,

had increased sensitivity to the feelings of others,

greater understanding of the consequences of their

actions, and an increased ability to analyze and

understand interpersonal situations and plan appropriate actions, according to one assessment (59).

Participants also enjoyed a more positive selfconcept, were rated by their teachers as better

adjusted, showed improved ability to handle the

transition to middle school, and were relied upon by

their peers for help with problems.

An evaluation of the Comprehensive Stress Management Program for Children found that adolescents who participated in the program, as compared

with controls, demonstrated a higher ability to use

emotion-focused coping skills and had a decreased

perception of stress (48). The elementary school

children in the program also self-reported fewer

symptoms of anxiety and depression than their

control counterparts.

The Maryland Department of Education’s Instructional Leadership Project has resulted in heightened satisfaction and feelings of empowerment for

both teachers and students participating in the

program (1 35).

Programs with a social-competence-promotion

focus that have been targeted to specific risk factors

have also shown success. Participants in the Children of Divorce Intervention Project program (relative to controls) have demonstrated reductions in

behavior problems and improvement in their school

adjustment, according to ratings by children, teachers, and parents (5,154,155).

A number of studies have shown the LST [Life

Skills Training] program to be successful in delaying, or perhaps eliminating, substance use. Although

the changes have been small, participants in LST

programs were found to be less likely than controls

to begin smoking cigarettes (30,31,32) or marijuana

(28) or drinking alcoholic beverages (27). The extent

to which generic life skills are developed during the

course of the program is unclear, however (27a) .22

In 2- and 5-year followups on the School Transitional Environment Project program, participating

students were compared with controls in the same

schools. The dropout rate for School Transitional

Environment Project students was half that of

students in the control group. The studies also

suggested that School Transitional Environment

Project students had higher self-concept and lower

incidence of behavioral and emotional troubles,

including decreased likelihood of engaging in illicit

substance use (62).

Problems in Mental Health Promotion

Problems in Program Design--Compas warns

that too little has been done to assess what adolescents’, parents’, teachers’, and other stakeholders’

expectations are for the outcomes of positive mental

health promotion programs (47). In the absence of

such assessments, mental health promotion programs have tended to be designed to provide

outcomes valued by mental health professionals;

these outcomes may or may not be consistent with

the expectations of adolescents and others affected

by the programs. If the expectations are not congruent, the effectiveness of the programs may suffer.

The effectiveness of positive mental health promotion programs can also be affected by the site of

the program. Shaffer observes that school boards and

community mental health centers may fail to implement an intervention appropriately because the

organization is not ready to accept the program

z~Lif~ Skills Training studies arc discussed more fully in ch. 12, “Alcohol, Tobacco, and Drug Abuse: Prevention and Services, ” in this volume.
//-446 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

(169). The intervention may be inappropriately

presented by its supporters, or it may have to be

adapted to local conditions, thereby losing, distorting, or damaging necessary or core program elements. Weissberg, Caplan, and Sivo note that many

social-competence-promotion programs have originated in elementary schools (225). These authors

point out that it is administratively easier to introduce such programs at the elementary school level

than at the secondary school level, in part because of

the greater stability and structure of the school day

(e.g., elementary students typically remain in a

single classroom for longer periods of time and

classes are smaller and more manageable) (225).

Two additional design-related problems relevant

to mental health promotion programs should be

noted. First, there is a need to identify what factors

contribute to the continuation of successful projects

after project funding has ceased. And secondly, there

is a need to identify and develop appropriate

methods for replicating successful positive mental

health promotion models beyond project sites (27a).

Potential Harmful Effects-The promotion of

positive mental health among adolescent populations requires careful curriculum design and implementation by properly trained and skillful staff.

Programs that assist adolescents in the development

of coping, decisionmaking, or other life competencies may occasionally touch upon sensitive topics

for individual adolescents. Capable personnel are

essential to handle such difficulties and help these

adolescents work through their problems.

Some observers have noted that universal interventions, if improperly designed and implemented,

can sometimes cause more harm than good (58,79,

124,132). One study demonstrated, for example, that

apparently premature application of a preventive

intervention to reduce anxiety and aggression actually increased the occurrence of anxiety and aggression in the experimental population (79). In other

words, the major risk to the target population seemed

to be the intervention itself. While such studies may

speak more to the design and implementation of

particular programs rather than to the concept of

positive mental health promotion itself, they do

provide a cautionary note of potential iatrogenic

effects and emphasize the need for standards to

assure the quality of both program content and staff

training.

On the other hand, selected or indicated interventions that require the identification of adolescents at

risk raise the disturbing possibility that young

people with only minimal symptomatology may be

adversely labeled (169). Avoidance of stigmatization is a difficult issue, particularly in school-based

programs.

Preventing Adolescent Suicide

Interventions to prevent adolescents from attempting or completing suicide have a less positive

focus than many mental health promotion programs.

As noted earlier, suicide consistently ranks as the

second or third leading cause of death among

adolescents (219). Although suicide can result from

the interaction of numerous personal and environmental factors and should not be viewed as solely a

mental health problem, it is sometimes associated

with mental health problems and is considered in

this chapter because of its programmatic affinity

with mental health services.

Factors Associated With Suicide Risk

In reviewing reported factors associated with

suicide risk, one should bear in mind that most

studies of completed suicide in adolescence have, of

necessity, included extremely small numbers of

subjects. Studies with sample sizes of 30 or fewer,

covering a wide range of ages, are common. Few

studies have used control or comparison groups.

Thus, it is unclear to what extent characteristics

found to be common among adolescents who

commit suicide are also common among other

groups of emotionally disturbed or even normal

adolescents.

Individual Factors--As shown in figure 11-1,

male adolescents are more likely to commit suicide

than females. Females, however, are more likely to

make a suicide attempt. Estimates of the ratio of

adolescent female-to-male suicide attempts have

ranged from approximately 2.5: 1 (11) to almost 8:1

(184).

Some researchers have theorized that because

young women are more likely to attempt suicide

without killing themselves, while young men are

more likely to complete suicide, males’ attempts are

indicative of more serious suicidal intent (96,97).

Others have theorized that the differences relate to

socially approved gender roles which permit females

to express themselves through emotional gestures
Chapter n-Mental Health Problems: Prevention and Services . II-447

Figure 11-1—U.S. Suicide Rates

Race and Age, 1986

Deaths per 100,000 population

60

i

~ White males

—A— Black males

50 — White females

—o—— Black females

40

I

suicide rates for races other than white and black

more closely approximate the rates for white adolescents (208,209). Those aggregate figures obscure the

fact that in 1986, American Indian adolescents,

although not a monolithic group, generally had a

much higher suicide rate-four times higher than all

other races among 10- to 14-year-olds (6.9 suicides

per 100,000 population among American Indians v.

)

1.6 suicides per 100,000 population among all other

races) and almost 21/2 times higher than all other

older adolescents (26.3 v. 11.3 per 100,000) (204).

20-

10-

0 - 1

5-14 25-34 45-54 65-74

15-24 35-44 55-64 75-84

Age group

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, Alcohol, Drug Abuse, and Mental Health Administration, Report of the Secretary’s Task Force on Youth Suicide,

Vohmre //: Risk Factors for Youth Sukide, DHHS Pub. No.

(ADM) 89-1622 (Washington, DC: U.S. Government Printing

Office, January 1989).

which males often repress until they reach a more

intense level (189). A third reason offered to explain

the different suicide rates for males and females is

that males are more likely to have access to guns or

other lethal weapons which, once used, provide little

margin for recanting a suicidal intent. Young women,

on the other hand, may select the less lethal means

that are more socially acceptable (e.g., prescription

and nonprescription drugs) and accordingly be more

likely to survive a suicide attempt (130,233).

As figure 11-1 also shows, white adolescents are

more likely than black adolescents to commit

suicide. White adolescent males have a higher

suicide rate than black adolescent males, white

adolescent females, or black adolescent females

(90,219).

Information on adolescent suicides among other

racial and ethnic groups is more limited.23 Data from

national mortality statistics suggest, however, that

Beyond simple demographic descriptors, a previous suicide attempt is possibly the most important

risk factor for completed suicide. Studies of adolescent suicides have found that as many as half had

made previous attempts (50,54,168).

Mental health problems are common among

adolescents who attempt or commit suicide (190a).

In a study of adolescents attending clinics designed

to comprehensively serve the health problems of

high-risk adolescents and young adults, 25 percent

of the suicide attempters could be diagnosed as

experiencing major depression (184). Thirty-five

percent of the depressed adolescents in the sample

had attempted suicide. Several studies have found

that as many as a third of their subjects were

receiving mental health treatment at the time they

committed suicide (50,77,168).

Many of the characteristics of adolescents who

commit suicide are also commonly found in adolescents receiving treatment for mental health problems. Thus, potential risk factors may provide clues

for early intervention strategies, but they are not

specific enough to exclude many nonsuicidal adolescents who may be experiencing mental health

problems. In a small study, researchers found that

suicidal ideation and high levels of hopelessness

distinguished between adolescents who had attempted suicide and adolescents with other known

risk factors who had not attempted suicide (190a).

Substance abuse problems are also frequently

associated with completed or attempted suicide in

adolescence (122,160) and suicidal ideation (183,190a).

As noted elsewhere in this Report, reports from

hospital emergency rooms in major metropolitan

areas find that over 60 percent of 10- to 17-yearolds’ drug-related encounters are actually suicide

Zne ~auci~ of ~m on tie he~th StatUS of raci~ and ethnic minority grOUpS is discussed ~eriKI ch. 18! ‘‘Issues in the Delivery of Services to

Selected Groups of Adolescents,” in Vol. III.
II-448 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

attempts (213b).24 Alcohol consumption is often

implicated as a contributory factor in adolescent

suicides (173,166).

Sexual identity issues may similarly increase the

risk of adolescent suicide attempts. There is some

evidence that gay and lesbian adolescents are

significantly more likely to attempt suicide than

their heterosexual peers (80,138).

Prior school problems appear regularly among

young people who commit suicide, although one

study found above average intellectual ability in

adolescents who killed themselves (168). It is

unclear whether declining school achievement is the

result of a common underlying factor or a discrete

causal factor in suicide (151a).

Family Factors-Family disruption and parental

loss (e.g., divorce, death, abandonment) occur with

greater frequency in the families of adolescents who

commit suicide than among the general population

(50,168). Having a parent with a serious emotional

disability or substance abuse problem may also

place an adolescent at greater risk of suicide.

Adolescents in families where a suicide has been

attempted or committed are at a higher risk of

suicide themselves, perhaps because of the imitative

or role modeling effect or increased genetic risk

(168). Although there is very little information

available on the relationship between sexual abuse

by family members and suicide risk, it has been

suggested that sexual abuse may be a contributing

factor in suicidal behavior among some adolescents

(lo).

Social/Environmental Factors-Changes in peer

relationships, especially rejection by a boyfriend or

girlfriend or a fight with a close peer, seem to place

some adolescents at a greater risk of suicide.

However, the cause-and-effect relationship in these

situations is unclear (166).

Perhaps the most troublesome social factor is the

so-called cluster effect, where a number of adolescent suicides occur over a short period of time and

in close geographical proximity. Having a friend or

acquaintance who commits or attempts suicide

seems to create a greater risk for vulnerable adolescents (34,87), although one study found no relationship (54). The potential for imitation or copycat

suicides may be increased through media accounts

of actual or fictional suicide (68,156), but, here

again, the research is inconclusive (21,109).

Environmental features such as the relative size of

the adolescent population and an increased competition for available jobs also have been hypothesized

to influence the adolescent suicide rate. Holinger

and Offer suggest that entire generations of adolescents may be placed at relatively greater or lesser

risk at different points in time as a result of such

subtle interplay between complex environmental

factors and individual characteristics (100).

Means of Suicide---The method of implementing

a suicide attempt appears to influence substantially

the risk of death. As figure 11-2 shows, handguns

and other firearms are by far the most commonly

used instruments in suicides among adolescents. In

1987, handguns and other firearms accounted for

over half of all completed suicides among adolescents ages 10 to 19. The rate of suicide involving

firearms increased 225 percent among adolescents

ages 15 to 19 between 1968 and 1987, while the rate

by other means increased about 180 percent (66).

This increase has been hypothesized to be a reflection of increasing accessibility and availability of

handguns during this period (33,167).

Overall, the second most frequent method of

adolescent suicide is by hanging, strangulation, or

suffocation (220). Self-poisoning, through ingestion

of solid or liquid substances (e.g., prescription

drugs) or inhalation of gases or vapors (e.g., carbon

monoxide), constitutes the third most prevalent

means of suicide.

Drug overdoses account for the largest proportion

(about 38 percent) of adolescent suicide attempts

that come to the attention of health care providers,

although self-inflicted lacerations are almost as

high, constituting about one-third of all attempts

(75). These methods are followed in prevalence by

injuries due to firearms, injuries from jumping from

high places, attempted hangings, and carbon monoxide poisoning (75).

Primary Prevention of Adolescent Suicide

Although much has been written about adolescent

suicide, knowledge about its causes and effective

means for prevention remains extremely tentative.

Preventive interventions for adolescent suicide are

largely at the formative stage. Although it is unlikely

~S(x ch. 12, ‘‘Alcohol, Tobacco, and Drug Abuse: Prevention and Services, ” in this volume.
Chapter n-Mental Health Problems: Prevention and Services . //-449

Figure n-2-Suicide Deaths Among U.S. Adolescents Ages 10 to 14 and 15 to 19,

by Method of Suicide, Sex, and Race, 1987

Adolescents ages 10 to 14 Adolescents ages 15 to 19

Q nnn . 2,00071,902

&,www

1,500

1,000

1,500

1,000

500 “

250

Total

198

H~

.7. .

,

52

Male Female

218

EL.

/ .-

25 7 ———.

White Black other

500

0

377

Total Male

B

..3.

,’;,.~

;9

Female

1,679

162

m.

White Black Other

_ Suicides by handgun ~~~ Suicides by mean s

and other firearms other t h an firearmsa

aMeans of suicide other than firearms include 1 ) hanging, strangling, or suffocation, 2) gases and vapors, 3) prescription or nonprescription dregs, 4) in9estin9

~ison, and 5) all other means (e.g., drowning, motor vehicle crashes, jumping from high places, jumping or lying down before a moving object, fire or burns,

cutting or piercing injuries).

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics,

unpublished 1987 data on suicide deaths among adolescents, Hyattsville, MD, 1990.

that adolescent suicide can ever be totally eliminated, innovative primary prevention strategies are

being tested in attempts to significantly reduce its

incidence. The examples of school- and communitybased primary prevention programs below indicate

the breadth of those efforts and examine their

potential effectiveness.

School-Based Suicide Prevention Programs--

The number of school-based programs for suicide

prevention has been increasing in recent years.

Although there are no current figures on the total

numbers of such programs, one survey in 1986 found

over 100 school-based suicide prevention efforts

which were estimated to reach about 180,000

adolescents, mostly high school students (78). Approximately 44 percent of surveyed programs provided interventions in the elementary grades.

The major goals of these school-based suicide

prevention programs were as follows:

● increasing student, teacher, and staff awareness

of the problem of adolescent suicide;

● promoting case-finding or identification of

potentially suicidal adolescents by teachers or

students;

. providing information about existing mental

health services in the community; and

. enhancing adolescents’ problem-solving and

coping skills (171).

Programs may use small discussion groups of

targeted students, present information in school

assemblies, or integrate suicide prevention into

existing curricula. Most programs are not lengthy. In

fact, a national survey found that 66 percent of the

115 responding school-based interventions to prevent suicide were only 2 hours or under in duration

(78).

Only three systematic evaluations of the impact of

school-based primary suicide prevention programs

have been identified. One study assessed students 10

weeks after completing a suicide prevention curriculum and found significant but relatively small

increases in knowledge and a decrease in feelings of

hopelessness (18 1). The changes this study detected

in students’ attitudes toward the problem of suicide

(as distinguished from knowledge or feelings of

hopelessness) were attributed to sensitizing from a
11-450. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

pretest rather than to the program itself.25 Another

study found that a school-based suicide prevention

program had very little impact on students’ knowledge or attitudes toward suicide (172). The third

study found that participants in a school-based

prevention program had significantly higher levels

of knowledge about suicide than a pretest group had

(144). Attitudes about suicide also shifted, although

the magnitude of the difference was small. Changes

in suicide rates—the ultimate indicator of a suicide

prevention program’s effectiveness—were not investigated and would be difficult to demonstrate in

relatively small samples like the samples used in

these studies.

Unfortunately, the link between changes in attitudes toward and knowledge about suicide and

behavioral outcomes is unknown. As Wynne has

pointed out, not much is known about the types of

information or attitudes that may help protect

adolescents against suicidal thoughts or actions

(234). Shaffer and his colleagues recently found that

self-identified suicide attempters were less likely

than non-attempters to endorse views consistent

with suicide prevention curricula at baseline, suggesting that suicide attempters may indeed have

attitudes toward suicide that differ from adolescents

who have not attempted suicide (172a). Unfortunately, Shaffer and his colleagues also found that

attempters’ views were not influenced in the desired

direction by exposure to the suicide prevention

curricula, and that in some instances suicide attempters developed attitudes more favorable toward

suicide as a solution to life’s problems and less

favorable toward getting assistance for those problems (172a).

Brief school-based suicide prevention programs

may alter adolescents’ knowledge or attitudes and

strengthen their coping skills, but research has not

shown that such programs have an impact on

suicidal behavior. In light of evidence that some

school-based (172a) and mass-media suicide prevention programs (discussed below) have adverse

effects (86), there is some fear that poorly designed

programs may have an iatrogenic effect (171).

On the other hand, some evidence suggests that

school-based suicide prevention programs may increase the demand for mental health services among

adolescents (128). One suicide prevention center

that sponsored an intervention found that the number

of students contacting the center increased almost

threefold following the school-based suicide prevention program, as did the number of requests from

school personnel for consultation and assistance

with suicidal adolescents (163). Increased demand

for mental health services may reflect the effectiveness of a suicide prevention program, or it may be

yet another expression of iatrogenic impact in that

discussion of suicide may have caused distress

among adolescents. Further research is necessary to

fully assess these findings.

Community-Based Suicide Prevention Interventions-Beyond the school-based suicide prevention programs, other initiatives have been developed

at the community level to focus on the stresses

affecting adolescents, with the ultimate aim of

reducing suicide risk. Some preventive interventions

have been guided by the research that points toward

chronic family problems as likely predictors of

suicide. These community-based interventions have

generally sought to strengthen social supports for

families or to the adolescents themselves (96). Other

community interventions have focused on identification of adolescents at risk or on improving existing

community services for dealing with the mental

health needs of potentially suicidal adolescents

(171).

Still other community-based interventions seek to

increase awareness of the problem of youth suicide

and reduce the possible contagion effect of suicides

which have already occurred. After a suicide death,

for example, some interventions involve efforts to

work with target family members and friends of the

suicide victim as well as others in the victim’s school

or community. Such interventions often use trained

crisis teams to provide individual and group counseling to suicide survivors (i.e., family and fiends).

Suicide survivors may also be given information on

warning signs for early identification and monitor-

~S~dents’ atti~des toward suicide were measured by agreement/disagreement with SG3tementS such as, ‘‘Teenagers who try to kill themselves are

‘weak’ or very disturbed, ’ or ‘It’s none of my business if my friend says he/she wants to kill Mm/herselfor tries to kill Mm/herself.’ Knowledge about

suicide was assessed by asking respondents to indicate if statements like the following were true or false (the accurate response is given at the end of

each statement): “lkenagers who talk about suicide don’t kill themselves” (False); ‘‘Giving away possessions is a sign that a student maybe thinhng

about suicide” (True); or “IfI talk to someone about their suicidal feelings it may cause them to commit suicide” (False).
Chapter n-Mental Health Problems: Prevention and Services . II-451

ing of others who may be contemplating suicide

(150).

Little is known about the impact of most community interventions designed to prevent adolescent

suicidal behavior. OTA is aware of only one study

that evaluated the impact of a community-based

program for adolescents thought to be at high risk of

suicide. Feldman, Stiffman, and Jung examined

support programs for families in which a parent has

a substance abuse or mental health problem and

found no evidence that such services had any impact

on attempted or completed suicide among participating adolescents (61).

Even more discouraging than the lack of evidence

for the effectiveness of community-based suicide

prevention strategies are the data suggesting that

some types of interventions may actually have

deleterious effects. A study of the impact of four

nationally broadcast television programs dramatizing an adolescent suicide or adolescents’ responses

to a parental suicide—all of which were intended to

increase public awareness and were coordinated

with existing community services-found that the

incidence of suicidal deaths and attempted suicides

among adolescents increased significantly following three of the four programs (86). These data

suggest that there is still much to be learned about

the prevention of adolescent suicide.

Interventions To Reduce Access to Means of

Suicide—As discussed above, self-inflicted gunshot

wounds are the leading method of adolescent

suicide, and medication overdose is the chief method

used in suicide attempts (see above). Thus, at least

one observer has suggested limiting access to

firearms through various gun control measures and

to prescription drugs with lethal potential through

restrictions on quantities dispensed (41). Holinger

has recommended that adolescents who are prescribed antidepressants or other psychotropic medications should also receive an emetic or antidote

with the original prescription, since overdoses of

such medications are sometimes used in subsequent

suicide attempts (100). Strategies for reducing

access to other instruments of suicide (e.g., ropes

used for hanging or strangulation, gases and vapors,

automobiles) have not been devised.

Epidemiological studies have been used to estimate that perhaps as many as 20 percent of all youth

who would commit suicide by firearms may be

deterred completely by restricting access to guns,

and another 50 percent would turn to other, perhaps

less lethal, methods (41,100). A comparison between the rates and methods of suicide in King

County, Washington, and Vancouver, British Columbia, revealed a higher suicide rate among 15- to

24-year-olds in King County; the higher rate was

almost entirely accounted for by the rate of handgun

suicide in King County-10 times the rate in

Vancouver (178). Possibly, however, social and

cultural factors influenced these findings (120).

In the United States, Lester and Murrell looked at

the relationship in each State between suicide rates

for all ages and the strictness of gun control laws

(121). They found that as gun control laws increased

in strictness, suicide rates decreased among males.

While their findings suggest that strict gun control

laws have a preventive effect on males, the correlations may also be related to other factors as yet

unidentified and not necessarily imply a causal

relationship. It would be difficult, but not impossible, to design several studies to assess more rigorously the impact of reduced access to guns on

adolescent suicide.

Holinger has estimated that an additional 3

percent of adolescent suicides could be prevented

each year by providing emetics or antidotes along

with prescribed antidepressants or psychotropic

medications dispensed to adolescents (100). Supporting this view, some have cited legislative

restrictions on access to prescription sedatives and

hypnotic drugs as the primary reason for the decline

in suicide rates in Australia during the 1960s (151).

In England, self-asphyxiation with cooking gas

declined from accounting for 40 percent of all

suicides to less than 10 percent of all suicides by

1971, as a result of the conversion of home heating

systems from coke gas (which has a high carbon

monoxide content) to natural gas (118). After the

conversion to natural gas, suicide attempts increased, but completed suicides remained at the

lower level for over a decade (60).

Secondary Prevention of Adolescent Suicide

Secondary prevention programs are programs that

seek to prevent suicidal adolescents from attempting

suicide or completing or repeating a suicide attempt.

These efforts tend to fall into two categories: crisis

intervention services and treatment interventions
II-452 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

designed to prevent repeat suicide attempts.26 In

addition, the provision of mental health services for

all adolescents with mental health problems, as well

as those who may be suicidal, has been viewed as a

suicide prevention strategy (4,96). These types of

prevention efforts and evidence on their effectiveness in terms of preventing adolescent suicide are

discussed further below.

Crisis Intervention Services--Adolescent suicide attempts are often impulsive, precipitated by a

crisis, and accompanied by serious ambivalence in

the wish to die (171), and that observation has led to

the development of services that respond to a crisis

situation and seek to deter individuals from selfdestruction until the immediate crisis has passed.

Survey data indicating that adolescents are frequently unaware of suicide prevention services or

perceive them to be inaccessible (8) have led to

proposals to make those services more readily

available and accessible.27 Most crisis intervention

services and suicide prevention centers provide a

telephone hot line that is available when traditional

mental health services are not (e.g., nights, holidays,

and weekends). Some crisis intervention services are

staffed 24 hours a day (68). Others provide drop-in

counseling or information and referral functions

linking clients with existing community services

(170). Volunteer workers (including adolescent

peers) predominate on the staff of many suicide

prevention centers (176).

Studies of hot lines indicate that adolescents

constitute only a small proportion of all callers

(123). This situation may exist because adolescent

suicide attempters are significantly less aware of

crisis services than adult attempters (89). It is

important to note that hot lines are more accessible

to some adolescents than to others; adolescents from

impoverished homes may not have phones available

to them, they may have less privacy, or they may fear

that their parents will discover their call on telephone bills (204b).

Three studies known to OTA evaluated crisis

intervention services specifically designed for young

people (1 11,136,177). Two of these focused on hot

lines and did not review the broader array of crisis

intervention services available in some programs.

One of the two found a high level of user dissatisfaction with the hot line called, but it did not determine

how many users were suicidal or assess the impact

of hot line intervention on subsequent suicidal

behavior (177). The second study found that onefifth of the women and one-third of the men who

used a hot line in a college community believe their

contact had worsened their problems (111). Other

users also expressed dissatisfaction with the assistance they received.

The third study that evaluated crisis intervention

services found a small but significant reduction in

the rate of suicide among young white women in

communities which began crisis centers (136).

Given that young women are the most frequent users

of hot lines (171) and more satisfied with their

encounters ( 11 1), these results suggest that some

crisis intervention services are helpful for certain

users.

A 1988 review of the data on general hotlines (not

limited to suicide prevention hot lines) concluded

that the effectiveness of these services might be

improved by greater training of volunteers, combined with standardized procedures and active

followup and outreach to suicidal hot line users

(171). In addition, the available data suggest that

more intensive and directed advertising might make

adolescents more aware of crisis services and

increase adolescent utilization. Adolescents themselves have suggested that “800” (toll-free) numbers be used for hot lines, so that calls cannot be

traced (204b). In the light of negative findings about

the effectiveness of some services, it is unclear

whether merely increasing awareness and access

would have beneficial effects.

Interventions To Prevent Repeat Suicide Attempts--

Efforts to keep adolescents who have unsuccessfully

attempted suicide from trying again are generally

grouped into three categories: inpatient hospitalization, outpatient therapy, and psychopharmacological treatments.

Inpatient hospitalization is perhaps the most

common response to an adolescent suicide attempt

that comes to the attention of health care providers

(129,190). The hospitalization of an adolescent who

26Al~ough tie ~tementiom de~cfi~d are pm of tie ment~ heal~ ~ea~ent syste~ tiey Me evaluated here as a secondary prevention Strategy (to

prevent high-risk individuals from making or repeating a suicide attempt).

zTA~ost ~~of g~ ~d 1~ grade studen~ in tie Natio~ Adolescent Smdent Heal~ Smey didn’t knOW whether they could loCate a COmm~ty

agency for suicide prevention; about 20 percent said that they could nor locate such am agency (8).
Chapter n-Mental Health Problems: Prevention and Services . //-453

has attempted suicide is one way to provide an

opportunity for intensive assessment of the adolescent’s mental health status and of the likelihood of

a repeat suicide attempt, It can also allow planning

for continued outpatient therapy (96).

The most common outpatient therapies following

a suicide attempt are family counseling and individual psychotherapy (96). While family support can be

important in recovery from an attempted suicide

(96), adolescents may resist family involvement in

therapy, Further, some families with chronic problems may be resistant to participation. Further,

family therapy is not always available, owing to the

scarcity of trained family therapists (96).

Very little information is available on the use of

pharmacological agents for suicidal adolescents

(196). Antidepressants are becoming more common

in treating adolescents with major depression, and

lithium and monoamine oxidase inhibitors have

been used with adolescents who suffer from bipolar

disorder (165). Anecdotal evidence suggests that

many mental health providers are reluctant to

prescribe drugs for adolescents. Reasons for limiting

use of pharmacological agents with suicidal adolescents include possible suicidal abuse of medications,

the potential for dependence, withdrawal symptoms,

and complications associated with concurrent substance abuse (96, 165). The new antidepressant,

fluoxetine, appears to avoid most of the adverse

effects associated with earlier antidepressants. There

have been reports of increased suicidal ideation and

actual suicides in patients using fluoxetine (193b),

but it is far from clear that fluoxetine has been the

cause of the suicides (91a), Adolescents have not

been involved in trials of fluoxetine for depression

(193a), 28

Generic Mental Health Services--Because of

the apparent link between suicide and mental health

problems among adolescents, improved screening,

diagnosis, and treatment of depression and other

psychological disorders have been suggested as a

preventive strategy (24). These proposals also seek

to increase the ability of health care professionals to

detect potentially suicidal adolescents and refer

them to appropriate services (191). Access issues

have been addressed by recommendations for extended hours, low-cost or no-cost services, and site

locations convenient for adolescents, although little

has been done to implement such recommendations

(19,176). 29

Overall, there is very little information about the

effectiveness of treatment for adolescents who are

suicidal (196). In a review of methods of treating

suicidal adolescents, Trautman found several studies

documenting that adolescents who had attempted

suicide had very low rates of keeping outpatient

therapy appointments following emergency room

treatment or brief hospitalization and high rates of

dropout following one or two sessions of outpatient

therapy (196). Trautman suggested that cognitive

behavioral treatment may be especially effective

with suicidal adolescents, given its systematic,

highly structured approach and its relatively brief

course (196). Although cognitive therapy has been

found to be at least as effective as some antidepressant medications with depressed adults (17,197), its

impact on suicidal adolescents is unknown (196).

Clearly, more research is needed on the treatment of

the substantial number of adolescents who appear to

be at high risk for suicide.

Services for the Treatment of Mental

Health Problems of Adolescents30

Perspectives on the Current Mental Health

Treatment System for Adolescents

It is somewhat misleading to speak of a mental

health treatment system for adolescents. An integrated and well organized mental health system, as

such, does not exist for any group in the United

States, including adolescents. Instead, one finds a

collection of service components which may or may

not be linked, organized under different auspices

nln l~e ~1~ its general Pollq on restricting exposure of investigational new drugs tO minors md women of childbefig age, tie Food ~d D~g

Administration in DHHS specifically requested that adolescents not be included in clinical trials for fluoxetine during the IND (investigational new drug)

stage (193a).

2~Onc increasingly popular measure is the placement of comprehensive health services in (or near) schools. As discussed inch. 15, “Major Issues

Pertaining to the Delivery of Primary and Comprehensive Health Services to Adolescents, ‘‘ in Vol. KII, mental hcxdth counseling has become an integral

part of these services.

~The smtiom of this chapter that discuss mental health services are based largely on “Mental Health Services for Adolescents” (39) and “Use of

Mental Health Sector Services by Adolescents: 1975, 1980, 1986, ” both prepared for OTA by Barbara J. Burns, Carl A. Taube and John E. Taube.
II-454 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

(e.g., public, private) and varying in configuration

and composition from one part of the country to

another.

Despite the lack of an integrated and wellorganized mental health treatment system, there

have been extensive efforts to implement legitimate

systems of mental health care. Significant efforts

among these include the child guidance movement

and the community mental health center and neighborhood health center movements in the 1960s. In

education, the 1975 Education for All Handicapped

Children Act (Public Law 94-142)31 was thought to

have the potential to pull together the range of

services needed by children and adolescents with

disabilities, including mental health problems,

through the school system. More recently, the

National Institute of Mental Health (NIMH),

through its Child and Adolescent Service System

Program (CASSP) and the 1986 Comprehensive

Planning for Mentally Ill Individuals Act (Public

Law 99-660),32 has been encouraging States to

develop comprehensive mental health services for

seriously emotionally disturbed children.

The aims of a mental health service system, its

operating principles and service components, have

been described in the professional literature (187,

202,204). In defining a system of care for severely

emotionally disturbed children and adolescents, for

example, Stroul and Friedman noted that services

should be child-centered, family-focused, and community-based and should include the following

components: mental health services, social services,

educational services, health services, vocational

services, recreational services, and operational services (187).

How reality diverges from the ideal mental health

treatment system postulated by Stroul and Friedman

becomes evident when one considers data on the

utilization of mental health treatment services by

adolescents. Fragmentation and lack of coordination

are characteristic features of mental health service

delivery and are reflected in the segmented, sitespecific manner in which utilization data are traditionally considered, with scant attention paid to

client movement along a continuum of care (186a).

Utilization of Mental Health

by Adolescents

Sources and Limitations of Data

Many concerns have been raised that children and

adolescents do not have appropriate access to mental

health services (e.g.,115,202,139). However, it has

been difficult to draw firm conclusions about access

because of limitations in information about children’s use of available mental health services (202).

Further, most analyses have focused on children

under age 18 as a group and have not disaggregated

information about utilization and access for adolescents separately (e.g.,202). This section discusses

sources and limitations of current data on the

utilization of mental health services by adolescents.

It then provides an overview of available estimates

of the use of mental health services by adolescents,

and draws a tentative conclusion about whether

adolescents in need are getting access. Then, using

the leading, but quite limited, source of information

on mental health services utilization by adolescents

—NIMH’s Inventory of Mental Health Organizations (208,209,210,21 1,212)--the section reviews

current patterns of utilization by setting and adolescent patient characteristics (e.g., race, ethnicity,

diagnosis, source of payment), and reviews shifts in

patterns of utilization over the period 1975 through

1986.

There are few sources of data on the utilization of

mental health treatment services by adolescents and

each source has limitations. DHHS National Ambulatory Care Survey (NAMCS), a periodic survey of

office-based private physicians, provides some information about adolescents’ visits to physicians,

including psychiatrists.33 The last NAMCS survey

for which data were available for this Report was

conducted in 1985. The 1988 National Health

Interview Survey (NHIS), also conducted by DHHS,

asked respondents to report on whether their chil31This Wm ~end~ in 1990 by the Education of the Handicapped Act Amendments of 1990 (Public hW 1014’76).

32~s Wa m~d~ in 1990 by the Mental Health Amendments of 1990 (Public Law 101-639).

33~e ~e~~s ad ]fii~tions of NAMCS ~discuss~ in app. C, “Issues Related to tie ~ck of Inforrr@on About Adolescent Health ~d Related

Services,” in Vol. I, ch. 6, “Chronic physical Illnesses: Prevention and Services, “ in this volume, and ch. 15, ‘‘Major Issues Pertain@ to the Delivery

of Primary and Comprehensive Health Services to Adolescents, ” in Vol. III.
Chapter n-Mental Health Problems: Prevention and Services . II-455

Box n-B-Mental Health Service Organizations Surveyed by the National Institute of

Mental Health: Definitions

Mental health service organizations surveyed by the National Institute of Mental Health (NIMH) can be split

into four levels. Those levels, from the most restrictive to the least restrictive, are defined as follows:l

. Inpatient psychiatric facilities-Psychiatric inpatient units in State and county mental hospitals, general

hospital psychiatric units, and private psychiatric hospitals.

. Residential treatment centers--Residential organizations, not licensed as psychiatric hospitals, whose

primary purpose is the provision of individually planned programs of mental health treatment services in

conjunction with residential care for children and youth primarily under the age of 18. Programs must be

directed by a psychiatrist, social worker, or psychiatric nurse who has a master’s and/or a doctorate degree.

At least half of the admissions must be for mental illnesses that can be classified by DSM-II/CDA-8 or

DSM-III/ICD-9-CM codes other than mental retardation or substance abuse codes.

. Partial hospitalization/day treatment-A planned program of mental health treatment services generally

provided in sessions of 3 to 6 hours to groups of patients or clients who do not require 24-hour supervision.

This level of care offers more intensive treatment than the usual outpatient care (once a week psychotherapy)

and provides a range of treatment modalities (individual and group therapy, education, and rehabilitation).

Partial care/day treatment can be offered in general hospitals with separate psychiatric services, psychiatric

hospitals, freestanding psychiatric outpatient clinics, or multiservice mental health organizations.

. Outpatient mental health services provided in organized mental health settings-Mental health

services provided to ambulatory patients or clients who do not need either 24-hour supervision or partial

hospitalization. As a general matter, outpatient services include the provision of psychotherapy and

psychotropic prescriptions in outpatient clinics, crisis services such as home-based treatment, and services

in emergency rooms. NIMH only collects data on outpatient services provided in organized mental health

settings (e.g., federally funded community mental health centers, freestanding psychiatric outpatient clinics,

and multiservice mental health organizations). Information about mental health services provided in private

office-based practices and other settings is very limited.

1- does not Mve a specific deilnition of a “mental health organization.” Rather, it collects data on patient - episodes *e@t

types of mental health organhations: State and county mental hospitals, private psychiatric hospitals, Department of Veterans Affairs (formerly

Veterans Ahmm“ “stration) psychiatric orgaruzations, “ general hospitals with separate psychiatric semices, residential treatment centers for

emotionally disturbed chikireq fiwxtanding psychiatric outpatient clinics, freestanding psychiatric partial care orgamzations, “ and multiservice

mental health organi~ons. Omitted from the NIMH inventory are patient care episodes in all psychiatric services maintained by Federal

agencies other than the Department of Vet- Affairs, such as the Public Health Sewice, Indian Health Service, Department of Defense, and

the Bureau of Prisons.

SOURCE: B.J. Burns, CA. ‘Ihube, and J.E, ‘Rmbe, “Mental Healtb Services for Adolescents,” contract paper prepared for the Office of

‘lkchnology Assessmen4 U.S. Congress, Washington DC, 1990.

dren had seen psychologists, psychiatrists, or other

mental health providers ever and in the past year.34

Data on the utilization of mental health services

provided by ‘‘specialty mental health organizations’ are available from the National Reporting

Program of the DHHS, NIMH, Division of Biometry

and Applied Sciences. These data are relied upon

extensively in this chapter but are also limited. The

types of mental health service organizations surveyed by NIMH are inpatient psychiatric facilities,

residential treatment centers, partial hospitalization/

day treatment, and outpatient services provided in

organized settings (see box 1 l-B). Inpatient data are

available from NIMH’s survey for 1975, 1980, and

1986; residential treatment center data for every 2

years between 1969 and 1983, and then 1986; partial

hospitalization data for 1986 only; and outpatient

data for 1975 and 1986 (210,211,212).

In 1986, NIMH surveyed 4,747 specialty mental

health organizations in the 50 States and the District

~ me 19gg Natio~ He~th Interview Survey is described, and its ~tatiOI15 discussed, ~ app C., “Issues Related to the Lack of Information About

Adolescent Health and Related Services” in Vol. I and inch. 6, “Chronic Physical Illnesses: Prevention and Semices,” in this volume. Parents who

reported a specitlc condition were asked whether the child had been treated for the condition ever and in the last 12 months. Parents who had not reported

a specific condition were asked ‘Has [your child] ever seen a psychiatrist, psychologist doctor, or counselor about any emotional, mental, or behavioral

problem?’
II-456 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

of Columbia (159).35 The data from NIMH surveys

do not include private office-based mental health

services (e.g., provided by primary care physicians,

psychiatrists, social workers, clinical psychologists,

and nurse-therapists outside the auspices of a clinic

or residential setting) and do not include mental

health services provided in human service sectors

such as health, education, social welfare, and juvenile justice. As discussed briefly in this chapter and

elsewhere in this Report, however, mental health

services are not typically available in non-mentalhealth sectors. However, mental health services are

provided extensively outside of specialty mental

health organizations (e.g., in private practices) by

primary care physicians, psychiatrists, psychologists, social workers, nurse-therapists, and other

providers. Tremper has estimated the utilization of

school psychologists by adolescents (198).

A further source of information is a 1986-87

survey of States conducted by the National Mental

Health Association (NMHA), which obtained estimates of children and adolescents in institutional

settings (143). Placements made or paid for by

different State government entities (mental health,

social services, juvenile justice and education) to

State hospitals and out-of-state residential treatment

centers were reported.

Information about the utilization of some services—

e.g., group homes, therapeutic foster care, homebased crisis treatment, emergency rooms, and hot

lines-is not collected in any systematic fashion,

and their utilization is not discussed below.

Other potential sources of information about the

receipt of mental health services include data from

Education for All Handicapped Children Act programs mandated by Public Law 94-142 (amended by

the Education of the Handicapped Act Amendments

of 1990 [Public Law 101-476]) (134a), and mental

health services provided in school-linked health

centers (SLHCS).36 Mental health services provided

under Public Law 94-142 and in SLHCs are discussed below (see ‘‘The Public School System’ ‘).

Estimates of Utilization

The following estimates of adolescents’ utilization of mental health services can be made from

available data sources:

*

●

●

●

NAMCS: 2 percent (1.004 million visits) of

visits by 10- to 18-year-olds to private, officebased physicians in 1985 were to psychiatrists

(220).

NHIS: According to parents’ reports, 10 percent of all children ages 3 to 1737 (or an

estimated 75 percent of all those who had ever

had emotional or behavioral problems) had

received treatment or counseling for emotional

or behavioral problems at some time in their

lives (235). Five percent were reported to have

received this help within the previous 12

months .38

NIMH: In 1986, an estimated 1.9 percent of the

10- to 17-year-old adolescent population (586,

845 adolescents) was served by specialty mental health organizations (212). Of the 1.9

percent, 1.3 percent were served by partial

hospitalization or outpatient facilities, and 0.6

percent were served in general hospitals, inpatient psychiatric facilities, or residential treatment centers.39

NMHA: States reported to NMHA that, in the

year 1986-87, they had placed at least 4,00040

children (including adolescents) with emotional problems in out-of-State placements, and

about 22,000 in State mental hospitals. According to NMHA, “State agencies often do not

know the exact number of children they place

in out-of-State and in-State psychiatric facilities, the amount of money being spent on their

treatment, their diagnosis, or even their whereabouts” (143).

qSFor thoSe ment~ he~~ orgtintio~ unable to provide patient care episode data on NIMH’s inventory forms or during a subsequent telephone

followup, data were imputed by NIMH (159).

36S& ch. 15, ‘‘Major Issues Pataining to the Delive~ of Primary and Comprehensive Health Services to Adolescents,’ in Vol. III.

qTDa~ me not av~~le separately for adolescents.

38 Bmause complete ~~ ~not av~able on tie~~prev~ence of men~ he~~ problems (tit is, the proportion of children ~d adolescents who

experienced an emotional or behavioral problem in the year preceding the survey), it is not possible to determine what percentage of those in need in

the last year actually received mental health treatment.

Wme ~~&ta us~ fi ~s pm of tie c~pter ~ve not been tested for s~tistic~ sigtilc~ce, md for further guidance in interpreting the figures

presented herein the reader is cautioned to consult relevant NIMH publications (e.g., 159).

‘Only a minimum number was able to be estimated, because 14 States were not able to provide complete data to NMHA.
Chapter n-Mental Health Problems: Prevention and Services . II-457

●

●

Public Law 94-142: Of the 341,000 seriously

emotionally disturbed individuals ages 3 to 21

identified under Public Law 94-142 in 1986-87,

less than one-third received psychological,

social work, or counseling services (136a).

Tremper: An estimated 2 percent of adolescents

in any one year may be seen by school

psychologists 41 (198).

It is important to note that these estimates from

varying sources do not allow an overall estimate of

mental health services utilization by adolescents,

and thus make it difficult to assess possible gaps

between service need42 and access. Of the available

sources, probably the best estimate of utilization is

from NHIS, because NHIS records the proportion of

children and adolescents who have had a visit to any

mental health professional.43 However, NHIS did

not estimate mental health visits separately for

adolescents. If one assumes that the level of care for

adolescents is the same as that for all 3- to

17-year-olds combined, then one would estimate

that, in 1988,5 percent of all adolescents had had at

least some contact with a mental health provider.

Because the NHIS relies on parents as informants,

and adolescents may seek care on their own without

their parents’ knowledge, this may reflect an underestimate. There is no national estimate of adolescents’ seeking of care for mental health problems on

their own.

However useful the estimate based on the NHIS

is, NHIS data on mere contact do not reflect the

duration (e.g., one visit v. sustained contact over the

year), purpose (diagnostic v. therapeutic), or quality44 of the contact.

Further Examination of Patterns of Utilization

Using NIMH Survey Data

As noted above, NIMH data on the utilization of

mental health services by adolescents are seriously

Table 11-3-Admissions of U.S. Adolescents Ages

10 to 18 to Specialty Mental Health Care in

Organized Settings, by Level of Care, 1986

Number of Percent of Admissions/

Level of care admissions admissions 100,000

Inpatient care . . . . . . . . . . . 127,351 22% 406

Residential treatment

center . . . . . . . . . . . . . . . 44,375 8 141

Partial hospitalization . . . . 15,967 3 50

Outpatient care . . . . . . . . . . 399,152 68 1,273

Total . . . . . . . . . . . . . . . . . . . 586,845 100% 1,870

SOURCE: B.J. Burns. C.A. Taube, and J.E. Taube, “Use of Mental Health

Sector Services by Adolescents, 1975, 1980, 1986,” contract

paper prepared for the Office of Technology Assessment, U.S.

Congress, Washington, DC, 1990, based on 1986 data from the

U.S. Department of Health and Human Services, Public Health

Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute of Mental Health, unpublished National

Institute of Mental Health Inventory of Mental Health Organizations, Rockville, MD, 1989.

limited. But despite having numerous limitations,

available NIMH data on the utilization of mental

health services by specialty mental health organizations serve three useful functions: 1) they enable

some examination of current patterns of service use,

2) they allow exploration of the characteristics of

adolescents who use each level of care, and 3) they

document shifts in patterns of service use over time.

Thus, this section is devoted to a detailed examination of NIMH survey data.45

Current Patterns of Service Use—NIMH survey data offer some perspective on the relationship

between institutional and noninstitutional mental

health care. As shown in table 11-3, outpatient

mental health services in organized mental health

settings accounted for 68 percent of admissions of

adolescents to specialty mental health organizations

in 1986, with the remainder accounted for by

hospital inpatient services (22 percent), residential

treatment centers (8 percent), and partial hospitalization (3 percent).

41~e ~um~r of School ~Sycholo@sts ~ the Nation’s schools is c~enfly es~ated at 1 per 2,633 students. Moreover, these psychologists are able

to devote only between 5 to 9 percent of their time to direct counseling and therapy (198).

42As dlscuss~ ~ tie ~~nning of ~s chapter, it is difficult to esti~te need for menti health services fora number of reaSOllS, including uIICellfitieS

about diagnosis for this age group and, in part as a consequence of uncertainties about diagnosis and measurement, the lack of national epidemioloa”cal

studies.

431n Conmst N1~ dab Petiln t. individu~s but we limited t. Cwe provided in mental health organizations; NAMCS data are limited to visi~ (in

contrast to individuals) to psychiatrists; NMHA data are limited to placements (in contrast to individuals), to residential placements, and to placements

made by public entities; and Tremper’s data are limited to school psychologists.

441n a previous repo~, OTA defined fie quall~ of m~ical cue m tie degee to which the process of care increases the probability of OUtCOmeS desired

by patients and reduces the probability of undesired outcomes, given the state of medical knowledge” (202a).

45 For addltio~l de~ls, see B,J. BUI-IIS, C,A. Taube, and J.E. Taube, “Use of Mental Health Sector Services by Adolescents: 1975, 1980, and 1986”

(39a).
II-458 . Adolescent Health—Volume //: Background and the Effectiveness of Selected Prevention and Treatment Services

Thus, about 2.4 times as many adolescents

receiving mental health treatment in a specialty

mental health organization receive care in nonresidential settings (outpatient facilities and partial

hospitalization) as are treated in a residential setting

(hospital inpatient psychiatric facility or residential

treatment center). Of the funding for services in

specialty mental health organizations, however, 74

percent goes to residential (overnight) care and 26

percent to nonresidential care (39).

Characteristics of Adolescents in Specialty

Mental Health Organizations, 1986--Major demographic and clinical characteristics of adolescents

receiving treatment in specialty mental health organizations are highlighted below:

●

●

●

●

Male adolescents are much more likely than

females to use partial hospitalization (73.2

percent of patients are male) and residential

treatment centers (approximately two-thirds

are male); gender differences in the use of

outpatient services in organized settings and

the use of hospital inpatient psychiatric services, however, are less pronounced, with 59.6

percent of outpatients, and 50.7 percent of

inpatients, male.

Racial and ethnic minority adolescents make up

a larger share of users of partial hospitalization

(24 percent) and residential treatment centers46

(about 30 percent) than they do of users of

outpatient services in organized settings (14

percent) and of inpatient psychiatric services

(about 20 percent in State and county mental

hospitals and general hospital psychiatric units,

and 8 percent in private psychiatric hospitals).

The most common inpatient diagnosis, accounting for about one-third of inpatient admisions of adolescents in 1986, was affective

disorder, followed by adjustment disorder or

behavior disorder (depending on the age of the

adolescent) (see table 11-4).

In 1986, the most common diagnosis of adolescents receiving outpatient and partial hospitalization services in mental health organizations

was adjustment disorder (accounting for 30

percent of admissions), followed by behavior

Table 11-4-Distribution of Admissions of U.S.

Adolescents Ages 10 to 14 and 15 to 17 to All

Inpatient Psychiatric Services, by Diagnosis and

Age, 1975 and 1986

Percent of admissions

Age, diagnosis 1975 1986’

Ages 10 to 14 . . . . . . . . . . . . . . (N= 25,834)

Mental retardation . . . . . . . . . . . 1.970

Substance abuse . . . . . . . . . . . 2.1

Affective disorder . . . . . . . . . . . . 10.1

Schizophrenia . . . . . . . . . . . . . . . 6.3

Anxiety disorder . . . . . . . . . . . . . 6.9

Adjustment disorder . . . . . . . . . 43.9

Behavior disorder . . . . . . . . . . . 18.7

Other . . . . . . . . . . . . . . . . . . . . . . . 10.4

Total . . . . . . . . . . . . . . . . . . . . . . . 100.0%

Ages 15 to 17 . . . . . . . . . . . . . . (N= 54,648)

Mental retardation . . . . . . . . . . . 2.2%0

Substance abuse . . . . . . . . . . . 5.5

Affective disorder . . . . . . . . . . . . 15.6

Schizophrenia . . . . . . . . . . . . . . . 22.4

Anxiety disorder . . . . . . . . . . . . . 4.7

Adjustment disorder . . . . . . . . . 25.4

Behavior disorder . . . . . . . . . . . 8.2

Other . . . . . . . . . . . . . . . . . . . . . . . 16.1

Total . . . . . . . . . . . . . . . . . . . . . . . 100.0?40

(N= 38,682)

●

●

30.6%

●

11.9

11.5

26.5

21.0

100.0%

(N= 68,707)

●

9.6%

34.0

5.1

●

19.5

17.2

12.1

100.0?40

+ntries ma~~ with an asterisk had five or fewer eases and therefore did

not meet standards of reliability or preeision.

SOURCE: 1975 data: U.S. Department of Health and Human Serviees,

Public Health Serviee, Alcohol, Drug Abuse, and Mental Health

Administration, National Institute of Mental Health, Use of

Psychiatric Faalities by Children and Youfh, U. S., 1975, DHHS

Pub. No. (ADM) 81-1142 (Washington, DC: U.S. Government

Printing Office, 1981). 1986 data: U.S. Department of Health

and Human Serviees, Public Health Serviee, Alcohol, Drug

Abuse, and Mental Health Administration, National Institute of

Mental Health, unpublished sample survey data, Washington,

DC, 1986.

disorder (about 20 percent of admissions). The

two leading diagnoses for 1986 outpatient

admissions were followed by either anxiety

disorder (5 percent of diagnoses for 10- to

14-year-olds) or substance abuse(11 percent of

diagnoses for 15- to 17-year-olds). Affective

disorders (16 percent) and substance abuse (9

percent) diagnoses were the third and fourth

leading reasons for admission to partial hospitalization in 1986 (for 10- to 17-year-olds

combined).

. Involuntary commitment in 1986 occurred for

15 percent of outpatient admissions, for 22

~one ~wonfor the *titer ~on~ rwm~ntation ~ residenti~ ~atment cente~ my IJC tit most referrals to residential treatment centers aremade

by entities other than the mental health treatment system, such as the juvenile justice (17 percent), social serviees (46 percent), and education (28 pereent)

systems (143),
Chapter 11-Mental Health Problems: Prevention and Services ● II-459

Table n-5-Distribution of Outpatient Admissions of

U.S. Adolescents Ages 10 to 14 and 15 to 17 in

Mental Health Organizations, by Source of

Payment, 1975 and 1986

Percent of admissions

Age, source of payment 1975 1986a

Ages 10 to 14 . . . . . . . . . . . . . .

No payment , . . . . . . . . . . . . . . .

Personal payment . . . . . . . . . . .

Commercial insurance . . . . . . .

Medicaid . . . . . . . . . . . . . . . . . . . .

Other governmentb . . . . . . . . . .

Other c . . . . . . . . . . . . . . . . . . . . . .

Total . . . . . . . . . . . . . . . . . . . . . . .

Ages 15 to 17 . . . . . . . . . . . . . .

No payment . . . . . . . . . . . . . . . .

Personal payment . . . . . . . . . . .

Commercial insurance . . . . . . .

Medicaid . . . . . . . . . . . . . . . . . . . .

Other governmentb . . . . . . . . . .

Other c . . . . . . . . . . . . . . . . . . . . . .

Total . . . . . . . . . . . . . . . . . . . . . . .

(N=134,202)

25.0

40.4

9.4

16.1

9.0

●

(N=206,407)

12.3

30.7

24.4

21.0

●

11.5

100.0%

(N=94,382)

34.4

35.5

6.7

9.5

13.5

●

100.O%

(N=164,900)

12.6

36.3

22.6

14.6

●

13.5

100,O% 100.O%

aEntries mar-k~withan asteriskhadfive orfewereases andthereforedid

not meet standards of reliability or precision.

%hisincludes1986datafortheCivilian HealthandMedicalProgramofthe

Uniformed Services and Medicare.

~hisincludas social services and State and Iocal sources.

SOURCE: 1975 data: U.S. Department of Health and Human Serviees,

Public Health Services, Alcohol, Drug Abuse, and Mental Health

Administration, National Institute of Mental Health, Use d

Psychiabic Fadities by Chi)dren and Youth, U. S., 1975, DHHS

Pub. No. (ADM) 81-1142 (Washington, DC: U.S. Government

Printing Office, 1981). 1986 data: U.S. Department of Health

and Human SeMces, Public Health Services, Alcohol, Drug

Abuse, and Mental Health Administration, National Institute of

Mental Health, unpublished sample survey data, Washington,

DC, 1986.

percent of partial hospitalization admissions,

and for 20 percent of inpatient admissions.47

. About two-thirds of adolescents using partial

hospitalization and inpatient psychiatric services in 1986 had received prior mental health

treatment, in contrast to a third of adolescents

using outpatient services.

. Commercial insurance (60 percent) is the most

frequently used source of payment for inpatient

psychiatric treatment, Medicaid (28 percent)

for partial hospitalization, and the patients

themselves (33 percent) for outpatient services

(table 11-5).

Shifts in Patterns of Service Use, 1975-1986--

From 1975 to 1986, the latest year for which NIMH

survey data are available, the provision of mental

health services to adolescents ages 10 to 1748 in

Figure 11-3-Distribution of Admissions of

Individuals Under Age 18 to Inpatient Psychiatric

Services, by Type, United States, 1975,1980, and 1986

‘oo”’o~

800/0

600/0

40%0

200/0

00/0

1975 1980 1986

= State and county

~ General

m Private

SOURCES: 1976 data: U.S. Department of Health and Human Serviees,

Public Health Service, Alcohol, Drug Abuse, and Mental

Health Administration, National Institute of Mental Health, Use

of Psydiatric Faa.lities by Children and Youth, U.S. 1975,

DHHS Pub. No. (ADM) 81-1142 (Washington, DC: U.S.

Government Printing Office, 1961). 1980 data: U.S. Department of Health and Human Services, Public Health Service,

Alcohol, Drug Abuse, and Mental Health Administration,

National Institute of Mental Health, Natiorra//rrstitute ofMenta/

Health Statistical Note 175, Washington, DC, 1986. 1986

data: U.S. Department of Health and Human Serviees, Public

Health Service, Alcahol, Drug Abuse, and Mental Health

Administration, National Institute of Mental Health, unpub

Iished National Institute of Mental Health Inventory of Mental

Health Organizations data, Washington, DC, 1989.

organized mental health settings increased. The

greatest increase was in adolescent treatment episodes in residential treatment centers. These increased 66 percent between 1975 and 1986. Adolescent admissions to outpatient services provided in

organized mental health settings increased 62 percent between 1975 and 1986, meaning that 170,000

more adolescents were admitted in 1986 than in

1975. Inpatient psychiatric admissions of 10- to

17-year-olds increased 33 percent between 1975 and

1986.

The growth in inpatient psychiatric admissions of

adolescents since 1975 has been controversial,

because it has been largely due to growth in

admissions of adolescents to private psychiatric

hospitals (229) (see figure 11-3). A small portion of

the increase in adolescent admissions to private

psychiatric hospitals may be due to decreased use of

State and county hospitals for adolescents. Other

dTIt sho~d be noted that 32 States permit parents to tie ‘‘voluntary’ admissions of a minor, with or without consent of the minor. For further

discussion see ch. 17, “Consent and Contldentiality in Adolescent Health Care Decisionrnakm‘ g,” in vol. m.

4s~s age *OUP is ~~d for ~ross-time Compfisons ~ause data on 18-year-olds are not available for comp~son in 1975 ad 1980.
II-460. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 11-4—lnpatient Admissions to Specialty Mental Health Organizations

Among U.S. Children and Adolescents Under Age 18, by Race and Ethnicity,

1975, 1980, and 1986a

Admissions/100,000 population

200

150

100

5 0

0

161.8

I 1 (

118.8

. . . ... —.——

: 1 :

75.7

, 62.2

>,,TIVVXTI I

liiM14.6

\\

25.0

\ \\ \

31.6

64.1

VVhlite, All other ~

non- combined”

Hispanic

1975

127.5

75.8

130.9

75.5

White, All other ~

non- com bined

Hispanic

1980

_ Admissions to fi~ Admissions t.

State and county private psychiatric

mental hospitals hospitals

189.8

w~ite, All other b

non- combined

Hispanic

1986

] Admissions to

general hospital

psychiatric units

aBreakdowns by race and ethnicity are not available separately for adolescents. In 1986, however adOleS@ntS ages

10 to 17 acmunted for 98 percent of child inpatient admissions to the organizations surveyed by NIMH.

bFiner ra~al and ethnic breakdowns are not possible for purposes of these calculations.

SOURCE: 1975 data: U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse,

and Mental Health Administration, National Institute of Mental Health, Use of Psych%ttic Facilities by

Chi/dren and Youth, U. S., 1975, DHHS Pub. No. (ADM) 81-1142 (Washington, DC: U.S. Government

Printing Office, 1981). 1980 data: U.S. Department of Health and Human Services, Public Health Service,

A!cohol, Drug Abuse, and Mental Health Administration, National Institute of Mental Health, Natkmal

Institute of MerWHedfh Statiska//Vote 175, Washington, DC, 1986.1986 data: U.S. Department of Health

and Human Services, Public Health Service , Aicohoi, Drug Abuse, and Mental Health Administration,

National Institute of Mental Health, unpublished 1986NIMH Inventory of Mental Health Organizations data,

Washington, DC, 1989.

explanatory factors may include the following: an

increase in mental health problems, such as depression and suicide, among adolescents; decreased

stigma and greater acceptance by adolescents and

their families of mental health care; increased

insurance coverage for inpatient psychiatric treatment; and effective marketing by private psychiatric

hospitals.

Other major shifts in patterns of hospitalizing

adolescents for mental health treatment from 1975 to

1986 include the following:49

● A far greater proportion of the adolescent

inpatient population was white, non-Hispanic

in 1986 than in 1975 (see figure 11-4).50

. Several shifts in inpatient and outpatient diagnoses for adolescents, with large decreases in

4~or ~ddltjon~ &=~jlS, SW B~, ~~b~, ad Ta~&, “use of M~nt~ H~l~ Sector Servims by Adolescents, 1975, 1980, 1986” (39a).

~~though the ~ropo~ion of nonw~te adolescen~ decl~~ ~ ~ ~s of ~patient facfities formen~ heal~ @eatment, the ~eiltest decline OCClllTd

in State and county mental hospitals (from 30.5 percent nonwhite in 1975 to 18.3 percent nonwhite in 1986) (see f@re 11-4). As noted above, however,

nonwhite adolescents are less likely than white non-Hispanic adolescents to use private psychiatric facilities.
Chapter n-Mental Health Problems: Prevention and Services . II-461

●

●

●

admissions for adjustment disorder51 and schizophrenia, 52 and large increases in admissions

for affective disorder53 and substance abuse

(table 11-4).54

The provision of about 20 percent less individual and group therapy to adolescents in State

and county hospitals.

A major increase in the use of commercial

insurance for psychiatric admissions to inpatient settings in conjunction with a reduced role

for Medicaid coverage.

55 The change was most

pronounced for private psychiatric facilities.56

No significant decrease in the length of stay for

adolescents admitted to hospitals for mental

health treatment despite the decrease in length

of stay observed for adult psychiatric admissions.

The trend toward increased use of outpatient

mental health services from 1975 to 1986 is

probably tied to increased awareness and acceptance

of using mental health services as well as better

reimbursement by private insurers (39).57 The proportion of adolescents using commercial insurance

for outpatient mental health services in organized

mental health settings increased from about 8

percent in 1975 to 24 percent in 1986 (see table

1 1-5).

The decrease in use of outpatient and inpatient

mental health services by racial and ethnic minority

adolescents may be related to the overall increasing

reliance on commercial insurance to fund such

services. The rate of use of outpatient services in

organized mental health settings by minorities was

higher than for whites in 1975, but it dropped below

the rate for whites in 1986 (see figure 11-5). In 1986,

Figure 11-5-Outpatient Admissions to Speciality

Mental Health Organizations Among U.S. Children and

Adolescents Under Age 18, by Race and Ethnicity,

1975 and 1986a b

Admissions/lOO,OOO population

~I nnn ——.. . . . . .

Wwu

–. ..——

800 I

600 J

400 -

200 “

o -

719.5

929.4

629.4

White, All other White, All other

non-Hispanic combined

b non-Hispanic combined

b

1975 1986

agreakdowns by race and ethnicity are not available separately for

adolescents. In 1986, however, adolescents ages 10 to 17 accounted for

67 percent of child outpatient admissions to the organizations surveyed by

NIMH.

bFiner racial and ethnic breakdowns are not available for 1985. ~ 1986

adolescent outpatient admissions to specialty mental health organizations, however, 78.4 percent were white, non-Hispanic, 10.1 percent were

black, non-Hispanic, 10.1 percent were Hispanic, and 1.4 perc%nt were

“other, non-Hi spanic. ”

SOURCE: 1975 data: U.S. Department of Health and Human Services,

Public Health Services, Alcohol Drug Abuse, and Mental Health

Administration, National Institute of Mental Health, Use of

Psychiatric Faa”litkm by Children and Youth, U. S., 1975, DHHS

Pub. No. (ADM) 81-1142 (Washington, DC: U.S. Government

Printing Office, 1981). 1986 data: U.S. Department of Health

and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration, National Institute of

Mental Health, unpublished 1986 NIMH Inventory of Mental

Health Organizations data, Washington, DC, 1989.

20 percent of black, non-Hispanic adolescent outpatients in the NIMH survey used Medicaid; 29

percent made a‘ ‘personal payment,’ and 23 percent

51From 31 percent ~flnpatient ~dmissi~n~ ~ 1975 t. 17 percent in 1986, ~d from# per~nt of outpatient timissions in 1975 to 30 percent h 1986.

52From 15 percent of ~patlent ~~~~ions ~ 1975 t. less ~ 5 pmcent iII 1986, ~d from 2.8 percent of outpatient admissions in 1975 to less thao

10 sample cases (percentage unable to be calculated) in 1986.

jsFrom 11 percent of ~patient a~issions in 1975 to 23 percent in 1986, and from 2.6 percent of outpatient admissions k 1975 to 6.6 percent in 1986.

~From 4,4 percent of ~patlent admissions in 1975 to 6 percent in 1986, and from less than 10 sample cases of outpatient admissions (percentage umble

to be calculated) in 1975 to 5 percent in 1986.

sSIn 1975, comerclal insurance paid for 44 pe~ent of inpatient care provided to 10 to 14-year-olds and 50 percent of the care provided to 15- to

17-year-olds. IrI 1986, the percentages paid by commercial insurance were 61 and 67 percent, respectively. In 1975, Medicaid paid for approximately

21 percent of adolescent inpatient care, and in 1986, 11 percent, See ch. 16, “Financial Access to Health Services, “ in Vol. III for a discussion of the

limitations in Medicaid that may account in part for the reduction in Medicaid coverage for inpatient mentat health treatment. For example, 13 States

(25 percent) do not allow payment for such care. Even States that do pay for inpatient treatment maintain precetilcation requirements, restrictions on

length of stay, and payment rates regarded as unreasonable by some in the psychiatric community (e.g., 194). Imw payment is an often cited reason for

physicians’ lack of participation in Medicaid.

56~ 1975, M~ic~d pad for a~ut 8 ~rcent of adolescent a~ssions to private psychiatric facilities. In 1986, the number of adolescent admissions

paid by Mdicaid was too small (five or fewer sample cases) for a statistically reliable estimate to be made.

sTA]though Covemge my ~ve fiprov~ ~~een 1975 and 1986, mental heal~ benefits are still less gen~ous than nUUIy other health Care benefits.

In the face of rising health care costs, some commercial insurers are now considering placing additional limits on mental health benefits, particularly

for adolescent dependents. See ch. 16, “Financial Access to Health Services, ” in Vol. III.
II-462 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

made no payment; only 7 percent of black, nonHispanic adolescent users of organized outpatient

mental health services used commercial insurance,

in contrast to 24 percent of white, non-Hispanic

users (212).58

An issue which may merit attention is the growth

in substance abuse treatment. In 1975, not even 1

percent of adolescent outpatients were diagnosed

with a substance abuse disorder, but by 1986, 11

percent of 15- to 17-year-old outpatients in mental

health organizations were given a substance abuse

diagnosis (221). Inpatient admissions of 15- to

17-year-olds for substance abuse disorders also rose

between 1975 and 1986, from 5.5 percent to 9.6

percent (see table 11-4). These changes are difficult

to interpret.

Effectiveness of the Mental Health Treatment

System for Adolescents

Research on the effectiveness of inpatient psychiatric services, residential treatment centers, day

treatment and partial hospitalization, and specific

therapeutic modalities for adolescents with mental

health problems is reviewed below. The review

relies heavily on a 1986 children’s mental health

report by OTA (202), updated with new studies.

Effectiveness of Inpatient Psychiatric Services and

Residential Treatment Centers

As described in box 11-B, inpatient psychiatric

facilities are in many ways distinct from residential

treatment centers. However, there is often much

overlap between the two types of facilities, and they

have in common the fact that they offer 24-hour

residential care for adolescents. In addition, they are

often located away from the adolescent patients’

home communities (143). Sometimes, residential

treatment centers, which are less medically intensive, are located on the same campuses as inpatient

psychiatric hospitals, and serve as an interim step

between discharge from the psychiatric hospital and

release to less restrictive treatments such as partial

care, outpatient or ambulatory treatment, or to home.

Further, the literature on the effectiveness of inpatient psychiatric treatment does not always distinguish between hospital care and residential treatment center care (202). In this section, the research

on the effectiveness of inpatient care refers generally

to both hospital care and residential treatment center

care. The section then reviews available studies

relating specifically to residential treatment center

care.

Inpatient Psychiatric Service--Controversy exists over the use of inpatient psychiatric services for

adolescents with mental health problems. In 1982,

Knitzer reported that at least 40 percent of hospital

placements of adolescents with mental disorders

were inappropriate, and that these clients could have

been more effectively treated in an outpatient setting

or in a residential care setting (115). Recently,

concerns have arisen with regard to increases in

admissions of adolescents to private hospital inpatient psychiatric facilities (229). Judging the appropriateness of this increase in admissions is difficult

because of the limited research on the effectiveness

of inpatient psychiatric care.

Some researchers suggest that hospital and residential services are no more effective for the

majority of adolescents with mental health problems

than are outpatient services (70). However, it is

difficult to separate effects attributable to particular

treatment modalities from effects attributable to

particular settings (202). The limited research on the

effectiveness of inpatient psychiatric settings for

adolescents with mental health problems suggests a

critical need for research on this type of care

(108,139,155a,202).

In its 1986 report on children’s mental health,

OTA concluded that ‘‘questions about the effectiveness of mental health treatment in psychiatric

hospitals and residential treatment centers are difficult to answer because of the lack of systematic

research’ (202). OTA noted a particular lack of true

experiments, or even quasi-experiments, in this area

(49,201). True or quasi-experiments would measure

treatment outcomes of patients with similar diagnoses and severity of illness placed randomly in either

inpatient or ambulatory settings.

59 This approach

would allow researchers to begin to distinguish the

effects of the treatment settings from those of the

clients and other factors. Clearly, however, such

experimental research is “complex, difficult, and

s8~teres~gly, 42 Pticent of msptic adolescent outpatients used commercial insurance. Twenty-one percent us~ Medic~d, 13 Wment ~& a

“personal paymen~” and 20 percent made no payment (212).

590f ~ou=, ~ch ~~s ~o~d ~so m~t~ some con~ol over (or at 1east memure) tie ~=tment m~iti~ deliver~ in the different Set@s.
Chapter Il—Mental Health Problems: Prevention and Services . II-463

expensive’ (85); furthermore, it is regarded by some

as unethical (202).

At the time of OTA’s study, the most comprehensive review of the outcome literature on inpatient

treatment for children and adolescents was Blotcky

et al. 1984 review (23a,202). However, this review

and the studies included in it were seriously flawed

(202). In 1990, Pfeiffer and Strzelecki attempted to

update and improve upon Blotcky’s review by

reviewing new studies and attempting to conduct a

quantitative meta-analysis of outcome studies conducted since 1975 (including those reviewed by

Blotcky using a narrative review) (155a). Unfortunately, Pfeiffer and Strzelecki were not able to

conduct a true quantitative meta-analysis because

only 2 of the 34 studies they found reported the

necessary information (155a). In addition, only 4

studies were uncovered that examined the effects of

aspects of treatment on outcome. Most studies were

concerned with the impact of various patient characteristics (e.g., age, gender, intelligence, pattern of

symptoms) on outcome (155a). The aspects of

treatment examined in the studies reviewed by

Pfeiffer and Strzelecki were: completion of the

treatment program; planned discharge; a cognitivebased problem-solving skills training package, and

therapeutic alliance (155a).

Using a relatively unrefined method of rating

studies for their effectiveness (i.e., a score of +1, O,

or -1, depending on the patients’ outcome, adjusted

for various factors such as the number of subjects in

the study), Pfeiffer and Strzelecki concluded that all

4 treatment studies reviewed found a positive

relationship between inpatient treatment and the

patients’ outcome. Nevertheless, Pfeiffer and

Strzelecki noted serious conceptual and methodological shortcomings in the existing literature, including failure to delineate the critical dimensions of

inpatient treatment, an absence of consensus on

definitions of improvement, a limited range of

predictor variables, and failure to use adequate

research designs and powerful statistical techniques.

Pfeiffer and Strzelecki note that most of the outcome

studies they reviewed “had no recognizable research design beyond the modest reporting of one or

more measures taken after discharge’ (155a). This

was the same situation noted by OTA in 1986.

The sole clinical trial of inpatient psychiatric

hospitalization for adolescents, conducted in

Brooklyn by Winsberg and colleagues, found somewhat better outcomes for adolescents treated primarily in out-of-hospital settings (232). Behavioral and

educational outcomes were comparable for both

groups. On subsequent followup, though, one-half

of the hospitalized cohort were in institutions, and

only a quarter of the nonhospitalized adolescents

were in institutions. However, these results are

difficult to interpret because all patients in the

sample were initially hospitalized for a 1- to 3-week

evaluation.

Effectiveness of Residential Treatment CentersThe American Psychological Association’s Statement on Residential Treatment indicates that there is

a lack of consensus in the field regarding which

types of adolescents are best treated in residential

treatment centers (7). The American Psychological

Association reports that current criteria for placement are either too imprecise or too narrowly

conceptualized to be used for case-by-case placement decisions. Moreover, it states that no single

definition of a residential treatment center exists.

Therefore, the decision to place an adolescent in a

particular residential treatment center program cannot be reduced to a few universally acceptable

criteria.

The research on residential treatment centers

consists largely of uncontrolled studies. Two residential treatment center programs merit detailed

description because they represent the only programs for which (published) controlled studies were

identified. The first, called Project Re-Education

(Re-Ed), was started in the early 1960s (99). The aim

of Project Re-Ed was to develop anew approach for

working with emotionally disturbed children based

on educational, psychological, and ecological strategies. Teacher-counselors, backed up by consultant

mental health specialists, were trained to work with

the emotionally disturbed children and their families. The programs were located in the communities,

which facilitated therapeutic work with the family,

and the children went home every weekend. Camping was an important component of the program,

inspired by the Outward Bound schools in England.

The average length of stay was 4 to 8 months, and the

program was said to cost about half that of traditional residential programs.

Project Re-Ed has spread in the United States. In

1981, Project Re-Ed programs were located in nine

States. Although designed initially for children 6 to

12 years of age, Project Re-Ed has been applied to
II-464 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

older adolescents, apparently successfully (99). For

example, in a study of Project Re-Ed by Weinstein,

comparison groups included 122 emotionally disturbed adolescent males participating in Project

Re-Ed, 128 untreated disturbed adolescents, and 128

nondisturbed adolescents (223). The groups were

equivalent in age, intelligence, and socioeconomic

status. At discharge, the Re-Ed staff rated 94 percent

of the adolescents participating in Project Re-Ed as

moderately or greatly improved; 18 months after the

clients had returned home from Project Re-Ed, their

families reported significant improvement compared with adjustment before entering the program.

The Project Re-Ed adolescents improved in self-

-esteem, control of impulsiveness, and internal control.

The only other controlled study of residential

treatment center use was conducted by Rubenstein

and colleagues in Ontario, Canada (164). In this

study, a group of adolescents in a Parent Therapist

program with specially trained foster parents was

compared with a similar group treated in a residential treatment center. Both client groups shared

comparable backgrounds and made similar progress

in their respective treatment programs.

Aside from concerns about the lack of evidence

for effectiveness of residential care, there are concerns about the cost of such care (70), the potential

for institutional dependence, trauma associated with

the separation from the family, difficulty recentering

the family (or even abandonment by the family), and

the learning of antisocial or bizarre behavior from

intensive exposure to other disturbed children (14).

Some have observed that adolescents in inpatient

psychiatric and residential facilities may be subject

to harsh treatments (e.g., prolonged isolation) (229).

No specific standards prohibit such treatments.60

Research is essential to determine when and for

whom the potential benefits of inpatient care and

care in residential treatment centers outweigh potential risks.

Effectiveness of Day Treatment61

Research on day treatment for adolescents as an

alternative to inpatient psychiatric treatment or as

followup to inpatient or residential treatment center

care suffers from many of the same limitations as

research on inpatient care.

Most day treatment programs are like schools

with treatment worked into the curriculum (187).

The City Lights program in Washington, DC, for

example, enrolls adolescents who have been ‘ ‘written off by the schools as unteachable, by the juvenile

justice system as intractable, and by the mental

health system as untreatable’ (195). During the day,

the environment is structured, but the patient is

allowed to return home at night. This type of care

fosters continuing involvement with family and

peers. The City Lights program uses self-paced,

computer-assisted education in the context of a

therapeutic milieu. A long-term evaluation is

planned, but initial results suggest that it is possible

to keep this population of juveniles in school, to

increase their reading and math skills by 1.5 grade

levels a year, and to return only 10 percent to

hospitals or jails (195). Unfortunately, however, the

study on which these promising results are based

suffers from the lack of a comparison group.

A Florida day treatment program for emotionally

disturbed adolescents emphasizes the development

of social skills to deal with peer conflict (e.g., “fair

fighting” is taught) and disruptive behavior in ways

that promote problem-solving (70). Initial results,

which addressed the issue of placements at a l-year

followup, cited reductions in placements to foster

care, shelter care, psychiatric units, and settings for

delinquents (70).

Reviews of the literature have pointed to positive

gains from adolescent use of day treatment in three

‘%VhiIe there are no restrictions on the use of treatments that may be regarded by some as harsh the National Association of Private Psychiatric

Hospitals, a membership organization of 300 private psychiatric hospitals, does require that each member hospital have written policies and procedures

regarding patients’ rights (142). These policies and procedures are required to address ‘the use of high-risk or restrictive procedures, including seclusiom

restrain~ and behavior modification that employs noxious stimulation or deprivation of nourishment’ (142),

61A more generic tem for&y ~a~en~p~~ hospi~~tion is “p~~ c~e” (e.g., 159). As defined by NIMH for its inventory of mental health

organiza tions, partial care is a ‘‘planned program of mental health treatment services genexally provided to groups of clients/patients in sessions lasting

3 or more hours” (159). Included by NIMH as partial care are “&y/evening frearnzenz” (programs that place heavy emphasis on intensive short-term

therapy and rehabilitation), “day/evening care” (programs that focus on sustainment maxbizatiom or socialization through recreation and/or

occupational activities, etc., including sheltered workshops), and ‘‘education and training” (programs that focus on change through an integration of

educatiom habilitatioq and trainin g, including special education classes, therapeutic nursery schools, and vocational training) (159). Most programs for

adolescents are day programs that include education and training. As noted in box 1 l-B, partial care can be delivered in psychiatric hospitals, freestanding

psychiatric partial care organizations, or multiservice mental health organizations.
Chapter II—Mental Health Problems: Prevention and Services . //-465

areas: 1) academic and behavioral improvement, 2)

reduction or delay of hospital and residential placements, and 3) a return to less restrictive school

placements for about 75 percent of adolescents

receiving treatment (13,73). However, as noted

above, there have been no methodologically rigorous studies of this type of intervention.

Day treatment programs are not being used as

frequently as they might be because private thirdparty payers seem reluctant to support this type of

treatment (1 14). Critics claim that day treatment is

an ambiguous modality; that it creates demand for

services; and that length of stay, treatment outcomes, and costs are unpredictable (114). Research

to address the validity of these concerns is needed.

Effectiveness of Therapeutic Modalities

The research on the effectiveness of mental health

treatments for children and adolescents was thoroughly reviewed in OTA’s 1986 report on children’s

mental health (202). In general, the studies accumulated considerable evidence suggesting effectiveness for a wide range of treatment modalities for

children and adolescents, Most studies reviewed by

OTA, however, were plagued by methodological

problems.

More recently, a 1987 review of psychotherapy

outcomes for children and adolescents through age

18 found that, although the overall effect of treatment was positive, therapy was less effective with

adolescents than children. Professional training

seemed to be more critical for older clients than for

children (228).

A subsequent study raised a question about

whether the implementation of psychotherapy for

children and adolescents in clinic settings is optimal

(227). The study compared outcomes for children

and adolescents from nine clinics who completed a

course of therapy and for those who dropped out

after an intake evaluation. The groups were comparable at intake on demographics, family, and clinical

measures. Followup evaluations at 6 and 12 months

after termination of therapy showed no significant

effects of therapy for 6- to 12-year-olds and 13- to

17-year-olds.

Research on the effectiveness of psychopharmacological agents has also been reviewed extensively

(202). According to Ryan and Puig-Antich, the

psychiatric disorders that are responsive to psychotropic medications are similar for adolescents

and adults, including schizophrenia, bipolar and

unipolar depressive disorder, panic attacks, and

generalized anxiety disorder (165). Despite Ryan

and Puig-Antich’s assurances that adults and adolescents have similar responses to psychotropic medications, the authors are careful to identify a number

of caveats because of the very limited research

literature specific to adolescents (165). For example,

they note that only two studies, with small numbers

of subjects, have addressed the effectiveness of

tricyclic antidepressants for adolescents; there are

no controlled studies on the use of lithium for

adolescents; and for anxiety disorders, controlled

studies have been done only on separation anxiety

disorders. In contrast, the evidence for effective use

of stimulants for attention deficit disorder and

hyperactivity which continues into adolescence is

stronger; the evidence for the use of neuroleptics for

adolescents with schizophrenia is also stronger, but

special attention to the side effect of tardive dyskinesia is urged as it may occur within 3 months of

neuroleptic treatment (165).

Two of the most promising new drugs for mental

health problems are fluoxetine (trade name

Prozac®) and clozapine (trade name Clozaril®). As

noted above, there have been no studies of the

effectiveness of fluoxetine for depression in adolescents (193a). Studies are underway, however, on the

effectiveness of fluoxetine for obsessive-compulsive disorders, bulimia, and smoking in adolescents

(193a). Clozapine is a new drug for schizophrenia

that is helping many patients who were previously

considered untreatable; however, its availability is

raising cost and access issues (114a).

A 1989 Institute of Medicine review of child and

adolescent mental health research needs questioned

the assumption that the psychiatric disorders that are

responsive to psychotropic medications are similar

for adolescents and adults (139). The Institute of

Medicine noted that animal studies of neurotransmitters revealed markedly different sequences of

formation, differentiation, and synaptogenesis (formation of nerve interconnections) of neuronal pathways related to psychiatric areas of interest. The

differential development of these neuronal systems

were conjectured to correspond with age-related

onset of certain psychiatric symptoms in humans.

Medications were found to have different effects on

these neuronal pathways; for example, stimulants

increase motor activity in adults and decrease it in

immature animals, and dopamine D-2 receptor-
II-466 ● Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

blocking antipsychotic drugs exhibit striking differences in effect on behaviors of prepubertal and

postpubertal animals. The Institute of Medicine

concluded that psychopharmacological interventions have not been adequately studied for shortterm and long-term side effects and for both

effectiveness and appropriateness to specific age

groups.

As did OTA in 1986 (202), the Institute of

Medicine in 1987 (139), an NIMH National Advisory Mental Health Council (213) concluded that

more research on the effectiveness of a wide range

of therapeutic modalities for children and adolescents is critical.

Access to Mental Health Treatment Services

Access to mental health treatment services refers

to the ability to get treatment, when needed, at an

appropriate level, in a facility which is competent to

provide the services at an affordable cost (either

financial or psychological). For adolescents to have

access to mental health treatment services three

requirements must be met:

1)

2)

3)

Mental health treatment services must be

available, meaning that appropriate referrals

are made (from either the public or the private

sector) and competent clinicians and organizations exist to assess and provide mental health

services in the community;

Mental health treatment services must be

affordable, either through insurance, personal

resources, or other reasonable means; and

Mental health treatment services must be

approachable, meaning that policy and program barriers (e.g., eligibility requirements)

and sociocultural issues (e.g., fears due to

stigma or a lack of confidence in treatment) do

not hinder use.

The availability, affordability, and approachability of mental health treatment services for adolescents are discussed below. It is important to note that

adolescents (and children) with mental health problems face special access issues related to their

dependent status. Parental consent is necessary to

obtain treatment in most help-seeking situations,

and parental involvement is usually required to

obtain health insurance coverage.62

Availability of Services

Limited availability of mental health treatment

services contributes to the access problem. Although

an effective mental health treatment system should

be able to meet the mental health needs of those who

require treatment, serious concerns have been raised

about the lack of mental health services for adolescents.

One way to look at the issue of availability is to

compare estimates of the need for mental health

treatment services with actual use, since a gap

between use and need would strongly suggest that

adequate services are not available. No national

studies have examined the relationship between the

need for mental health treatment services based on

state-of-the-art psychiatric epidemiological measures and the use of services for the adolescent

population.63 Thus, the only method available to

identify the gap between need and use involves

applying available prevalence estimates to available

mental health service utilization data. These sets of

data are, as noted, extremely limited and they do not

address issues of intensity, duration, quality, or

effectiveness of services. However, if, as estimated

above, between 5.6 million (18 percent) and 6.8

million (22 percent) of U.S. adolescents are in need

of mental health services, yet only 1.2 million (6

percent) receive such services, then between twothirds and three-quarters of adolescents do not

receive needed services.

Any number of reasons can account for this level

of failure in providing mental health services by the

mental health treatment system. In some areas, the

problem is that mental health treatment services are

not available (134,204a). Even nationally, there are

fewer mental health professionals specially trained

62se Ch. Itj, “H.nancid Access to Health kViCW, “ in Vol. III, for a discussion of health insurance coverage of mental health treatment and ch. 17,

“Consent and Conf’’dentiality in Adolescent Health Care Decisionmakm‘ g,” in Vol. ~ for a discussion of parental consent requirements.

63~e 1988 N~o~ H~~ ~tervi~w Swey WS) cit~ e~lier iII this c~pter inked p~nts but the efistence Of an emotional Or behaViOrd

problem in their adolescents. ‘fhe development of a valid diagnostic intewiew applicable to children and adolescents has proven to be very diffkult

(139,202). NIMH currently has in the field pilot studies of a diagnostic interview schedule for use in estimating the lifetime and point prevalence of

diagnosable mental disorders, and utilization of mental health services, of children and adolescents in the United States.
Chapter Il—Mental Health Problems: Prevention and Services . II-467

to deliver care to adolescents than are believed to be

needed.

The question of what constitutes an adequate

number of mental health professionals for adolescents is difficult to answer. Such an estimate is made

difficult by the fact that both the total number of such

specially trained mental health professionals in the

United States and standards for provider-topopulation ratios are generally not available. The

American Academy of Child and Adolescent Psychiatry approximates that 5,000 psychiatrists specially trained to treat children and/or adolescents are

currently available (see 204). Approximately 1,400

psychologists have declared an interest in working

with adolescents,64 and 5,150 licensed clinical social

workers appear to have a primary interest in treating

adolescents (25a), but these data are rough estimates.

In 1981, the Graduate Medical Education National Advisory Committee (GMENAC) recommended to the Secretary of Health and Human

Services that 8,000 to 10,000 child psychiatrists (not

including other mental health professionals) be

available by 1990 (see 204). A GMENAC panel

estimated, however, that psychiatrists would be

needed to treat approximately 25 percent of the

mental health needs of children and adolescents,

with the other needs being treated by primary care

physicians, pediatricians, and other mental health

professionals. Since then, the advisability of primary

care physicians’ treating mental disorders has been

questioned (see 20465). Thus, OTA concludes that

GMENAC’s recommended total number of child

and adolescent mental health professionals (including, but not limited to, psychiatrists) could be

increased to between 32,000 and 40,000 in 1990.

This estimate remains somewhat conservative in

that an oversight panel of GMENAC reduced their

original recommended projection of child psychiatrists from 25,000 to between 8,000 and 10,000 in

part because of ‘‘a lack of capacity to train an

adequate number of professionals to treat the large

unmet need by 1990’ (see 204).

These estimates of the need for mental health

professionals do not differentiate between the needs

of children and adolescents. One indication of

differential need is the variation in prevalence of

mental health problems. Using current diagnostic

criteria for the prevalence of mental health problems, it appears that adolescents are somewhat more

likely to require mental health services than are

younger children (e.g., 51,235).

In situations where mental health services do

exist, barriers to gaining access (e.g., lack of

insurance to pay for care, stigma, lack of belief in the

value of treatment) may result in low rates of use.

Limited coordination of services between the large

public and private sector agencies where adolescents

receive other services (schools, juvenile justice,

health, social services) may also discourage use of

mental health services but some evidence suggests

that if services were known to be available, they

would be used more often.66

Affordability of Services

The impact of financial barriers is difficult to

examine without information about persons who do

not use care because they lack adequate financial

resources or insurance coverage. It seems probable,

however, that limited insurance coverage may prevent many adolescents and their families from

seeking mental health care. A substantial proportion

of adolescents (15 percent of 10- to 18-year-olds in

1987) have no health insurance coverage, and the

rates of no coverage are higher for Hispanics and

blacks than they are for non-Hispanic whites (203).67

Insured Hispanics and blacks are more likely than

whites to be covered by Medicaid, which varies

considerably by State in its mental health benefits. In

comparison with physical illness coverage under

most insurance policies, mental health coverage has

more limitations (e.g., higher copayments, annual

and lifetime benefit limitations, and greater deductibles). Thus, for many adolescents and their families,

cost is likely to be a major issue in access to mental

health services.68

‘See ch. 15, “Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Services to Adolescents, ” in Vol. III.

65~so see Ch. 15, ‘$~jor Issues pe~ng t. we J)eliveg of _~d comprehensive Health Se~ices to Adolescents, ” hl VO1. ~, which rWOllS

evidence that primary care physicians believe themselves to be not adequately trained to meet the psychosocial needs of adolescents, and that objective

studies have found that primary care physicians have difficulty recognizing mental health problems in adolescents.

66sm ~h. 15, f ‘Major Issues pe~~fig t. tie Delivel-y of ~im~ ~d comprehensive Health Services to Adolescents, ’ hl VO1. ~.

GyFor a discussion of adolescents’ healti insurance coverage, see ch. 16, ‘‘Financial Access to H~~ Sewices, ” ~ VOI ~.

68 For a fuller discussion of issues s~o~d~g i~~ance and f~cial across to health care, see ch. 16, “Financial Access to Health Services, ” in

Vol. III.
//-468 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Approachability of Services

The approachability of the mental health treatment system is a much more complex issue to assess.

A recent professional experience related to access to

mental health services in a crisis situation involving

a suicidal adolescent is described inbox 1 l-C. In this

case, getting access to appropriate services at a time

of critical need required almost 24 hours. Fortunately, a hot line provided some assurance that help

could be obtained, but professional mental health

resources were either unavailable, delayed, or believed by some mental health professionals not

likely to be constructive (the State hospital). At a

minimum, three general hospitals with psychiatric

units contacted for help could have offered to

arrange a referral to a private psychiatric hospital,

but they did not. This kind of system insensitivity is

not unusual. When even mental health professionals

cannot get the system to work, it is not surprising

that families and adolescents, especially those without resources, become extremely frustrated. Little is

known about how adolescents view the mental

health services system.

The notion that adolescents in many respects

require a different approach to the delivery of health

services in general is coming to be accepted,

although a full conceptualization of this approach is

yet to be developed and applied.69

Shifting to the issue of access to mental health

services for minority adolescents, a series of serious

consequences associated with minority status and

serious emotional disturbance were reviewed by

Cross and his colleagues (53):

●

●

●

There is a tendency to place black adolescents

in the juvenile justice system instead of the

treatment settings likely to be obtained by their

white counterparts (46,95).

A Native American child is more likely than a

white child to go without treatment or to be

removed geographically from the family and

tribe (20,175,204).

A Spanish-speaking Hispanic child probably

will be assessed in a language that is not his or

her own (152).

Box n-C-An Adolescent Mental Health

Crisis Situation Described by a Mental

Health Professional

One Sunday evening about 7 p.m., I received a

call from parents of an 18-year-old male saying that

their son was suicidal (he later admitted to taking an

overdose of pain pills shortly before the call). I

agreed to find a source of help and called the local

general hospital with a psychiatry unit. The hospital

staff said they could not handle anyone who was

suicidal but that the adolescent could be sent to the

State hospital (not an appropriate option for a first

episode where the environment would be threatening and only protection from further self-inflicted

injury might occur). As the family had insurance,

calls were made to two teaching hospitals an hour

away from their home. Neither had a psychiatric

bed available, and both would have required a

3-hour wait in an emergency room before a

psychiatrist could be seen. AU that they could offer,

after a psychiatric evaluation, was referral to the

State hospital.

The only help received that night was an

encouraging conversation between the adolescent

patient and a volunteer on a suicide hot line. There

was no offer of crisis intervention from any of the

emergency rooms (other than that a psychiatrist

could be called for an evaluation) or any possibility

of a home-based team that could come in and work

with the family and adolescent. Late the next day,

an admission to a private psychiatric hospital was

arranged for the adolescent.

l~s ~Ci&nt was related by BJ, Burns, one of ti autim

of the background paper on which this section of the chapter is

based.

SOURCE: BJ. Burns, C.A. Taube, and J.E. ‘lhube, “Mental

Health Services for Adolescents,” contract paper

prepared for the OJXce of l?xhnology AssessrM@

Us. congress, wasMngtOrL DC. 1990.

. An Asian child with a mental health problem is

not likely to come to the attention of the mental

health system (53).

The preceding observations imply that different

approaches to designing or altering the mental health

treatment system may be needed to increase access

for each minority group.70

G~ese issues we discussed more fully in ch. 15, “Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Services to

Adolescents, ” in Vol. HI.

mch$ 18, ~ ‘Issues in tie Delivery of Servi@s to Selected (kOUpS of Adolescents, ‘‘ in Vol. III, discusses access issues relating to racial and ethnic

minority adolescents in greater detail.
Chapter 11—Mental Health Problems: Prevention and Services ● II-469

Mental Health Treatment Costs

Estimating the costs of treatment for a specific

illness within a particular age group is difficult. A

1989 Institute of Medicine study noted that the

difficulty in quantifying costs arises from the failure

to collect relevant age-specific data necessary to

calculate such costs (139). The usual technique is to

apply the percent of total admissions that are

accounted for by adolescents to total expenditures,

within major setting types. This method does not

distinguish between unique costs associated with

treating adolescents and the costs of treatment for

the average patient. It also assumes that the percent

of admissions is a reasonable measure of caseload,

which is probably more true for short stay facilities

than longer stay facilities. Further, according to the

Institute of Medicine, the dearth of services for

adolescent mental health problems artificially deflates potential costs (139).

Using the best evidence and method available,

OTA estimates that the total cost of mental health

treatment for U.S. adolescents in 1986 was about

$3.5 billion (see table 11-6). Forty-six percent of the

total was spent for hospital inpatient care; 28 percent

for residential treatment center care; and 26 percent

for ambulatory (outpatient) care. Comparing adolescent expenditures with expenditures for other age

groups (192), one finds the following:

●

●

●

Adolescent care includes a major expense

category, residential treatment centers, which is

not part of the adult costs. The cost and use of

residential care has risen dramatically in the

past decade. An estimated $359.1 million was

spent on residential treatment centers in 1977,

increasing to $573 million by 1983. By 1986,

expenditures for residential treatment center

care rose to $978 million a year, 29 percent of

the total costs of adolescent care (192).

Adolescent costs account for 13 percent of the

total specialty psychiatric costs for all ages in

1986, 7 percent of the hospital costs, and 18

percent of the outpatient costs.

Inpatient hospital expenditures for adolescents

are a much smaller proportion of total costs (46

percent) than for all ages (78 percent) .71 However, when residential treatment center costs

Table 11-6-Rough Estimate of Direct Expenditures

for Mental Health Services for U.S. Adolescents

Ages 10 to 18, 1986a

Estimated expenditures

in millions

Hospital inpatient, total . . . . . . . . . . . . . . $1,592.1 ‘

Psychiatric hospital, total . . . . . . . . . . . . 852.4

State . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304.9

Private . . . . . . . . . . . . . . . . . . . . . . . . . . 547.5

General hospitals, total . . . . . . . . . . . . . . 739.7

Specialty psychiatric units . . . . . . . . 192.2b

Medical units . . . . . . . . . . . . . . . . . . . . 547.5’

Residential treatment centers for

severely emotionally disturbed . . . . $ 978.0d

Ambulatory care, total . . . . . . . . . . . . . . . $ 883.3

Organized settings . . . . . . . . . . . . . . . . . . 489.3”

Office-based practice . . . . . . . . . . . . . . . 394.0f

All specialty mental health

facilities, total . . . . . . . . . . . . . . . . . . . . . $3,453.4

aEStinlated expenditures were obtained by applying the Percentage of

admissions of individuals ages 10 to 18 (National Institute of Mental Health

sample survey) to the total expenditures for mental health services

estimated in C.A. Taube, “Funding and Expenditures for Mental Illness:

Persistence of Trends,” 1989 (192).

bhis figure includes all specialty psychiatric units and inpatient units of

what the National Institute of Mental Health classifies as “multipurpose

mental health organization s.”

~his assumes the same adolescent percentage as occurs in specialty

units.

*his assumes 100 percent of expenditures are for adolescents and

represents a slight overestimation as residents less than 10 years old,

although expected to be a small number, are included in this figure.

eThis figure includes hospital outpatient programs, free-standing clinics,

and other speeialty mental health outpatient programs.

~his assumes the same adolescent percentage as in organized settings.

SOURCE: B.J. Burns, C.A. Taube, and J.E. Taube, “Mental Health

Services for Adolescents,” contract paper prepared for the

Office of Technology Assessment, U.S. Congress, Washington,

DC, 1990.

are added to hospital costs, the percent for

institutional costs is 76 percent; 24 percent of

costs are for services in the community (outpatient treatment, partial hospitalization).

Coordination Between the Mental Health

System and Other Systems of Care

Numerous analyses have concluded that coordination of treatment services for adolescents with

mental health problems is the exception rather than

the rule (1 15,127,202). Instead of an orderly provision of appropriate services in a timely manner, one

typically finds fragmented services provided across

multiple jurisdictions--e. g., mental health systems,

social services, schools, juvenile justice, and sub71~~osp1t~ ~xpendi{ures for ~~ychlatric ~wc tic a]se about ~ua]ly split be~cen psychia~ic hospi~als and generaJ hospitals; however, the COStS fOr

adolescents in private psy~huitnc hospitals represents a larger share of hospital costs (34 pcrccn[) than for all ages (12 percent), The cost of hospitalization

ranges from $300 to $500” a day ( 187J. This is the most expensive treatment setting available to an adolescent patient with mental illness. In 1988, the

pcr eplsocfc cost of private psych lfitrlc h{)splt.illzition for adolescents was greater than $1 fi,()()() per adolcscmt ( 140).
II-470 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

stance abuse programs. Where linkages between the

mental health and other service systems exist, they

are generally the result of governmental mandate

and encouragement, innovative demonstration projects, or the personal efforts of individual providers.

For an adolescent with mental health problems, the

only way to get comprehensive-but not necessarily

coordinated-treatment may be through application

to numerous agencies, each with its own eligibility

criteria, legal scope of authority, diagnostic and

treatment perspectives, independent resources and

benefit structure, and administrative requirements.

Frustration for adolescents with mental health

problems, for their families, and for service providers is a common result of system fragmentation.

Because of the difficulty in locating and qualifying

for various services, potential beneficiaries may

abandon the effort and forgo needed treatment.

Parents may be required to relinquish custody of

their children (143). Interagency differences and

confidentiality requirements may hamper professionals who attempt to create cooperative arrangements to facilitate service delivery or followup on

clients in other agencies.

To highlight these problems, brief reviews of the

general health care system, the juvenile justice

system, the child welfare system, and the public

school system, and their interactions with the mental

health system, are presented below.

The General Health Care System

Adolescents enter the general health care system—

hospitals, emergency rooms, clinics, private physician offices-for a variety of reasons (checkups,

illness, accident, disability, substance abuse, pregnancy). But whatever the reason, adolescents who

enter the general health care system may also have

mental health problems that merit treatment (145).

Some adolescents or their families may seek out a

general health care provider specifically because of

a mental health problem.

Unfortunately, the mental health needs of adolescents entering the general health system are frequently not recognized by the attending physician,

nurse, or other provider (38).72 Even if their mental

health needs are recognized, such adolescents may

not be appropriately referred. Health care professionals frequently lack state-of-the-art information

about diagnosis and treatment of mental health

problems and may be unfamiliar with referral

resources (38).

To overcome this problem, some health centers

have employed specially trained and funded, multidisciplinary teams, although these teams remain

rare examples in the general health care field. These

teams have been able to detect mental disorders

more effectively than traditional health care models

(56). 73 Community health centers with a mental

health component have demonstrated the value of an

interdisciplinary team approach where a full range of

services are available within a single agency (37). A

Federal effort to coordinate care between community health centers and community mental health

centers was never fully implemented because of a

shift in policy priorities in 1980 (82,202).

The Juvenile Justice System74

For some adolescents with mental health problems, the police or courts maybe their first encounter

with a public agency. Police may be called upon to

intervene in an aggressive act or violation of the law

by a minor with a mental health problem; and the

court may order a mental health assessment when

appropriate. Mental health screening of adolescents

involved with the juvenile justice system is not a

universal practice, but for those adolescents who are

screened and found to have significant problems, a

“brush with the law” may be the opening wedge to

needed treatment. The courts may not only call upon

the expertise of mental health professionals for

diagnosis and evaluation, but also may order commitment of adolescents for mental health treatment.

The 1989 survey by the National Mental Health

Association (NMHA) found that 17 percent of

placements of children and adolescents to out-ofState mental health residential treatment were ordered by State juvenile justice systems (143).

The provision of mental health services through

the juvenile justice system has not been systematically studied, but it is thought to be limited once

72s= Ch. 15, ‘‘Major Issues pertaining to the Delivery of Primmy and Comprehensive Health Services to Adolescents,’ in Vol. III.

73U~o~tely, speci~ly tided adolescent h~th c= te~ in ~s s~dy w~e no more eff~tive bno~dti clinics in reduc~ mental health

problems a.rnong adolescent clients (56).

ydForamore Cxtemive discussion of he~~s~ic~ for adolescents in tie juvenile justice Systeq StX ch. 13, ‘‘Delinquency: Prevention and Services,’

in this volume.
Chapter n-Mental Health Problems: Prevention and Services .11-471

disposition of a pending case is made. Interaction

between the court and the mental health system is

often fragmented and time-limited, but litigation

may force changes in this area. A suit brought on

behalf of four North Carolina minors (Willie M. et al.

v. James B. Hun?, Jr.), which claimed the four

minors had been denied rightful education and

appropriate mental health treatment, was settled in

favor of the plaintiffs and the class of children

‘‘likely to be institutionalized’ that they represented

(18). This case and similar class litigation may inject

the courts into a more visible oversight role vis-a-vis

services for adolescents with mental health problems,

The Child Welfare System75

Adolescents tend to enter the child welfare system

because of families or environmental factors which

place them at risk-e. g., neglect, abuse, or other

need for protective intervention. Many adolescents

who enter the child welfare system may need mental

health treatment. In some States, the child welfare

agency may provide its own diagnosis and treatment

(whether directly or through referral or purchase of

services). In others, the child welfare system may

turn to the State mental health authority for diagnosis and treatment or referral. High caseloads for

social workers, lack of available services, funding

problems, and other impediments may work against

appropriate placement and treatment.

Further difficulties arise over legal questions. For

example, the Adoption Law and Child Welfare Act

of 1980 (Public Law 96-272) has been interpreted

differently in different States. Under its provisions,

States may require parents to relinquish custody in

order to obtain mental health treatment for their

adolescent child. Following loss of custody, the

adolescent may be removed from the home and

community and placed in a residential treatment

center (39). In areas where services such as crisis

intervention, day treatment, and family preservation

services are available, greater cooperation between

child welfare agencies and mental health seem to be

occurring (1 16a).

The Public School System

The 1975 Education for All Handicapped Children Act (Public Law 94-142) has provided the

potential for stronger linkages between public

schools and the mental health sector. This landmark

legislation requires a free and appropriate education

(and “related services”) in the least restrictive

setting for all children, including those with mental

disorders. Individual education plans are required

for all students with disabilities. If mental health

services are deemed necessary for a student

educational progress, they must be provided.

Despite the promise implicit in Public Law

94-142, recent research indicates that there are

serious limits to mental health services currently

available in school settings. As reported by Tremper,

there is one school psychologist per 2,633 pupils,

and typically school psychologists devote only 5 to

9 percent of their time to direct counseling or therapy

(198).

Knitzer recently estimated that only 19 percent of

students of all ages with serious emotional disturbance are currently being served under Public Law

94-142 (116). Even among the 341,000 emotionally

disturbed 3- to 21-year-olds identified under Public

Law 94-142 in 1986-87, an analysis for the U.S.

Department of Education found that less than

one-third received psychological, social work, or

counseling services (136a). Fiscal concerns and

other factors have led some States to determine that

mental health services do not have to be provided

through the schools when they are not directly

related to educational objectives (1 16).

Recently, however, the Education of the Handicapped Act Amendments of 1990 (Public Law

101-476) authorized funding of $35.5 million over

4 years for two new competitive grant programs

designed to improve services for children and youth

with serious emotional disturbance (20 U.S.C. 1426,

Section 627). These grant programs do not go so far

as to mandate that mental health be included under

‘‘related services, ’ but one grant program is for the

use of local educational agencies working in collaboration with mental health entities (20 U.S.C. 1426,

Section 627(b)).

Another approach to delivering mental health

services to adolescents in schools is through school75 Adole~cent~ ~ tie ~hj]d welf~e system me discussed in ch. 3, “Parents’ and Families’ Influence on Adolescent Health. ”
II-472 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

linked health centers (SLHCS).76 The SLHC model

for providing comprehensive health and related

services to adolescents has received considerable

attention and has the potential to reach many

underserved adolescents. Definitions of SLHCs

vary, and the precise number of SLHCs is not

known, but their number has grown in recent years,

particularly in the latter half of the 1980s. As the

movement to provide health services in or near

schools has advanced, SLHCs have found that

mental health services are in great demand by

students and, on behalf of students, by school faculty

and SLHC staff. For example, in the 1988-89 and

1989-90 school years, mental health-related conditions were the second leading cause of clinic visits

to the 23 SLHCs funded by the Robert Wood

Johnson Foundation, accounting for 20 percent of

visits. Mental health visits to these SLHCs were

almost as frequent as those for the leading cause of

visits, acute illness and accidents (25 percent of

visits).

Although the duration and intensity of the services provided is not known, 90 percent of in-school

SLHCS

77 surveyed by the Center for Population

Options reported that they provided some level of

mental health and psychosocial counseling in the

1988-89 school year. Nonetheless, a group that has

been charged by the Robert Wood Johnson Foundation with advancing the provision of mental health

services in SLHCs notes that the need for mental

health services is far from met, even in schools that

have SLHCs (3a).

Barriers to Coordination Between the Mental Health

System and Other Systems

Experience has shown barriers to greater coordination and integration of mental health services for

adolescents to include the following:

●

●

●

●

multiple entry points and jurisdictions;

lack of interagency linkages, coordination mechanisms, communication, and trust;

lack of continuity of care over time, as adolescent mental health needs change and are served

by different providers;

the absence of programs specifically designed

for adolescents;

●

●

●

●

inadequate research on optimum treatment

approaches and outcomes;

the absence of appropriate legislative mandates;

isolation of providers and lack of information

about available services, resources, and funding outside one’s own arena; and

incongruent missions and responsibilities of

agencies.

There is not yet a universally accepted model for

coordinating and integrating adolescent mental

health services with other systems of care. The range

of services required by some adolescents is very

broad: primary health care, education, legal, social

welfare, and mental health. For the most part, each

adolescent requiring services must be dealt with on

an individual basis by multiple agencies and individuals. Fragmentation of this magnitude limits the

ability of systems to provide continuity of care in a

comprehensive manner.

These barriers are not insurmountable, but success will require several factors: mechanisms to

bring representatives from different systems together formally and informally at the State and local

levels, enhanced training for professionals through

workshops targeted toward adolescent mental health

concerns, greater reliance on case conferences which

include all parties concerned with an adolescent’s

welfare, and similar creative strategies. Innovative

approaches are being devised and tested in communities around the country. Selected models of

innovative mental health services and model systems of coordinated and comprehensive mental

health services are discussed in the sections that

follow.

Selected Models of Innovative Mental

Health Services

In addition to schools as centers for providing and

increasing referrals to mental health services (see

above), innovative mental health services include

home-based mental health services for disturbed

adolescents at high risk of out-of-home placement,

therapeutic foster care for adolescents with mental

disorders who cannot be managed in their own

homes, and therapeutic group homes for emotionally

‘%ke ch. 15, “Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Services to Adolescents, in Vol. III, for a discussion

of SLHCS, including bibliographic sources for the information discussed here.

7TSLHCS need not & on school grounds. However, the Center for Population Options survey has to date been conducted o~y mong tiose SLHCS

actually located in schools.
Chapter n-Mental Health Problems: Prevention and Services ● II-473

and behaviorally disturbed adolescents. Homebased mental health services are by definition

provided in an adolescent’s own community, and

therapeutic foster care is likely to be provided in an

adolescent’s own community. As is evident from the

discussion below, innovative community-based mental health services are likely to require collaboration

among different service systems.

Home-Based Mental Health Services

The goal of home-based mental health services is

to preserve the family. Services are provided within

the homes of disturbed adolescents and their families on an outreach basis. Home-based services have

three primary objectives: 1) to preserve the family’s

integrity and prevent unnecessary out-of-home placements, 2) to introduce and connect adolescents and

their families to community agencies and individuals in order to create an outside support system, and

3) to strengthen the family’s coping skills and their

capacity to function effectively in the community

after crisis treatment is over ( 185). Only adolescents

at high risk of placement in out-of-home settings

(e.g., those perceived as dangerous to self or others)

are accepted for home-based mental health services.

Home-based mental health services are provided

by both public and private agencies. The services are

multifaceted, including evaluation and assessment,

counseling, skills training, and coordination of

services. Program staff usually have caseloads

ranging from two to four families, and the length of

intervention is typically between 2 to 5 months.

Small caseloads are essential to provide immediate

and intensive service. Treatment is often provided

by a team of at least three professionals. Generally,

a primary counselor is assigned to the case, with

backup counselors enabling 24-hour coverage. The

estimated cost of a three-person program (including

secretarial and administrative expenses) has been

estimated to range from $120,000 to $160,000 per

year (185).

Early demonstrations of home-based services

report encouraging results. These include the Homebuilders Program in Tacoma, Washington (1 12,92);

the Systemic Crisis Intervention program in Houston, Texas; and other home-based services programs

in San Diego, California, Hennepin County, Minnesota, and Maine (188). Studies have suggested that

75 to 90 percent of the children and adolescents who

participated in such programs did not subsequently

require placement outside of the home; verbal and

physical aggression decreased; and fiscal savings

have been reported (91,98).

An evaluation of the Houston Child Guidance

Center’s program called the Systemic Crisis intervention Program followed 75 participating youths

over an 18-month period (91). Suicidal behavior was

the cause for treatment of 47 subjects (26 of these

had suicidal ideation and 21 had actually attempted

suicide). No suicide attempts were made during

treatment. Among those followed after treatment,

there was a significant decrease in the range of

problem behaviors. Only 5 of the 75 youths were

hospitalized or in residential placement at followup.

Two made minor suicide attempts during the followup period. The mean per patient cost of the

program was $3,200 per episode of care. Other

findings included regular school or work attendance.

The results from evaluations of home-based

programs are impressive, but methodological shortcomings exist in most of the research. Few studies

have assessed whether families continue to remain

intact after home-based services have been withdrawn. If the goal of home-based services is to

prevent out-of-home placement, it is essential for the

researchers to examine not only the short-term

results of intervention but also to conduct longitudinal followup studies. Another problem with available evaluations is that they have not included

control families with comparable characteristics and

problems for whom home-based services were not

provided (193). Without control groups, it is not

possible to predict whether comparable adolescents

would have entered or avoided out-of-home placement without the intervention.

Despite the preceding cautions, the early evidence

indicates that home-based programs, in their short

history, have demonstrated that many children who

would have been removed from their families can

best be served in their homes (72). If a community

is committed to a family-oriented system of care that

emphasizes treatment in the least restrictive setting

possible, in-home services should be tried before

out-of-home placements, unless an individual is in

immediate danger (12). When intensive services are

provided during a time of crisis, they may contribute

to lasting improvements in family functioning, and

these services may be cost-effective in relation to

residential placements (200).
II-474 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Therapeutic Foster Care

Therapeutic foster care, provided within the

private homes of trained families, is a relatively new

and specialized form of residential treatment for

adolescents with mental disorders who cannot be

managed in their own homes. The approach combines the normalizing influence of family-based care

with specialized treatment interventions (186). It is

the least restrictive of all residential placements for

adolescents with mental disorders and is capable of

providing individualized, intensive therapy even for

adolescents with severe disorders as an alternative to

highly supervised institutional settings.

The flexibility of therapeutic foster care programs

offers an opportunity to match adolescents to

specific social and cultural backgrounds and to

design individual treatment programs. No special

physical facility is required; therefore, there are no

zoning problems when establishing a new program.

Therapeutic foster care programs can expand or

contract as caseload demands change. All therapeutic foster care programs have a low staff-to-client

ratio, allowing the clinical staff to work closely with

each adolescent, with the therapeutic foster parents,

and, if they are willing and available, with the

biological parents. Linkages with schools and other

agencies are made.

The estimated annual cost of therapeutic foster

care ranges from $10,000 to $20,000 per adolescent

(187). Included in this cost are payments to staff and

therapeutic foster parents. A portion of the cost of

therapeutic foster care programs may be covered by

funds for regular foster care in the State. Programs

are typically jointly funded by child welfare and

mental health agencies, and costs are reported to be

lower than for other residential settings (186).

The Presley Ridge Youth Development Extension

in Pittsburgh collects annual followup surveys on

clients discharged from therapeutic foster care (103).

Seventy percent of discharged clients are still living

in a less restrictive setting than therapeutic foster

care at 1 and 2 years after discharge, and over 70

percent are attending school or are working. When

change in functioning is measured over time, behaviors are reported to have improved in more than 75

percent of discharges (103). Friedman reported that

significant progress on behavioral objectives was

made by 60 percent of youth discharged from

Florida’s therapeutic foster care programs (69).

Snodgrass and Bryant report that an average of 77

percent of children in therapeutic foster homes are

discharged to less restrictive settings (e.g., their

families, independent living arrangements, less structured group homes) (180).

As noted above, an Ontario study compared

outcomes of foster placement in the Parent Therapist

program with care in a residential treatment center

(164). Although clients were not randomly assigned,

the groups were roughly comparable in background

and made similar improvement. The significant

difference was that the foster care arrangement was

reported to cost only one-half as much as the

residential treatment for the same period of time

(164).

Although these findings are promising, the research studies on therapeutic foster care are flawed

by the same types of methodological problems as are

studies on other settings. Therapeutic foster care

would seem theoretically to meet the needs of some

adolescents more effectively than more institutional

alternatives, and some have suggested that the major

constraint in developing therapeutic foster care

programs has not been lack of enthusiasm about the

effectiveness of this type of service, but one of

recruiting and training qualified foster parents (40).

More research is needed before definitive conclusions can be reached.

Therapeutic Group Homes

Therapeutic group homes can theoretically provide emotionally and behaviorally disturbed adolescents with an environment in which to learn social

and psychological skills, In comparison with residential treatment centers, therapeutic group homes

are smaller, have fewer medical staff available, and

tend to be less security-oriented (187). Such homes

typically serve 5 to 10 clients and provide an array

of therapeutic interventions.

There are two major models of therapeutic group

homes. One is the teaching family model, developed

at the University of Kansas, then moved to Boys

Town in Omaha, Nebraska (157). The other is the

Charley model, developed at the Menninger Clinic.

In both models, staff are the key agents for change

in the disturbed adolescents; trained couples live at

the homes 24 hours a day, with some relief

assistance available. Other types of therapeutic

group homes may have rotating staff instead of

permanent houseparents.
Chapter n-Mental Health Problems: Prevention and Services . II-475

Therapeutic group homes vary with respect to the

types of treatment programs they offer, but often

combine individual psychotherapy, group therapy,

and behavior modification. The teaching family

model emphasizes structured behavioral interventions through teaching new skills and positively

reinforcing improved behavior. Other types of therapeutic group homes use individual psychotherapy

and group interaction. Vocational training, work

experiences, and recreation are normally included as

part of the treatment program for adolescents.

Some research has suggested that therapeutic

group home programs produce positive gains for

adolescents while they are in the group home, but

that these gains do not appear to be maintained after

discharge (1 13). However, a 1987 dissertation studied changes in relationships between 20 adolescents

treated in a therapeutic group home and their parents

and peers over an 18-month followup period (162).

The study also looked at changes in work relationships and adolescents’ level of psychopathology.

Twenty untreated adolescents served as controls. At

followup, 90 percent of adolescents treated in the

therapeutic group home had fair or good relationships, while only 45 percent of adolescents in the

untreated group achieved similar ratings. The treated

group realized a significant decrease in psychopathology, while the untreated group did not. Future

research would benefit from further longitudinal

assessments and, perhaps, evaluation of alternative

strategies for treatment after discharge from a

therapeutic group home. In addition, adolescents

with severe character pathology or major psychiatric

disorders were not included in the dissertation study,

suggesting the need for more analysis of appropriate

matchings of clients to treatments (e.g., 202).

Models for the Provision of Comprehensive,

Coordinated Mental Health Services

Three models that exemplify successful alternatives to the fragmentation of systems of care for

adolescents are the Ventura County Project in

California, the Alaska Youth Initiative, and the

Kaleidoscope Program in Illinois.

Although they differ in approaches to organizing

services, these models of comprehensive services

share similar goals and philosophies. All three

models are designed to do the following:

. care for adolescents who are at risk of mental

health problems or who have been separated

●

●

●

●

●

●

●

from their home and family because of psychiatric hospitalization or placement in mental

health residential care;

maintain and preserve the family of the adolescent as a functioning unit;

to the extent possible, treat adolescents with

mental health problems in their homes and

communities;

maintain the adolescent’s personal freedom,

responsibility, and participation in normal community activities;

provide individualized treatment, tailoring the

program to meet the specific needs of the

adolescent;

make clinical and therapeutic services available

24-hours a day;

aid in developing self-sufficiency in the adolescent and family, teaching them the skills to

obtain any further aftercare or outpatient services needed, and to live independent and

productive lives; and

encourage and maintain the involvement of

multiple agencies in assisting the adolescent

clients.

Ventura County Project

The comprehensive service model developed in

1985 in Ventura County, California, is identified as

a ‘‘satellite model” because multiple public agencies are linked together to provide mental health

services to severely emotionally and behaviorally

disturbed children and adolescents in decentralized

locations throughout the community (104). Agencies involved in the Ventura County demonstration

project authorized by the California legislature

include mental health, social services, juvenile

justice, and special education. Services, staff, and

funding are blended together across agencies in

order to reach the treatment goals. Case management

is provided to ensure that each client receives

individual, appropriate, and easily accessible treatment at a low cost. Outcomes are individually

monitored for as long as the client receives mental

health care. The data are analyzed and used for

program improvement.

The Ventura County Project has been reported to

decrease rates of out-of-home placement of severely

emotionally disturbed adolescents and facilitated

earlier return of adolescents to their homes and

schools when placement does occur (104). Dowrick

estimated that short-term reductions in recoverable
II-476 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

State general fund expenditures have offset costs by

more than 50 percent and that the Ventura model

will enable California to save almost $17 million a

year in State hospital costs (55). Since 1985,

out-of-county, court-ordered juvenile justice and

social services placements have been reduced by 46

percent in Ventura County, according to Dowrick

(55). OTA did not attempt to validate these estimates, but, if true, the model could be promising.

Alaska Youth Initiative

The Alaska Youth Initiative provides highly

individualized mental health services to severely

maladjusted children and adolescents in Alaska (36).

The Alaska Youth Initiative was created by the State

government to bring young people placed out of

State back to Alaska and to limit out-of-State

placements for children, adolescents, and young

adults between the ages of 7 and 20 years of age. The

Alaska Youth Initiative is called a “wraparound”

service system. The dollars available to buy services

are allocated to the community by the State government. The service package is developed by the child

or adolescent’s case manager and is purchased from

vendors. Both the funds and the services are

‘‘wrapped around’ the child or adolescent, providing the most individualized treatment and education

possible. The essential concepts are flexible funding

and flexible service delivery. When a service for a

given child or adolescent is not available from an

existing organization, funds are used to develop the

service. For example, instead of bringing an adolescent male with schizophrenia from a remote village

into Anchorage for treatment, a mental health

consultant was flown to his village to work with the

school and family to set up a community-based

program for the boy (55).

An interdepartmental team, consisting of staff in

the State Department of Education, the Division of

Mental Health and Developmental Disabilities, and

the Division of Family and Youth Services, manages

the Alaska Youth Initiative and evaluates the

strengths and gaps in the continuum of services in

the communities. Regional coordinators organize

local treatment and education teams that devise the

individualized service plans for each youth. On

average, 4.3 agencies are represented on an individual treatment team, although participation may

range from 3 to 7 agencies at a time with one case.

For each child served by the Alaska Youth

Initiative, the average yearly cost is reported to be

$40,562 (including administration, direct service,

and State education costs) (55). This cost may seem

high, but costs in residential treatment centers would

have been closer to $50,000 to $75,000 per year.

Costs for an adolescent in his or her second year of

the program are estimated to be 24 percent less than

first year costs. The average length of participation

in the Alaska Youth Initiative is 11.8 months.

Initial outcomes (as of January 1989) from the

frost and second years of the Alaska Youth Initiative

are encouraging. Almost half of the young people

participating in the Alaska Youth Initiative were

diverted from out-of-State placements and remained

in Alaska, Two of these youth subsequently required

out-of-State placement, one short-term. The amount

of time spent with natural families or in family-like

care, as opposed to institutional care, increased.

Runaway episodes among participants decreased by

75 percent and substance abuse declined. Assaultive

behavior, property damage, contacts with police,

and suicide attempts were almost eliminated. Medication compliance, school attendance, and parental

involvement were also reported to have improved

(55).

The Alaska Youth Initiative approach seems most

appropriate for isolated or sparsely populated rural

areas because it permits an infusion of resources and

expertise to maintain community-based alternatives

to more institutional and centralized services. There

are plans to systematically produce long-term client

outcome data on each severely emotionally disturbed child and adolescent being served by the

Alaska Youth Initiative. Further, this model has

been extended to other States (Washington, Montana, and Wyoming), where client outcomes are also

being monitored (39,55).

Kaleidoscope Program

The Kaleidoscope Program, a private umbrella

organization in Chicago, offers a continuum of

services for adolescents with diagnosable mental

disorders and members of their families (185).

Support for the Kaleidoscope Program comes from

the Cook County Region of the Illinois Department

of Children and Family Services, from other regions

of that department, and from the Joint Services

Children’s Initiative of the Illinois Department of

Mental Health. Additional support includes funds

contributed by the private sector and from fundraising.
Chapter n-Mental Health Problems: Prevention and Services . II-477

The underlying philosophy of treatment at Kaleidoscope is normalization and unconditional provision of care. Adolescent clients are treated in a

normal environment so that they may learn from

their surroundings. All adolescents referred to the

Kaleidoscope Program are accepted provided there

is an opening (185).

Three basic program models are provided by

Kaleidoscope: 1) therapeutic foster care (see above);

2) a youth development program, which places and

supervises older adolescents in apartments in the

community and helps them live on their own, and 3)

satellite family outreach, which reunites adolescents

placed in residential treatment with their families

and prevents the unnecessary removal of adolescents

from their families.

The adolescent clients’ regular caregivers—

parents, child care workers, or foster parents-are

the Kaleidoscope Program’s key resources for treatment. They provide around-the-clock care and are in

charge of the client’s treatment plans. Mental health

professionals are available for specialized treatment

and consultation.

Kaleidoscope staff provide child care, diagnostic

assessments, and a wide range of therapeutic services. About 70 staff and 45 professional foster

parents are employed. All staff have at least a

bachelor’s degree, and about 20 have master’s

degrees.

The home-based services provided to Kaleidoscope clients are estimated to cost approximately

$1,200 per month (185). The average 18-month

episode is estimated to cost $21,600 (185).

Kaleidoscope has not yet formally evaluated the

program’s effectiveness but has estimated that at

least 50 percent of adolescents referred for services

are maintained outside of the residential placement

system for a minimum of 18 months (185). When

clients are discharged, at least 50 percent of their

families require less intensive services at followup

(185). Research support for additional evaluation

seems warranted.

More information about innovative financing

alternatives to financing and coordinating mental

health services for adolescents will be forthcoming

from the Robert Wood Johnson Foundation (161)

and NIMH (186a,2 13a).

Major Federal Policies and Programs

Pertaining to Adolescent Mental Health

Historically, most public mental health prevention, promotion, services, and treatment have been

the exclusive domain of State and local governments, with no discernible Federal role beyond

research and research training. It was the movement

to deinstitutionalize persons with mental illnesses

that caused a shift in Federal policies, focusing

attention on the need for a community-based infrastructure for mental health services.

Passage of the Community Mental Health Centers

Act (Public Law 88-164) in 1963 promised a

stronger Federal presence in the mental health arena.

In 1981, however, this law was superseded by the

law establishing the alcohol, drug abuse, and mental

health (ADM) block grant, placing more responsibilities on States and local communities (see below).

Generally, national engagement in child and adolescent initiatives at the Federal level has remained

fragmented and erratic. In its 1989 report on child

and adolescent mental health research, the Institute

of Medicine observed:

Problems of children are of potential interest to

many Federal agencies. For example, the Department of Education addresses problems of children

with emotional or developmental difficulties that

interfere with learning; the Office of Children,

Youth, and Families in DHHS has programs for

delayed and deprived children, including Head Start;

Maternal and Child Health in HRSA [DHHS’ Health

Resources and Services Administration] works to

prevent problems and has especially close ties to

pediatrics; the Justice Department must cope with

children who violate societal norms; and other

agencies deal with issues of developmental disabilities, rehabilitation, and entitlement programs. However, none of these agencies have shown a strong or

consistent interest in children and adolescents with

severe mental disorders (139).

Although, as the Institute of Medicine noted, there

are extensive roles for the Federal Government to

play in improving the mental health of adolescents,

this chapter emphasizes major Federal programs

related to financing of mental health treatment for

adolescents. Federal activities related to the coordination of services for adolescents with mental health

problems, and research on adolescent mental health
II-478 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

issues. An overview of the Federal role in adolescent

health is provided elsewhere in this Report.78

Financing of Mental Health Treatment

for Adolescents

Medicaid

The major vehicle for Federal financial involvement in adolescent mental health-the Medicaid

program-is not primarily a mental health program

nor is it targeted specifically to adolescents. Rather,

Medicaid (Title XIX of the Social Security Act) is a

joint Federal/State program for financing general

health care services for families (and some individuals) who meet certain eligibility criteria.79 Covering

an estimated 4.5 million individuals ages 10 to 18

and representing approximately 55 percent of all

public health funds spent on children and adolescents, Medicaid is the major health care financing

mechanism for low-income adolescents. A Medicaid program is available in every State except

Arizona, where a special waiver program is in effect.

Medicaid is managed at the State level, and the

Federal Government gives States considerable latitude in decisions about what services to cover, what

eligibility standards to apply, and what limitations to

impose on services. Some services, including hospital and physician services, are mandatory, while

other services are optional. States have substantial

flexibility in financing mental health services are

generally among those services. Thus, for example,

individual States are permitted to cover the services

of psychologists or inpatient psychiatric services for

persons under age 21 but are not required to do so.

As of 1989, 38 States covered inpatient care in

freestanding psychiatric facilities; 10 permitted

reimbursement for residential treatment centers

which have not been specifically certified as psychiatric facilities; and 18 States covered partial hospitalization as a mental health service.80 The Health

Care Financing Administration in DHHS, which

administers Medicaid, estimates that 10.5 percent of

Medicaid expenditures on behalf of adolescents ages

10 to 18 in fiscal year 1988 were for hospital-based

mental health services. Outpatient mental health

benefits vary among State Medicaid programs and

also fluctuate depending upon the treatment setting

and provider. Estimates of Medicaid expenditures

on outpatient mental health treatment for adolescents are not available. Medicaid restrictions can

make it difficult to provide the kind of comprehensive, coordinated case that may be needed by

low-income adolescents covered by Medicaid.

A potentially important reform under Medicaid

occurred in the Omnibus Budget Reconciliation Act

of 1989 (Public Law 101-239), when Congress

refined the Early and Periodic Screening, Diagnosis

and Treatment (EPSDT) Program. EPSDT mandates

States to conduct periodic screenings for treatable

conditions of Medicaid-eligible children and adolescents, with appropriate followup, referral, and treatment. The 1989 amendments would override any

State-imposed Medicaid coverage limitations on

conditions discovered during screening for which

medical treatment is necessary and allowable under

the Federal guidelines. Thus, an adolescent with a

mental health problem detected during an EPSDT

screening could obtain necessary mental health

services under Medicaid, notwithstanding a State

Medicaid standard which would have restricted such

services. As far-reaching as the EPSDT reforms may

become, it is still too early to assess their impact.

EPSDT reforms will not help the one out of three

poor adolescents not covered by Medicaid (203).

Alcohol, Drug Abuse, and Mental Health Block Grant

The Alcohol, Drug Abuse, and Mental Health

(ADM) Block Grant program is unlike Medicaid in

that it was developed specifically to help States

finance mental health and substance abuse treatment. Enacted in 1981 as Public Law 97-35, the

ADM Block Grant Program is administered at the

Federal level by the Alcohol, Drug Abuse, and

Mental Health Administration in DHHS. It is

currently the only Federal program that provides

funding to States for the support of outpatient

community mental health services. ADM block

grant funds cannot be used for inpatient institutional

care.

For fiscal year 1990, Federal ADM block grant

funds totaled $1.133 billion. Of the total, $237.5

million was allocated for mental health services and

76s= ch. 19, ‘ ‘me Role of Federal Agencies in Adolescent Heal@” iII VOI. ~.

7!@or more i~o-tion on M~icaid eligibdi~ ties, see ch. 16, ‘‘F~cial Access to Health Services, ” hl VO1. ~.

SOS= ch. 16, “F~cial Access to Health Services, ’ in Vol. ~.
Chapter 11-Mental Health Problems: Prevention and Services . II-479

$895.6 million was allocated for substance abuse

programs.

81 Both parts of the ADM block grant are

subject to 10 percent set-asides. Ten percent of the

substance abuse funds must be used for services to

pregnant women and women with dependent children. Ten percent of the mental health funds must be

set-aside for new programs for underserved populations, with a priority given to severely emotionally

disturbed children and adolescents (105). In 1986,

OTA noted that the ADM block grant set aside fo r

mental health services for children was so small that

its significance was more symbolic than substantive

(202).

Coordination of Mental Health Services

for Adolescents

Child and Adolescent Service System

Program (CASSP) of NIMH

A relatively small, but important, program in the

area of adolescent mental health is the Child and

Adolescent Service System Program (CASSP) administered by NIMH. CASSP was created by

Congress in 1984 to promote greater coordination

among public and private agencies providing services to children and adolescents with mental health

problems (202).

Since 1984, CASSP has provided 47 States with

technical assistance, training programs, and planning grants (126). States receiving CASSP grants are

required to have a child mental health authority and

mechanisms for interagency coordination of services involving mental health, juvenile justice, social

services, and related agencies; family participation;

and culturally sensitive programs. In fiscal year

1990, Federal finding for CASSP was approximately $9 million, essentially the same level of

funding as in the previous year. From that amount,

CASSP is funding 45 State grants for State and local

systems development demonstrations and launching

several new research-oriented programs (126, 186a).

The State Comprehensive Mental Health

Services Plan Act

CASSP’s efforts at the State level have been

complemented by a recent Federal planning initiative which, even though originally targeted toward

adults, has helped focus attention on adolescent

mental health services. In 1986, Congress enacted

the State Comprehensive Mental Health Services

Plan Act (Public Law 99-660), mandating each State

to develop-with the advice of mental health

consumers, their families, and other advocates—a

comprehensive plan to serve the needs of seriously

mentally ill individuals. The emphasis under the

original act was clearly on services for seriously

mentally ill adults, although services for children

and adolescents were expected to be a part of each

State’s plan.82 The Mental Health Amendments of

1990 (Public Law 101-639), passed in late 1990,

imposed a requirement that States cover children

and adolescents in their comprehensive plans.

The State Comprehensive Mental Health Services

Plan Act created a small grant program to provide

resources for technical assistance to the States

during the course of the 3-year planning process, but

appropriations were cut back from the statutory

minimum grant level in each of the first 2 years and

completely eliminated in the third year. The State

plans developed under Public Law 99-660 were

approved by NIMH in mid-1990. Compliance monitoring of implementation also will be conducted by

NIMH, and States will be expected to submit

progress reports documenting substantial implementation in September 1991.

The Education for All Handicapped Children Act

For adolescents still in school, the Education for

All Handicapped Children Act (Public Law 94- 142),

has sometimes proven useful in obtaining needed

mental health services. This act requires all public

school systems to provide free and appropriate

education together with ‘‘related services, ’ in the

least restrictive environment, for children and adolescents with physical or mental handicaps. Some

school jurisdictions have interpreted the ‘‘related

services” provision as requiring them to provide

mental health care, while other local educational

authorities have excluded the provision of such care

from their obligations under Public Law 94-142.

Such uneven application of mental health services to

the mental health needs of children and adolescents

has been a cause of concern (205). As noted above,

recent amendments to Public Law 94-142 are

81~)c sub~tmcc ~busc ~omponcnt of tic A~M block grarl[ is fur~cr dl\,ldc(!—3s percent of ~C funds must IX devoted tO alcohol abuse programs,

35 percent must be used for drug abuse programs, and the rcmaimng 30 pcrcen[ may be used in a discretionary manner for the overall substance abuse

prevention and treatment flcld.

R2N1~fH requested states to include thCSC popukitions in ‘iCir P1~s
11-480. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

intended to improve the delivery of special educational and related services to seriously emotionally

disturbed adolescents.

NIMH estimates that Public Law 94-142 provided

$63.6 million in fiscal year 1983 expenditures for

both direct educational and related services (e.g.,

transportation, support, counseling, assessment, diagnostic, and medical services) to mentally ill

children and adolescents (131). An additional $23.5

million was paid to assist previously institutionalized students and for educational support for students in State-operated or -supported mental health

institutions under another related act, the Education

Consolidation and Improvement Act of 1981 (Public

Law 89-313).

Research on Adolescent Mental Health Issues

Three recent studies have evaluated the Federal

commitment to adolescent and child mental health

research and found it wanting.

In 1986, an OTA study on children’s mental

health found that Federal research efforts on child

and adolescent mental health were seriously underfunded (202). OTA’s study recognized that the

Federal Government was virtually the only source of

funds for such research and suggested that children’s

mental disorders was a prime example of an area

with missed research opportunities.

In 1988, at the request of NIMH, the Institute of

Medicine initiated a study of mental, behavioral, and

developmental disorders among children and adolescents. The following year, its report, Research on

Children and Adolescents’ Mental, Behavioral, and

Developmental Disorders, faulted NIMH for failure

to exert leadership in relation to child and adolescent

mental disorders and called for a 5-year plan to

increase NIMH’s funding for child and adolescent

mental health research and research training to $162

million (139).

Following release of the Institute of Medicine’s

study in 1989, Congress asked NIMH to develop a

plan delineating how it would expand basic, clinical,

and services research in the area of children’s mental

health. In 1990, the National Advisory Mental

Health Council of NIMH released its National Plan

for Research on Child and Adolescent Mental

Disorders (213). A conclusion in that document was

that the Nation was “doing far too little to develop

the scientific knowledge needed to treat or prevent’

mental illness among young people (213). After

recounting several recent advances in research, the

document noted that NIMH had not been able to

provide the level of support necessary to sustain and

build upon those advances. The Advisory Mental

Health Council of NIMH expressed particular concern about the dearth of young scientists committing

themselves to research in adolescent and children’s

mental disorders. It recommended a phased increase

in NIMH support for research83 and research training

in adolescent and children’s mental disorders from

a total of $92.3 million in fiscal year 1990 to $283.3

million by fiscal year 1995 (213).84

The Federal Government has become involved

somewhat circuitously in financing adolescent mental health services, in funding and promoting research, and in fostering coordinated service delivery.

Either the activity’s focus has been broader than just

mental health, or adolescents have been beneficiaries of programs serving a larger population (e.g.,

low-income families as in Medicaid, children and

adolescents, all mentally ill individuals). Scant

regard has been paid to the unique developmental

aspects of adolescence which seem to merit a

distinction between adolescent mental health and

either child or adult mental health. While more than

an afterthought, adolescent mental health has not

been a high priority on the Federal agenda.

Conclusions and Policy Implications

Although a national systematic epidemiological

study has not yet been mounted, and definitional

issues persist, recent data suggest that approximately 1 out of 5 U.S. adolescents ages 10 to 18

suffers from a mental health problem severe enough

83~e ~comended ~aeaSe was to ~uppofi bo~ Clfical research ~d se~ices research. clinica/ re$earch is conducted h a C]illkd setting, fOCuSklg

on questions regarding such matters as epidemiology, etiology, or treatment effectiveness. Services research, on the other hand, examines systems issues

like services needs, effective delivery mechanisms, or financing options.

S4~e budgets forc~d ~d adolescent menhl healti recommended by the Institute of Medicine md by the Advisory COmCd of ~~were struc~~

differently aad cannot be directly compared. Nonetheless, the finding level recommended by the Advisory Council represents a signitlcant increase over

the recommended level of funding endorsed by the Institute of Medicine.
Chapter n-Mental Health Problems: Prevention and Services . II-481

to require treatment. About 1 out of 4 U.S. adolescents reports symptoms of emotional distress.85 In

general, the adolescents most likely to be diagnosed

with a mental disorder are male and/or of lower

socioeconomic status. Females are more likely than

males to report subjective distress.

Suicide is perhaps the most severe manifestation

of mental health problems among adolescents, and

the official suicide death rate has more than doubled

for 15- to 19-year-olds since 1968. Trends in

adolescent suicide attempts are not available, but in

1987, 1 out of 7 adolescent 10th graders reported

having attempted suicide. White, American Indian,

and male adolescents are most likely to commit

suicide. Female adolescents are more likely than

males to report suicide attempts,

While between 18 and 22 percent of all adolescents are estimated to need some mental health

treatment, perhaps 6 percent actually receive some

level of care from the mental health system in a

given year, meaning that at least two-thirds to

three-quarters of adolescents who do have--or are

likely to have—a diagnosable mental disorder have

no contact with a mental health provider. This

estimate of the gap between services and need does

not take into account the duration, intensity, appropriateness, or quality of the level of service provided; in addition, it does not include the adolescents

who may not have a diagnosable disorder but maybe

in need of services because they are experiencing

subjective distress.

In addition to attempting to estimate the gap

between mental health service need and availability,

this chapter evaluated the effectiveness of two levels

of prevention of mental health problems among

adolescents: promotion of positive mental health,

and prevention of suicide. In addition, it provided an

overview of the mental health treatment system,

including (to the extent possible) changes over time

in adolescents’ utilization of mental health treatment

services, reasons for the gap between service needs

and availability (including shortcomings in financing of mental health treatment services and lack of

coordination among systems charged with serving

the health and related needs of adolescents), the

effectiveness of mental health treatment for adolescents, and innovative approaches to service delivery.

Finally, it examined the Federal role in enhancing

mental health services for adolescents. The remainder of this chapter draws conclusions about each of

these issues, and notes the policy implications for

each of them.

The Promotion of Mental Health and Prevention

of Mental Health Problems Among Adolescents

Despite a mounting literature on positive mental

health promotion, there remains a need for additional, rigorous scientific research on mental health

risks, appropriate interventions, and program outcomes (both immediate and longitudinal). Additional research is needed on the social competence

model of mental health promotion to assess the

effects of various interventions on children with

different sociodemographic characteristics, adjustment levels, and learnin g styles (225). Nonetheless,

mental health promotion efforts seem a promising

way to help adolescents cope with the changes that

adolescence brings and develop the skills needed for

the future. Mental health promotion efforts may not

involve labeling any adolescent as having a mental

disorder, and, if done well, they can give adolescents

a chance to develop empathy, improve interpersonal

relations, and, perhaps, avoid experiencing untoward distress and serious behavioral problems (92a).

Programs for the prevention of specific mental

disorders have not been adequately assessed either,

although one observer goes even further in criticizing the state of the art in prevention. Shaffer asserts

that there is a consensus among mental health care

providers that primary prevention of mental disorders is not possible in most instances, precisely

because our knowledge of causes and mechanisms

of adolescent mental disorders is so limited (169).

He argues for more epidemiological and longitudinal research to correct the deficit, as well as for

increased attention to early intervention (secondary

prevention) for those adolescents exhibiting early

symptoms of mental health problems.

The effectiveness of suicide prevention efforts is

difficult to evaluate, in large part because the base

rate of completed suicides is low. Thus, the effec851t IS ~clea t. ~~t ~xtent fie ~ropo~lon of adole~~en~ ~h~ ~epo~ ~Wptom of distress overlaps wi~ &e propofiion who are found to have mental

disorders using standard diagnostic criteria.
//-482 . Adolescent Health—Volume //: Background and the Effectiveness of Selected Prevention and Treatment Services

tiveness of suicide prevention efforts is often assessed in terms of gains in knowledge and changes

in attitude. Shaffer’s comments about the difficulty

of primary prevention seem particularly applicable

to suicide, although there may be one exception.

Given that firearms are the leading method for

committing suicide (accounting for half of all

successful adolescent suicides), limiting adolescents’ access to firearms would probably reduce the

number of completed suicides, if not the number of

suicide attempts.

The Delivery of Mental Health Treatment

Services to Adolescents

In considering policy changes directed toward the

mental health treatment system, it is important to

review both recent encouraging developments and

persistent problems in the mental health treatment

system.

A number of gains in the mental health service

system for adolescents in recent years provide a

foundation for future policy changes:

A child and adolescent mental health presence

has been established in almost every State as a

result of CASSP (the Child and Adolescent

Service System Program) of NIMH. This presence has increased awareness of child and

adolescent mental health needs among legislators, service planners, and providers and identified promising approaches to address those

needs.

Models for the provision of comprehensive,

coordinated mental health services to adolescents have been developed in selected parts of

the country (e.g., the Ventura County Project in

California; the Kaleidoscope Program in Chicago; and the Alaska Youth Initiative), demonstrating that community-based, multisystem, public sector efforts are feasible and

apparently promising in terms of effectiveness.

There is a growing, though still incomplete,

research base on the potential effectiveness of

a range of mental health services for adolescents.

There was an across-the-board increase between 1975 and 1986 in the use of mental

health services in organized settings by adolescents. Increases were greatest in the use of

outpatient mental health services such as psychotherapy and partial hospitalization. National data are not available to track growth in

use of other nonresidential services, like homebased services and therapeutic foster care.

Perplexing and persistent problems in mental

health service delivery include the following:

●

●

●

Adolescents who need mental health and related (e.g., social, educational, general health)

services from multiple agencies continue to

suffer in most communities as they are bounced

from one bureaucracy to another, often preceded by a wait to meet eligibility requirements

for services. Interjurisdictional rivalries often

prevent the pooling of resources to enrich the

availability of community-based services and

deter development of a comprehensive and

effective mental health system. The State

Comprehensive Mental Health Services Plan

(Public Law 99-660, as amended) may help

alleviate this problem. That law may provide an

opportunity to identify local resources and

coordinate the array of services used by adolescents with mental health problems and their

families (e.g., intake and assessment, treatment, rehabilitation, crisis intervention, education, housing, recreation).

Even when mental health treatment services are

available for adolescents, some adolescents’

access to those services may be limited because

of their inability to pay for the services. The

lack of health insurance, health insurers’ limitations on mental health benefits, and restrictive

Medicaid policies in some States are all factors

that may limit utilization of mental health

services by adolescents in need.

In 1986, racial and ethnic minority adolescents

received disproportionately fewer inpatient and

outpatient services in specialty mental health

organizations than did white, non-Hispanic

adolescents. Further, racial and ethnic minority

adolescents received fewer services from such

facilities in 1986 than they did in 1975 (relative

to the size of their populations). It is unclear

why this change occurred, but it maybe related

to inadequate Medicaid funding, and the increase in reliance on commercial health insur-
Chapter 11—Mental Health Problems: Prevention and Services . /1-483

●

ance, for such services.86 Lack of ‘ ‘cultural

competency’ in the service delivery system

has also been implicated.

There are apparent shortages of mental health

professionals with expertise in treating adolescents, and such shortages may contribute to the

limited availability of mental health services

for the adolescent population.

The combination of encouraging developments

and persistent problems in the mental health treatment system just cited has a number of implications

for change. To begin to correct the problems of

mental health service delivery will require attention

at Federal, State, and local levels, across systems of

care which serve adolescents, and by the professional organizations of physical and mental health

providers concerned with the adolescent population.

Major implications for change in mental health

services can be grouped in five areas and are

discussed in more detail below:

1.

2.

3.

4.

5.

developing local systems for the delivery of

mental health services,

financing the delivery of mental health treatment services,

use of institutional mental health care,

training for mental health professionals, and

research on services for adolescents with

mental health problems.

Developing Local Systems for the Delivery of

Mental Health Services

If adolescents are to have mental health treatment

services available to them in proportion to their

need, the capacity of local communities to deliver

such services will have to be expanded. Furthermore, achieving a rational and integrated system of

comprehensive care for adolescents will require a

reconfiguration of the mental health service delivery

system. Critical areas for change in the mental health

service delivery system were specified recently by

Knitzer and Yelton:

1) strengthening, systematically, the range of nonresidential services that are available to children and

adolescents and families across systems, 2) anchoring responsibility for individual children (and adolescents) through a cross-agency case-management

system, and 3) creating a new organizational framework to facilitate cross-system decisionmaking and

resource sharing (1 17).

Such changes will require new resources. Federal

and other grants to build mental health system

capacity at the local level should encourage the

development of a continuum of care for mental

health and related problems in those agencies which

are most likely to serve adolescents. Funding should

be flexible so that implementation of individualized

service plans for adolescents with mental health

problems is feasible.

Priority should be given to increasing the availability of the least restrictive forms of treatment that

are appropriate (e.g., home-based crisis services, day

treatment, and therapeutic foster care). Research on

the appropriateness of various levels of care is

essential, so that decisions are not based solely on

insurance status or the physical availability of

mental health services,

Financing the Delivery of Mental Health Services

If State and local governments are to respond to

the need for developmentally appropriate mental

health services for adolescents, funding sources

must allow greater flexibility in the use of funds.

Fragmented and restrictive financing mechanisms

impede the delivery of comprehensive and coordinated mental health and related services. But if

resources could be pooled and redirected to meet

individual treatment needs of adolescents with

mental health problems, funding streams could

provide incentives for interagency linkages and a

more cohesive mental health ‘‘system’ might begin

to emerge. Programs also could more readily be held

accountable for client outcomes, since they would be

better positioned to garner the resources necessary to

do the job they were intended to do.

The challenge for Federal and other policymakers

is to forge funding approaches that respond to

individual treatment needs, rather than continuing to

S6A5 discussed in ch. 18, ‘ ‘Issues in the Delivery of Services to selected Groups of Adolescenki ‘‘ in Vol. III, half of black, Hispanic, and American

Indian and Alaska Native adolescents live in poor or near-poor families and are likely to depend on Medicaid to gain access to health services. Further,

not all poor or near-poor adolescents are eligible for Medicaid, and Medicaid coverage of mental health services is even more restricted than that for

services related to ‘‘physical ‘‘ illnesses and conditions (see above and ch, 16, ‘ ‘Financial Access to Health Semices,’ in Vol. III).
II-404 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

finance services tied to specific delivery sites (e.g.,

hospitals, residential treatment centers, day treatment programs, community mental health centers).

When the individual is the focal point of service

financing, jurisdictional barriers can be crossed and

interagency coordination and cooperation becomes

a necessity.

Examples of some models of mental health

service delivery that allow flexible funding already

exist. These examples illustrate that the seemingly

daunting task of relaxing fiscal constraints on

programs can be overcome. In the Alaska Youth

Initiative, for example, funds previously used for

residential treatment center placements were redirected toward development of community programs

for the same adolescents. Some private insurance

companies are beginning to experiment with individualized mental health treatment plans that are not

restricted by the usual outpatient benefit limits.

These plans permit reimbursement for communitybased alternatives when it becomes clear (on a

case-by-case basis) that institutional care would be

more expensive.

87 Similarly, Medicaid allows States

to apply for a waiver to use funds for innovative

community services. Only Vermont has taken advantage of this option however, and its impact has

not been evaluated.88

In the long term, Federal and other policymakers

should probably develop more durable and welldelineated policies to finance mental health services

in communities. In the public sector, these policies

might involve: 1) sharing resources across agencies

(e.g., social services departments could reimburse

the mental health system for in-State or community

care); 2) use of State Medicaid matching funds to

promote coordination across agencies; 3) more

creative and extensive use of the Medicaid Home

and Community Care option, which could substantially increase reimbursement for community-based

services; and 4) creative use of EPSDT Federal

regulations to correct the significant inequities in

coverage of mental health services by Medicaid

across States. Insurance companies may have to be

convinced with cost-effectiveness studies that the

range of community interventions being advocated

is both viable and effective.

Use of Institutional Mental Health Care

The third major policy area, concern about

extensive use of private psychiatric hospitals and

residential care for adolescents, requires careful

attention, although the Federal role in this area has

been limited. NMHA has proposed a number of

recommendations directed at reducing excessive use

of mental hospitals and residential treatment centers

for children (see box 1 l-D).

Hospitals and residential treatment centers provide an important component of care for severely

mentally disturbed adolescents, albeit on the extreme end of the continuum. Explicit criteria for the

most restrictive and expensive forms of treatment

need to be developed. The Federal Government

could support efforts to develop such criteria.

Resolving the issue of appropriate use of general

hospitals, psychiatric hospitals, and residential treatment centers vs. less restrictive levels of care for

adolescents with mental health problems is likely to

require major public/private sector negotiation. Private psychiatric hospitals-major providers of inpatient adolescent care-tend not to serve public

Medicaid patients. These hospitals are more likely to

offer comprehensive care than general hospitals,

however, and, in some communities, they have more

extensive resources than the public mental health

agencies. An area to explore is whether some of

these well-established hospitals could be interested

in providing comprehensive care for a broader

socioeconomic range of adolescent patients (as is

currently occurring at Sheppard Pratt Hospital in

Baltimore through a contract with the State of

Maryland) (39). Residential treatment centers, mostly

private, nonprofit organizations, are reimbursed

largely under governmental contracts with public

dollars. Possibly residential treatment centers could

offer a broader range of mental health services to

local populations in the areas where they are located.

Training for Mental Health Professionals

Although comprehensive data on the numbers of

mental health professionals trained to work with

adolescents are not available, the difficulties encountered in filling clinical positions (39) and with the

data that are available make it clear that there are

shortages. If adolescents are to receive mental health

87s& ~h. 16, $ ‘Fi~cial Access to Health Services, ’ ~ VO1. IH.

sasee ch. 16, ‘‘Fi~ci~ Access to Health Semices, ’ in VO1. ~.
Chapter n-Mental Health Problems: Prevention and Services . II-485

Box n-D-The National Mental Health

Association’s Recommendations To Limit

Use of Inpatient Mental Health Care

1. Create community-based mental health services.

2. Develop a child-centered and family-focused

system of mental health services.

3. Adopt a children’s Bill of Rights (to protect

against inappropriate placements).

4. Plan to return children home (applies to children placed out of State).

5. Prohibit placements outside of the State’s

jurisdiction.

6. Prohibit treatment of children in adult wards of

State hospitals.

7. Establish a gatekeeping system (i.e., local case

review committees to prevent out-of-home

placement unless there is no alternative).

8. Fully implement Public Law 94-142 (Education for All Handicapped Children Act).

9. Improve State monitoring.

10. Provide case management from the child’s

perspective.

11. Expand advocacy.

12. Mandate interagency planning.

13. Permit flexible use of funds.

14. Improve or repeal interstate compacts.

15. Improve data collection (refers to improving

data systems on services for children with

emotional problems).

16. Conduct a national study to determine the

status of children in private psychiatric facilities.

SOURCE: National Mental Health Association Report of the

Invisible ChiZdren Project (Washington DC: 1989).

services, a sufficient number of mental health

professionals must be recruited into the child and

adolescent mental health field and encouraged to

locate throughout the Nation. NIMH funding for

clinical training has diminished over the years. One

possibility is for States to assume a more significant

role in training clinicians to work with adolescents

and their families. Another possibility is for NIMH

to increase its funding for clinical training (127a).

Continuing education to promote clinicians’ awareness of innovations and successful models of service

delivery would also be useful.

Finally, as new policies for mental health services

are deliberated, sensitivity to the needs of different

cultural, ethnic, and racial groups needs to be a

priority. Designing services that are more responsive

to minorities may be a community-level issue, but

the recruitment and training of minority clinicians

and the development of appropriate knowledge

bases pertaining to adolescents, have implications at

the State and national level. A recent volume

describing the consensus about provision of mental

health services to minority children and adolescents

with mental illness delineates a number of useful

guiding principles (53,204), but as discussed more

fully in chapter 18, “Issues in the Delivery of

Services to Selected Groups of Adolescents, ” in

Vol. III of this Report, much more research needs to

be done on this topic.

Research on Services for Adolescents With

Mental Health Problems

Research on services for adolescents with mental

health problems has lagged behind research on such

services for adults. Ideally, service systems for

mental health problems should be designed on the

basis of clear conceptions about disorders (including

definition, etiology, course, and prognosis) and

knowledge about the efficacy of treatment for

specific disorders and populations. But controversy

surrounds both the diagnosis of adolescent mental

health problems and their treatment. Thus, there are

research deficits in epidemiological data, clinical

information, and services data.

Although the existing knowledge base offers

some general guidance to mental health providers

and policymakers, more precise guidance on the

types of treatment to be offered cannot be offered

without significant research advances. The unavoidable need for service systems development requires

that research on service systems proceed at the same

time that the epidemiological and clinical research

base continues to mature. Findings will have to be

incorporated into policy developments and into

research on service systems on an incremental basis.

The following implications for research touch

briefly on epidemiological and clinical research that

is directly relevant to mental health service systems

development. A more comprehensive research agenda

addressing these areas can be found in the 1989

Institute of Medicine and the NIMH Advisory

Mental Health Council reports on research pertaining to children and adolescents with mental, behavioral, and developmental disorders (139,213). Both

reports recommended significant increases in Federal support for research on mental health services
II-486 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

and systems of care for children and adolescents, and

even larger amounts for other types of research on

the mental health problems of children and adolescents (139).

Research is needed to accomplish the following

tasks:

1. Develop estimates of adolescents’ need for

mental health services based on epidemiological

surveys. At all levels of care, the utilization of

mental health services by adolescents is increasing.

Despite increases in service use, the low rate of

mental health service use relative to need represents

a significant concern. While an estimated 20 percent

of U.S. adolescents need mental health services,

only about 6 percent of adolescents use such

services. The possibility that a number of adolescents are receiving mental health care through

sectors other than the mental health system (i.e.,

health, education, social services, and juvenile

justice) needs to be examined in studies at the

national, State, and local levels to more accurately

assess the availability of mental health services. The

low rates of mental health service use by adolescents

also suggest a need to study the perceived accessibility of services to adolescents from the perspectives

of cost and comfort with seeking care.

Estimating adolescents’ need for mental health

care will require going beyond the usual approach of

identifying the gap between adolescents with a

mental health condition and those actually receiving

services. The need for treatment must be related to

specific system components and defined in terms of

severity of illness, level of functioning, family

concerns, community attitudes, and capacity. For

that reason, the inclusion of such parameters in the

forthcoming child and adolescent epidemiology

catchment area studies will be important.

2. Evaluate the effectiveness of various mental

health treatment modalities for adolescents. Given

the very limited and poorly controlled research

literature on the effectiveness of mental health

treatment modalities for adolescents, research is

needed on all levels of care and all types of services.

An initial priority for a research agenda should be

to carefully delineate the characteristics of adolescents who require and benefit from inpatient and

residential settings. Research on the more restrictive

and expensive forms of treatment needs to be

balanced with research on innovative and less

expensive forms of care. Future studies on the

effectiveness of psychotherapy, psychotropic medication, and other outpatient services should give

special attention to low-income and minority populations and should pay attention to specific clinical

conditions and comorbidities (particularly substance

abuse and other mental disorders). A major initiative

could be designed to assess the effectiveness of

different treatment modalities for adolescents with

conduct disorders, as this is a frequently identified

clinical population across levels of care and in

school-supported programs for emotionally disturbed children and adolescents (71). Research on

psychotropic medications requires larger adolescent

samples and longer followup periods than are

typically used. In addition, the appropriate modes of

treatment for subclinical problems that are disturbing to adolescents, but that may not meet the criteria

for diagnosable disorder, deserve attention.

In planning studies of the effectiveness of mental

health treatment for adolescents, it is important to

give methodological issues critical attention. Research on treatment modalities should be of experimental or quasi-experimental designs. Studies with

random assignment of subjects are preferable, but if

randomized studies are not feasible, researchers

should find acceptable comparison groups. To be

useful in assessing treatment effectiveness, studies

should be longitudinal, assess combinations of

treatments, and pay special attention to reliable and

valid outcome measures. With sound information

about effectiveness, the next level of studies can be

considered.

3. Assess the potential for substitution of communitybased mental health treatment services for restrictive institutional services. This undertaking seems

warranted because of observations that institutional

care may be overutilized for adolescents with mental

health problems and that the great majority of

service dollars are tied up in hospitals and residential

treatment settings. Some of these restrictive institutional services may neither be required nor effective

(at least for selected clinical groups), but these issues

ought to be very carefully examined. Alternative

service strategies should be in place before research

to test substitution of services is undertaken.

4. Develop criteria for quality mental health

treatment of adolescents. An initial step may be to

obtain descriptive data on the characteristics of

clients and clinical practices at each level of mental
Chapter n-Mental Health Problems: Prevention and Services //-487

health care. This would provide a basis for consensus groups to propose criteria or standards for care

that would define quality. A subsequent critical step

would be to explore and identify linkages between

clinical processes and client outcomes to be sure that

quality care does in fact result in positive outcomes.

5. Determine effective mental health service

system design and development. Comprehensive

service models using a continuum of care have been

reviewed (e.g., the Ventura County Project California, the Alaska Youth Initiative), and additional

research is underway. Further research opportunities

to compare approaches to organizing services will

emerge as the child and adolescent demonstrations

recently funded by the Robert Wood Johnson

Foundation get underway. In order to be most useful,

organizational models need to be clearly described,

fully tested, and replicated for their differential

ability to affect rates of service use by target

populations, quality of care, cost, and clinical

outcomes.

To determine whether increased availability and

provision of mental health services actually results

from capacity-building policy changes, the relationship between policy change and service system

capacity needs to be critically examined (186a).

There is also a need to evaluate service system

performance to assess whether clients who are the

most in need receive services in ways that meet their

needs. The usefulness of case management as a

systems level intervention also requires specific

attention. Case managers, particularly for seriously

emotionally disturbed youth, are being employed

across the country, but OTA is not aware of any

published research on their effectiveness with adolescent clients.

Finally, research on the extent, adequacy, and

appropriateness of mental health services for adolescents provided in sectors other than the mental

health system—primary health care, juvenile justice, social welfare, and the schools—should be

expanded in order to develop a complete picture of

adolescents’ access to appropriate and effective

mental health services. Currently, the lack of complete information may lead to diffusion of responsibility-a sense that the adolescent ‘‘must be’

receiving care in some other system. Areas for

investigation range from the adequacy of diagnosis

and the appropriateness of treatment provided in

these sectors to the mechanisms available for

coordinating care with the traditional mental health

system.

6. Evaluate alternative methods for financing

mental health services for adolescents. In order to

improve access for adolescents, techniques ranging

from varying insurance benefits to creating fiscal

incentives for improving community care, should be

explored to identify financing methods that facilitate

implementation and operation of a continuum of

care. Further, financing mechanisms that influence

utilization of mental health services (such as managed care with a network of contracted providers v.

a fee-for-service system) need further attention to

determine their impact on adolescent client groups.

7. Strengthen recruitment and training of researchers in adolescent mental health. In order to

eventually improve the system of care for adolescents, NIMH should continue to be encouraged to

support the recruitment and training of mental health

professionals prepared to conduct research on adolescent disorders, treatment, and services. This need

was reflected as a priority in the 1989 Institute of

Medicine report on research (139).

Summary of Federal Policy Implications

Although mental health policy and program

changes can be made in both the private and public

sectors, and at many levels of both sectors, the

Federal Government could take several steps to

improve adolescent mental health.

In order to make mental health services available

for more adolescents, the Federal Government could

support efforts to make health insurance more

available for mental health problems. One way to do

this would be to mandate changes in Medicaid rules

pertaining to mental health services. In order to be

consistent with the goal of providing care in the least

restrictive environment, any such changes could

favor outpatient and other nonresidential forms of

care over inpatient care.

To the extent that insurance reimbursement depends on the existence of a diagnosable mental

disorder, adolescents’ subjective distress may be

overlooked. In addition, the approachability of

mental health services for adolescents may be

reduced by insurance requirements for parental
II-488 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

consent or notification.89 In order to increase access

to mental health services for adolescents—based on

their subjectively perceived needs—the Federal

Government could support the increased availability

of mental health services for adolescents in accessible settings such as schools.90

One factor that impedes efforts to increase availability of mental health services to adolescents is the

paucity of mental health professionals specially

trained to deal with adolescents. The Federal Government could support a major clinical training

effort to increase the number of mental health

professionals trained to work with adolescents.

A second factor holding back a major effort to

increase mental health services for adolescents is the

paucity of research on the full range of issues related

to adolescent mental health, including epidemiology,

risk and protective factors, prevention, treatment,

and service systems. As recommended by the

Institute of Medicine and the NIMH’s National

Advisory Mental Health Council, Federal funds for

mental health research and research training need to

be increased dramatically for the foreseeable future

(139,213). Because the appropriateness and effectiveness of inpatient and residential treatment for

adolescents is so controversial an issue, objective,

scientific research on the topic requires particular

attention.

Much of the Federal Government’s attention to

mental health issues—for all ages combined—

pertains to serious mental disorders. This focus may

not be appropriate for adolescents, many of whom

may require help in learning how to deal with normal

life circumstances (e.g., 92a) and/or suffer from

subjective distress. In order to be responsive to the

needs of adolescents as a group, the Federal Government could initiate efforts to support: 1) the promotion of positive mental health (for all adolescents);

and 2) early treatment intervention for those adolescents at high risk for problems, as evidenced by their

subjective distress, their troubled behavior [which

may not meet the criteria of DSM-III-R], or their life

circumstances. Research efforts are needed to substantiate the most effective ways of meeting these

adolescent needs, although more progress has been

made in the area of mental health promotion. In sum,

a much more active effort is needed on the part of the

Federal Government if adolescents’ mental health

needs are to be met.

Specific options for congressional consideration

are listed in Vol. I of this Report, Summary and

Policy Options.

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Youth Suicide, Volume 4: Strategies for the Prevention of Youth

Suicide, AlcohoL Drug Abuse, and Mental Health Administration% Public Health Service, Department of Health and Human

Semices, DHHS Pub. No. (ADM) 89-1624 (Washington DC:

U.S. Government Printing Office, 1989).

Zill, N,, and SchoenboW C.A., ‘‘Developmental, harning, and

Emotional Problems,” Advance Data From Vital and Health

Statistics of the National Center for Health Statistics, No. 190,

National Center for Health Statistics, Centers for Disease

Control, Public Health Service, U.S. Department of Health and

Human Services, Hyattsville, MD, Nov. 16, 1990.
Chapter 12

ALCOHOL, TOBACCO, AND

DRUG ABUSE: PREVENTION

AND SERVICES

Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .499

Background on Psychoactive Substance Use and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .499

Definitions of Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .499

Trends in the Use of Psychoactive Substance Use by U.S. Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505

Sources of Data on the Incidence and Prevalence of Psychoactive Substance Use . . . . . . . . . . . . . . . . . . 505

Current Estimates of the Prevalence of Psychoactive Substance Use Among U.S. Adolescents

Based on Self-Report Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508

Estimates of the Prevalence of Psychoactive Substance Use Resulting in Death or the Need for

Emergency Medical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514

Arrests as an Indicator of Psychoactive Substance Use and Substance Use Problems . . . . . . . . . . . . . . . 516

Demographic Differences in Psychoactive Substance Use by Adolescents . . . . . . . . . . . . . . . . . . . . . . . . 517

Recent Trends in the Use of Psychoactive Substances by U.S. Adolescents . . . . . . . . . . . . . . . . . . . . . . . 519

Summary of Data on the Use of Psychoactive Substances by U.S. Adolescents . . . . . . . . . . . . . . . . . . . . 520

Factors Associated With Psychoactive Substance Use and Abuse by Adolescents . . . . . . . . . . . . . . . . . . . . 520

Methodological Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520

Family Factors Associated With Psychoactive Substance Use by Adolescents . . . . . . . . . . . . . . . . . . . . . 522

Peer-Related Factors Associated With Psychoactive Substance Use by Adolescents . . . . . . . . . . . . . . . . 524

Personal Characteristics of Adolescent Substance Users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .525

Relationship Between Mental Health Problems and Use of Psychoactive Substances by Adolescents . . 526

School, Work, and Societal Impacts on Psychoactive Substance Use by Adolescents . . . . . . . . . . . . . . . 526

Appetitive Effects of Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .527

Factors Associated With Adolescents’ Use of Alcohol and Cigarettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527

Summary: Factors Associated With Psychoactive Substance Use and Abuse by Adolescents . . . . . . . . . 528

Consequences of Psychoactive Substance Use by Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528

Physical Health Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529

Mental Health Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .530

Educational Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530

Employment-Related Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530

Sexual Activity, Pregnancy, and Pregnancy Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531

Marriage and Divorce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531

Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532

What Level of Psychoactive Substance Use Is Harmful to Adolescents? . . . . . . . . . . . . . . . . . . . . . . . . . . 532

Economic Costs of Drug Abuse by Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533

Prevention of Alcohol, Tobacco, and Drug Use and Abuse by Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534

Demand Side Prevention Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534

Historical Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .534

Categorizing Contemporary Demand Side Prevention Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534

Effectiveness of Demand Side Substance Use Prevention Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536

Selected Supply Side Substance Use Prevention Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 542

Conclusions About the Effectiveness of Prevention of Psychoactive Substance Use . . . . . . . . . . . . . . . . . . 544
Substance Abuse Treatment Services for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .544

Self-Help Groups for Substance Abusers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547

Outpatient Substance Abuse Treatment Programs for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549

Residential Substance Abuse Treatment Programs for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549

Inpatient Substance Abuse Treatment Programs for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .550

Issues Related to Substance Abuse Treatment for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .551

Methodological Issues in Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551

Client Characteristics Related to the Effectiveness of Substance Abuse Treatment . . . . . . . . . . . . . . . . . . 551

program Characteristics Related to the Effectiveness of Substance Abuse Treatment . . . . . . . . . . . . . . . 552

The Economics of Substance Abuse Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .552

Utilization of Substance Abuse Treatment by Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553

Assessment and Referral of Adolescents With Substance Abuse Problems . . . . . . . . . . . . . . . . . . . . . . . . 553

Standards for Placement of Adolescents With Substance Abuse Problems . . . . . . . . . . . . . . . . . . . . . . . . 556

Staffing of Substance Abuse Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .557

Conclusions About Substance Abuse Treatment Services for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . 558

Major Federal Policies and Programs Related to the Use and Abuse of Psychoactive Substances

by Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .559

Specific Federal Agencies and Their Roles in Substance Abuse Prevention and Treatment for Adolescents. 560

U.S. Department of Health and Human Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .560

U.S. Department of Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563

Other Federal Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563

Issues in Federal Programs and Policies Related to the Use and Abuse of Psychoactive Substances . . . . . 564

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565

Is Prevention Effective? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .565

What About Treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565

Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .567

Chapter 12 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567

Boxes

Box Page

12-A. Overview of Alcohol and Some Other Psychoactive Substances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .500

12-B. What Constitutes Substance Abuse by Adolescents? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503

12-C. Problems With Access to Substance Abuse Treatment Services in a Large Metropolitan &a.. . . . . . 554

Figures

Figure Page

12-1. Use of Alcohol in the United States, by Age, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513

12-2. Use of Cigarettes in the United States, by Age, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .513

12-3. Use of Any Illicit Drug in the United States, by Age, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .514

12-4. Use of Any Illicit Drug by U.S. High School Seniors, 1975 -89 . . . . . . . . . . . . . ................... 519

12-5. Use of Cocaine by U.S. High School Seniors, 1975-89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520

12-6. Factors That May Influence Alcohol, Tobacco, and Other Drug Use by Adolescents . . . . . . . . . . . . . . . 523

Tables

Table Page

12-1. Percentage of Surveyed U.S. Adolescents of Different Ages Reporting Ever

Having Used Alcohol or Other Types of Psychoactive Substances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509

12-2. Percentage of U.S. Adolescent Students in Selected Cities and States Reporting Ever

Having Used Drugs Intravenously, by Sex, Age Group, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 510

12-3. Current Estimates of Heavy Use of Alcohol Among U.S. Adolescent Students . . . . . . . . . . . . . . . . . . . 510

12-4. Current Estimates of Heavy Cigarette Smoking Among U.S. Adolescent Students . . . . . . . . . . . . . . . 511

12-5. Summary of Daily Use of Alcohol, Tobacco, and Illicit Drugs by U.S. Adolescent Students of

Various Ages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512

12-6. DAWN Emergency Room Drug Use by Patients Ages 6 to 17 Years of Age, 1987...............515

12-7. Arrestt Rates for Drug Abuse Violations in the United States, by Age and Sex, 1965-88 ..• ● . . . . . . . 516

12-8. Trends in the 30-Day Prevalence of Daily Use of 18 Types of Drugs Among High School Seniors,

1975 -89 . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .521

12-9. Overview of Selected Substance Abuse Prevention Programs . . . . . . . . . . . . . . . . . . . . . . . . . . ........ 537

12-10. Summary of Reviews of Evaluation Literature on Demand Side Substance Use

Prevention Programs for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545

12-11. Overview of Substance Abuse Treatment Services for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548
Chapter 12

ALCOHOL, TOBACCO, AND DRUG ABUSE:

PREVENTION AND SERVICES

Introduction

The use and abuse of alcohol, tobacco, and illicit

drugs are currently of great concern to the American

public (106,310,312). The abuse of alcohol and

other psychoactive (mind-altering) substances is

often seen as particularly dangerous for adolescents

because it can interfere with the ‘‘developmental

tasks’ of adolescence.1 2

Box 12-A provides a general overview of alcohol

and other major classes of psychoactive substances

with the potential for abuse and/or dependence. The

effects of psychoactive substances vary, depending

on the specific substance used, on the quantity,

frequency, and duration of use, on users’ expectations, on the mode of administration, and on whether

other substances are used simultaneously (147, 156).

It is beyond the scope of this chapter to delineate all

of the possible effects of psychoactive substances.

As discussed later, very little is known about the

specific effects of psychoactive substances on adolescents.

This chapter discusses definitions of substance

abuse and reviews available evidence on the use of

alcohol, tobacco, and other psychoactive substances

among U.S. adolescents. The chapter then examines

family, peer related, personal, and other risk factors

associated with the initiation and continuation of

psychoactive substance use; the consequences of

psychoactive substance use and abuse for adolescents; and the economic costs to society. It next

considers the effectiveness of preventive and treatment interventions. The chapter concludes with a

consideration of issues pertaining to relevant Federal programs and policies.

Background on Psychoactive Substance

Use and Abuse

Definitions of Substance Abuse

There is considerable controversy about what

constitutes substance abuse among adolescents (see

box 12-B). Some would maintain that any use of

alcohol and other drugs by an adolescent should be

considered substance abuse. Others suggest that

experimentation —particularly with such psychoactive substances as alcohol or tobacco that are

available for purchase by adults of legal age—is part

of normal late adolescent development and does not

necessarily have harmful consequences (26,208 ,252,

263).3 The Alcohol, Drug Abuse, and Mental Health

Administration (ADAMHA) within the U.S. Department of Health and Human Services (DHHS) has

expressed the view—through its Office for Substance Abuse Prevention (OSAP)---that any drug

use by adolescents should be prevented (311).

Another ADAMHA agency, the National Institute

on Drug Abuse (NIDA), has defined drug abuse in

other ways (302,303). The American Psychiatric

Association, using clinical criteria specified in the

Diagnostic and Statistical Manual of Mental Disorders, 3rd cd., revised (DSM-III-R), draws distinctions between psychoactive substance use, abuse,

and dependence, with dependence being more serious than abuse (see box 12-B). The criteria in

DSM-III-R make no distinctions between adults and

adolescents (4).

In the discussion that follows, except where

otherwise noted, the term ‘‘psychoactive substance

use’ includes the entire range of experience with a

psychoactive substance-from a single exposure to

prolonged and habitual use. The term ‘psychoactive

substance abuse’ is used whenever a more limited

meaning (i.e., use that results in injury, incapacity,

l~is chapter USCS the general term psychoactive substance to cover alcohol, nicotine (found in tobacco), ad illicit drugs (e.g., heroin, co~~e,

marijuana). Strictly speaking, all of these substances are drugs (i.e., chemical or biological substances that can be used to affect the structure or function

of the body). However, the term drug is sometimes used to refer specifically to illicit drugs.

ZFor a djs~ussion of some of the developmental tasks faced by adolescents, s~ ch. *> “What Is Adolescent Health?’ in this volume.

JHowever, it should & noted hat most researchers now ~lieve that the use of psychoactive substances in childhood or in the f~st Years of adolescence

is not normal and may be predictive of serious behavioral problems in later adolescence (263).

-II-499
11-500. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 12-A-Overview of Alcohol and Some Other Psychoactive Substances

Class of psychoactive substance Description Examples

ALCOHOL (ethyl alcohol)

SEDATIVES, HYPNOTICS, OR

ANXIOLYTICS

CANNABIS (THC)

NICOTINE (active ingredient

in tobacco)

Alcohol, one of the most widely used of ail

drugs, is a central nervous system depressant with effects similar to those of sedativehypnotic compounds (see below). At low

doses, alcohol maybe associated with behavioral excitation thought to be due to the

depression of inhibitory neurons in the brain.

Alcohol differs from sedative-hypnotic compounds in that is used primarily for recreational or social rather than medical purposes.

sedative-hypotics are drugs of diverse chemical structure that exert a nonselective general depressant action on the central nervous

system. In addition, they reduce metabolism

in a variety of tissues in the body, depressing

any system that uses energy. Depending on

the dose, any sedative-hypnotic compound

may be classified as a sedative (an agent

that allays excitement), a tranquilizer (an

antianxiety agent), a hypnotic (a sleepincluding agent), or an anesthetic (an agent

that eliminates pain). Sedative-hypnotics are

used medically as sedatives, anxiolytics (antianxiety agents), hypnotics, antiepileptics,

muscle relaxants, and general anesthetics.

THC (tetrahydrocannabinol), the active agent

in marijuana, alters perceptions, concentration, emotions, and behavior, though the

mechanisms of action are not entirely dear.

Researchers have found, however, that THC

changes the way in which sensory information is processed by the brain. it can be used

medically to relieve nausea and side effects

of chemotherapy in cancer patients; it is very

rarely used to treat glaucoma.

Nicotine, obtained naturally from tobacco, is

a central nervous system stimulant.c it exerts

its action secondary to stimulation of certain

cholinergic (excitatory) synapses both within

the brain and in the peripheral nervous

system.

1. Beer

2. Wine

3. “Hard” liquor (e.g., whiskey, gin).

1. Cigarettes

2. Smokeless tobacco (i.e., snuff or chewing

tobacco)

aA_~in* t~Julien, one ~uld~nc~vab~classify psy~o~tive dregs by at leastthr~ methods: 1 ) m~hani~ of action, 2) chemical StrUCtUr@, and

3) behavioral effects. Probabty the most useful approach would be to classify them by mechanism of action, but knowtedge of the brain’s physiology

istoo limited forthis approach to be comprehensive. A limitation of the second approach is that many drugs of apparently similar structure exert quite

different effeots, andmanydrugsofdissimilar structure exertquitesimilar effects. The classification inthistable Iargelyreflectsthe behavioral effects

approach, The classification used here is based on the categories in the American Psychiatric Association’s Diagnostic and Statisfkxd Manual of

Menfa/Disordsrs, 3rd cd., revised. According to the American Psychiatric Association, ali of the classes of psychoactive substances listed in this box

except niootine are assodated with both abuse and dependence. Nicotine is associated with dependence but not abuse.

bThe ~tential physiologi~l, psy~olq~l, and ~~~oral eff~ts of using the psy~o~tive substa~es shown are discussed in the sources !]stSd

below. The consequences depend in part on the speoific drug used, the dosage level and mode of administration.

C~~ “~wssystem @/~u/a~~ are drugs that can elevate mood, increase alertness, reduce fatigue, provide a sense Of in~~Sd ene~y,

decrease appetite, and improvetaskperformance. Theycan alsoproduca anxiety, insomnia, and irritability. Thedrugsdiffer widely in their mobcular

structures and mechanisms of action.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-501

COCAINE Cocaine, obtained naturally from coca 1. Cocaine hydrochloride powder (“coke” or

leaves, is a potent central nervous system “street cocaine’ ’)-usually snorted or instimulant. c It stimulates the sympathetic nerv- jected intravenouslyd

ous system, which regulates the activity of 2. Cocaine alkaloid (“freebase’’ or’’crack”)-

cardiac muscle, smooth muscle, and glands. smokede

It also produces bronchodilation in the lungs.

It is used medically as a topical anesthetic for

surgical procedures.

AMPHETAMINES AND RELATED

STIMULANTSf

1. Amphetamines Amphetamines are a group of three closely 1. Amphetamine (“speed” or “uppers”)

related compounds, all of which are potent [Benzedrine R

]--taken orally, injected, or

central nervous system and behavioral stim- snorted

ulants. c Some amphetamines are used rnedi- 2. Methamphetamine (“speed” or “crystal

cally to treat attention deficit disorder or meth” or “ice”) [MethadrineR

]--taken orally,

minimal brain dysfunction in children, narco- injected, or snortedg h

Iepsy (recurrent, uncontrollable, brief epi- 3. Dextroamphetamine [DexedrineR

]--taken

sodes of sleep), or (rarely) depression. orally, or injected

2. Nonamphetamine stimulants Like amphetamines, nonamphetamine stimu- 1. Pheumetrazine hydrochloride [PreludinR

]--

Iants are central nervous system and behav- taken orally or injected

ioral stimulants. Some nonamphetamine stirn- 2. Methylphenidate hydrochloride [RitafinR

]

ulants (e.g., PreIudinR

) are used for weight taken orally or injectedd

control, and some (e.g., RitalinR and CylertR) 3. Pemoline ICylertR

]--taken orally

are used medically to treat hyperactivit y,

minimal brain dysfunction, narcolepsy, or

(rarely) depression.

HALLUCINOGENS Hallucinogens, or psychedelics, area hetero- 1. LSD (lysergic acid diethylamide) or’’acid”-

geneous group of compounds that affect a taken orally, put in the eyes

person’s perceptions, sensations, thinking, 2. Mescaline (3,4,5-trimethyloxphenylethylself-awareness, and emotions.’ amide) or “mesc,” and peyote--disks

chewed, swallowed or smoked; tablets

taken orally

3. Psilocybin (“magic mushrooms”)-

chewed and swallowed

4. MDMA (methylene dioxymethamphetamine)-taken orally

dAc~rding the Amerimn Psychiatric Association, the route of administration of a psychoactive SUbStanCO is an important variable in determining

whether use will Ieadtodependence or abuse. In general, routes of administration that produce more efficient absorption of the substance in the blood

stream (e.g., intravenous injection) tend to incxease the likelihood of an escalating pattern of substance uses that leads to dependence. Routes that

quickly deliver psychoactive substances to the brain (e.g., smoking or intravenous injection) are associated with higher levels of consumption and

with an increased likelihood of toxic effects. Use of contaminated needles for intravenous administration of amphetamines, cocaine, and opiates can

cause hepatitis, HIV infection, and other illnesses.

eFr~~~e Cm.ne is a form of ~.ne made by ~nverting “str~t~ine”(mine hydrochi~de) to a purified base that is smoked. The effect of

smoking freebase is similar to that of intravenous injection but smoking provides a shorter more intense high than sniffing or ingestion because of

the rapid absorption of the drug through the lungs. “Crackcocaine” is the street namegiventofreebasa~” nethat has been processed from cocaine

hydrochloride to a chemical base by cooking it with baking soda and water. The term crack refers to the cxacking sound that is heard when them ixture

is smoked (heated), presumably due to the sodium bicarbonate.

fDe~fibing a drug as a stimulant does not adequately descri~ its properties. Drug use surveys typi~]ly mean amphetmirres when they USO the wOrd

stimulants. Some surveys regard as stimulants both prescription (amphetamines) and nonprescription substances (e.g., Caffein-based compounds

used in NODOZ, diet pills, and “fake pep pills”). Cocaine and nicotine (described above) are also central nervous system stimulants.

9According to the National Institute on Drug Abuse, designerdrugs are structural analogs of substances scheduled under the Cmtrollad Substances

Act that are prepared by underground chemists to mimic the psychoactive effects of controlled substances or produce other psyboactive effects.

Because such analogs are not identical to their parent compound, their manufacture and distribution does not violate the law. As of June 1986, there

were synthetic analogs of PCP, fentanyl and meperidine, and amphetamine and methamphetamine.

hln the past, abuse of methamphetamine had been in the form of tablets or intravenous injection. More rOCent!Y, “ice” (one of the more ~mmon‘treet

names for c%methamphetamine hydrochloride) has gained popularity in a form suitable for smoking.

iMost the agents indu&d in this class of dregs can indu~ hallucinations if the dose is high enough. But the term hallucinogen d09SIIOt d~llatdy

describe the range of pharmacological actions of the diverse group of substances usually Included in the class. The term psychedelic was proposed

by Osmond in 1957 to imply that these agents all have the ability to alter sensory perception and thus may reconsidered “mind expanding.” The effects

of hallucinogens are unpredictable and depend on the amount taken, the user’s personality, mood and expectations, and the surroundings in wh”~h

the drug is used.

Continued on next page
11-502 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

dysfunctionality, destruction, or danger to self or minimum age for the legal sale/purchase of cigaothers) is intended. rettes (which contain nicotine) varies by State (315).

As of June 1990, 17-year-olds could buy cigarettes

Some substances associated with abuse or depend- in four States (315). Inhalants such as airplane glue,

ence—notably beverage alcohol and tobacco-are paint thinner, typing correction fluid, and gasoline

legally available in this country, but only to individ- are generally legally available for purchase to

uals over a certain age. The minimum age for the individuals of all ages,

4 but not for the purpose of

legal sale/purchase of beverage alcohol in all States inducing intoxication (183). In the United States, a

and the District of Columbia is 21 (290). The legal number of substances associated with abuse or

4Some StateS ~d ~~cip~tieS ~ve en~ted res~ctions on me provision of tiese subst~ces to minors below statutofiy defined ages ( 159).
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services ● II-503

Box 12-B—What Constitutes Substance Abuse by Adolescents?

For the purpose of this chapter, the term drug or psychoactive substance use, unless otherwise noted, means

drug use (including alcohol or tobacco use) that results in injury, incapacity, dysfunctionality, or destruction or

damage to self and others. It is important to note, however that what constitutes drug or psychoactive substance

abuse among adolescents—arty use at all or ‘‘problem use"—is a matter of controversy. As noted below, the U.S.

Department of Health and Human Service’s Office for Substance Abuse Prevention (OSAP) is of the view that any

use is abuse. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 3rd

cd., revised (DSM-III-R), draws distinctions between substance use, substance abuse, and substance dependence.l

office for Substance Abuse Prevention

OSAP’s view is that any drug use, including alcohol use, by those under 21 is to be prevented (310).

National Institute on Drug Abuse

In discussing the results of its 1988 Household Survey on Drug Abuse, NIDA argued that frequency of drug

use in the last year might be the most appropriate indicator of drug abuse (303). A separate definition of abuse among

adolescents was not offered.

For the purpose of emergency rooms and medical examiners reporting to MDA’s Drug Abuse Warning Network

(DAWN) system, drug abuse is defined as “the nonmedical use of a substance for psychic effect, dependence, or

suicide attempt/gesture’ (302), According to NIDA’s 1988 DAWN report, nonmedical use includes the following:

● the use of prescription drugs in a manner inconsistent with accepted medical practice;

● the use of over-the-counter drugs contrary to approved labeling; or

. the use of any other substance (heroin, marijuana, peyote, glue, aerosols, etc. ) for psychic effect, dependence,

or suicide (302).

American Psychiatric Association, DSM-III-R

The American Psychiatric Association’s DSM-III-R notes that “In our society, use of certain substances to

modify mood or behavior under certain circumstances is generally regarded as normal and appropriate” (4).2 The

DSM-III-R diagnostic class “Psychoactive Substance Use Disorders” deals with “symptoms and maladaptive

behavioral changes associated with more or less regular use of psychoactive substances that affect the central

nervous system” (4). DSM-III-R notes that the behavioral changes used as criteria ‘would be viewed as extremely

undesirable in almost all cultures’ (4).

Listed below are the DSM-III-R criteria for diagnosing two categories of psychoactive substance use disorders

as mental disorders: 1) ‘‘psychoactive substance abuse disorder, ’ and 2) “psychoactive substance dependence

IIt is impotit to note hat the development of diagnostic criteria for mental disorders is a continuously evolving endeavor. me f~st

edition of the American Psychiarnc Association’s Diagnostic and Statistical Manual of Mental Disorders appeared in 1952; working groups

of the American Psychiatric Association are currentty working on DSM-IV (4), Classifications of mental disorders can also be found in the

International Classitlcation of Disorders (ICD) of the World Health Organization currently being revised for a loth edition (4). According to

the American Psychiatric Association: ‘‘The purpose of DSM-111-R is to provide clear descriptions of diagnostic categories in order to emble

clinicians and investigators to diagnose, communicate about, study, and treat the various mental disorders. . . The specified diagnostic criteria

for each mental disorder are offered as guidelines for making diagnoses, since it has been demonscated that the use of such criteria enhances

agreement among clinicians and investigators.,..These diagnostic criteria and the DSM-111-R classification of mental disorders reflect a consensus

of current formulations of evolving knowledge. . but do not encompass all the conditions that maybe legitimate objects of treatment or research

efforts” (4, italics added).

2DSM-IILR ~W notes that here me wide cultural variations in the United States and that ‘‘in some groups even the recreatioti use of

alcohol is frowned upoq whereas in other groups the use of various illegal substances for mood-ahering effects has become widely accepted.

In additiou certain psychoactive substances are used medically for the alleviation of pa@ relief of tensiom or to suppress appetite” (4).

3Ju5t as n. deffition adq~tely spw~les Precise boundaries for the concepts “physical disorder” ~d “pbic~ h~~” ~~e ‘e ‘0

precise boundaries for the concepts “mental disorder” or ‘‘mental health” (4). Nevertheless, the American Psychiatric Association found it

useful to present a definition of mental disorder that influenced the decision to include certain conditions in. . .DSM-111-~ as follows: ‘‘. . .a

ctinicalty sign~icant behavioral or psychological syndrome or pattern that occurs in a person and that is associated with present distress (a painfd

symptom) or with a signit3cantly increased risk of suffering deaa pm disability, or an important loss of freedom. In additioq this syndrome

or pattern must not be merely an expectable response to a particular event e.g., the death of a loved one. Whatever its original cause, it must

currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the person. Neither deviant behavior, e.g.,

political, religious, or sexual, nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or

conflict is a symptom of a dysfunction in the Perso% as described above” (4).

Mentat health and mental disorders in adolescents are discussed more generally in ch. 11, “Mental Health Problems: Prevention and

Treatmen4’ in this volume. Continued on next page
11-504. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 12-B—What Constitutes Substance Abuse by Adolescents?-Continued

disorder.” (Dependence is deemed to be more serious than abuse, in part because it involves a longer-term and more

pervasive behavioral pattern.)4

Separate DSM-III-R criteria are not available for adolescents.

DSM-III-R Diagnostic Criteria for Psychoactive Substance Abuse

A. A maladaptive pattern of psychoactive substance use indicated by at least one of the following:

● continued use despite knowledge of having a persistent or recurrent social, occupational, psychological, or

physical problem that is caused or exacerbated by use of the psychoactive substance;

● recurrent use in situations in which use is physically hazardous (e.g., driving while intoxicated).

B. Some symptoms of the disturbance have persisted for at least 1 month or have occurred repeatedly over a

long period

C. Never met the criteria for psychoactive substance dependence (see below) for this substance.

DSM-III-R Diagnostic Criteria for Psychoactive Substance Dependence

A. At least three of the following:

●

●

●

●

●

●

●

●

●

substance often taken in larger amounts or over a longer period than the person intended;

persistent desire or one or more unsuccessful efforts to cut down or control substance use;

a great deal of time spent in activities necessary to get the substance (e.g., theft), taking the substance (e.g.,

chain smoking), or recovering from its effects;

frequent intoxication or withdrawal symptoms when expected to fulfill a major role obligation at work,

school, or home (e.g., does not go to work because hung over, goes to school or work “high,” intoxicated

while taking care of his or her children), or when substance use is physically hazardous (e.g., drives when

intoxicated);

important social, occupational, or recreational activities given up or reduced because of substance abuse;

continued substance abuse despite knowledge of having a persistent or recurrent social, psychological, or

physical problem that is caused or exacerbated by the use of the substance (e.g., keeps using heroin despite

family arguments about it, cocaine-induced depression, or having an ulcer made worse by drinking);

marked tolerance, i.e., need for markedly increased amounts of the substance (at least 50 percent increase)

in order to achieve intoxication or desired effect, or markedly diminished effect with continued use of the

same amount.

characteristic withdrawal symptoms (see specific withdrawal syndromes under psychoactive substanceinduced organic mental disorders in DSM-III-R);5

substance often taken to relieve or avoid withdrawal symptoms.5

B. Some symptoms of the disturbance have persisted for at least 1 month or have occurred repeatedly over a

longer period of time.

In addition to criteria for diagnosing the presence of psychoactive substance dependence, DSM-III-R stipulates

criteria for severity of psychoactive substance dependence from mild (few, if any, symptoms in excess of those

required to make the diagnosis, and the symptoms result in no more than mild impairment in occupational

functioning or in usual social activities or relationships with others) to severe (many symptoms in excess of those

required to make the diagnosis, and the symptoms markedly interfere with occupational functioning or with usual

social activities or relationships with others6

). Clients may also be in partial remission (during the past 6 months,

some use of the substance and some symptoms of dependence) or in full remission (during the past 6 months, either

no use of the substance, or use of the substance and no symptoms of dependence).

4DSM.IIpR titixthese ~~vior~ly &jjned disordexs from another set of mental disorders called “psychoactive

Substance-induced Organic Mental Disorders,” a set of disorders caused by the direct effects of various psychoactive substances on the nervous

system. “Psychoactive Substance-induced Organic Mental Disorders” include intoxication withdrawal, delirhq withdrawal delirium,

delusional disorder, mood disorder, and other syndromes and differ depending on the substance used. Thus, the criteria for diagnosing these

organic disorders are not described here. Inmost cases, according to DSM-111-FL “the diagnosis of these Organic Mental Disorders will be made

in people who also have a psychoactive substance use disorder (4).

5DSM-111-R ~~s tit these criteria may not apply to cannabis, hallucinogens, or PCP (phacyclidtie).

6B=U= of the ~v~ab~i~ of ~gmttes @ other ficot~-conx subst~~s ~d the abxnw of a clinidly si@lcant nicotine

intoxication syndrome, impairment in occupational or social functioning is not necessary for a rating of severe nicotine dependence.

SOURCE: OffIce of ‘lkchnology Assessment, 1991.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . //-505

dependence are illegal for general sale, purchase, or

consumption regardless of age—among them heroin, cocaine, and inhalants such as amyl and butyl

nitrite, which are short-acting vasodilators.5

Trends in the Use of Psychoactive Substance

Use by U.S. Adolescents

Sources of Data on the Incidence and Prevalence of

Psychoactive Substance Use

Sources of data on the incidence and prevalence

of psychoactive substance use by U.S. adolescents

include self-report data from household and other

surveys sponsored by NIDA and others and also

include data from emergency rooms and data on

arrests.

Surveys That Collect Self-Report Data on

Psychoactive Substance Use-Various national

and other surveys discussed below have asked adults

and adolescents in the United States about their use

of alcohol, tobacco, and other drugs:

●

●

●

●

●

●

the NIDA Household Survey on Drug Abuse;

the Monitoring the Future/High School Seniors

Survey6 conducted by researchers at the Institute for Social Research at the University of

Michigan with NIDA’s support;

the National Adolescent Student Health Survey

conducted in 1987 by a consortium of groups

funded partially by the Federal Government;

the National PRIDE Survey sponsored by the

National Parents’ Resource Institute for Drug

Education;

the Youth Risk Behavior Surveillance System

(YRBSS) of the Centers for Disease Control

(CDC) within the Public Health Service of

DHHS; and

regional surveys such as those by the Universit-y of Minnesota’s Adolescent- Health Program.

NIDA’s Household Survey on Drug Abuse has

been conducted 10 times between 1971 and 1990

(303,306). The Monitoring the Future/High School

Seniors Survey has been conducted every year since

1975 (288,300). Other survey s---g.,., the National

Adolescent Student Health Survey (5) and the

National PRIDE Survey (206)-have been conducted only once.

Available data on the prevalence and incidence of

substance use and abuse by adolescents have major

limitations. For one thing, almost all estimates of the

prevalence, incidence, and trends in substance use

by U.S. adolescents rely on self-reports. Self-reports

are inherently subject to both faking and unintended

biases in reporting due to respondents’ potential

needs to provide socially desirable answers (13, 162,

184), Any reported changes in substance use over

time, therefore, may be due in part to changes in the

social acceptability of psychoactive substances in

general or of any particular substance. On the other

hand, Bachman and his colleagues have argued that

declines in the social acceptability of drug use have

had an impact on drug use, and that the declines seen

in the 1980s are therefore ‘‘real’ (11). Their

argument is buttressed by the fact that there have

been increases in the use of some drugs that have not

been the target of recent public attention (e.g.,

inhalants [288,289]), that arrests of adolescents for

drug violations have more or less tracked trends in

drug use (322), and that there is some evidence that

adolescents’ emergency room visits for drug-related

reasons are down (301 ,302,304 ).7 There remains,

however, persistent discomfort with reliance on

self-report data, and recognition of the need to use

sources of information other than self-reports, in

judging the prevalence of drug use in the United

States. Two sources of such data are discussed

following brief overview of available self-report

surveys.

NIDA Household Survey on Drug Abuse-The

NIDA Household Survey on Drug Abuse measures

the prevalence of drug use among the American

household population age 12 and over. Although

local surveys and clinical experience have found that

adolescents who are homeless or institutionalized

typically have higher rates of psychoactive substance use than do adolescents living at home,

homeless and institutionalized adolescents have not

51b~041utor~ arc agents hat cause the dilation (enlargement) of tie blood vessels.

~c Monitoring the Future/High School Seniors Survey is technically entitled “Monitoring the Future: A Continuing Study of the Lifestyles and

Wlucs of Youth. The survey studies a sample of all seniors in public and private high schools in the coterminous United States and also includes samples

of young adults from previous graduating classes, who are administered followup surveys by mail.

TAs dlscusscd &.low, dmg use data from tie WA sumcys of emergency rooms arc notoriously d~ficult to compare over time bCCaUSe Of

methodological problcms and frequent changes in methodology.

J(I7 ‘1 to ~1] I 7 (/1, {
11-506. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

been systematically surveyed by NIDA.8 The NIDA

Household Survey questions adolescents in their

own homes; what impact this approach has on the

results is not known. In addition, the NIDA Household Survey questions only 12- to 17-year-olds and

does not include younger adolescents (e.g., 10- and

11-year-olds). Further, the sample of adolescents the

NIDA Household Survey has surveyed has been

quite small (3,095 in 1988; 2,177 in 1990); as a

consequence, disaggregations of the data by adolescent age are not feasible, and only averages of 12- to

17-year-olds combined are possible. The number of

Hispanics and nonwhites surveyed in the NIDA

Household Survey is also small (747 black adolescents, 763 Hispanic adolescents, and 67 ‘‘other”

nonwhite adolescents in 1988) (303). DHHS is

planning to expand the number of individuals

surveyed in the NIDA Household Survey on Drug

Abuse (326,327).

Monitoring t/w Future/High School Seniors SurveyThe Monitoring the Future/High School Seniors

Survey (288,289) has long been criticizied for having

as its youngest respondents high school seniors. By

not surveying younger students and students who are

not in school, this survey has provided no information about drug use by students other than seniors or

about adolescents who have dropped out of school

prior to their senior year. There is some evidence that

school dropouts are more likely than current students to use psychoactive substances.9 Another

limitation of the Monitoring the Future/High School

Seniors Survey is that it does not sample sufficient

numbers of nonwhite students for distinctions by

race and ethnicity to be made on a routine basis. An

expansion of the Monitoring the Future/High School

Seniors Survey is planned, in that future surveys will

include younger adolescents as well as seniors (327).

National Adolescent Student Health Survey-In

1987, DHHS, in an attempt to ascertain the prevalence of a wide range of health-compromising

behaviors and attitudes among younger students,

helped support a survey of 8th and 10th graders

conducted by the American School Health Association, the Association for the Advancement of Health

Education, and the Society for Public Health Education (5). Although the National Adolescent Student

Health Survey sampled younger adolescents than

does the Monitoring the Future/High School Seniors

Survey, it too was limited to those adolescents still

attending school.

National PRIDE Survey-- The National PRIDE

Survey was based on a survey questionnaire devised

by the parents’ group, National Parents’ Resource

Institute for Drug Education (206). The validity of

the questionnaire design is unknown. The National

PRIDE survey, conducted in the 1988-89 school

year, has the advantage of including adolescents in

grades below the eighth grade, but the questionnaire

was not distributed to a representative sample of

schools. Only schools that were interested participated in the survey; further, participating schools

had the option of not reporting results back to the

National PRIDE office.

Youth Risk Behavior Surveillance System (YMSS)-

Reports of averages from national surveys are

controversial because they may seem to underestimate the use of drugs in particular locations. CDC is

beginning to support the collection and reporting of

data from cities and States (e.g., 314). Reporting of

such local data suggests the wide variation in drug

use across localities (314). Comparisons among

localities are sometimes difficult, however, because

these surveys also rely on school-based data and the

voluntary participation of localities.10 The Division

of Adolescent and School Health in CDC is now

supporting YRBSS (318). YRBSS will be administered locally and will also generate national data.

Questions about drug and alcohol use are included in

the survey, which will be administered to students in

9th through 12th grades.ll

gFor ~ ~~er disasslon of homeless adolescents, see ch. 14! “Homelessness: Prevention and Services,‘‘ in this volume. The health problems of

adolescents in juvenile justice facilities are discussed inch. 13, “Delinquency: Prevention and Sewices,” in this volume.

Wor a discussion of school dropouts, see ch. 4, “Schools and Discretionary Time,” in this volume.

IOB~ause of ~e~ focus on behaviors associated with infection with the h~ immunodeficiency virus (HIv)----the virus associated with the acquired

immunodeficiency syndrome (AIDS)--early reports from these surveys focused only on certain aspects of drug use (e.g., intravenous drug use). Future

YRBSS surveys will ask about a wider range of drugs (318). AIDS and HIV infection in U.S. adolescents are topics addressed in ch. 9, ‘‘AIDS and Other

Sexually Transmitted Diseases: Prevention and Services, ” in this volume.

1 I In addition, tie National Center for Health Statistics (NCHS) within D~Sis plarming to implement a Youth Risk Behavior Supplement to the

National Health Interview Survey (NHIS) in the years 1991, 1995, and 2000 (318). The NHIS Youth Risk Behavior Supplement will be administered

to adolescents who attend school and adolescents who do not. NHIS is discussed fhrther in ch. 6, “Chronic Physical Illnesses: Prevention and

TreatmenC’ in this volume.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services .11-507

The Minnesota Adolescent Health Survey----In

1984, the Federal Office of Maternal and Child

Health in DHHS’ Health Resources and Services

Administration awarded a grant to the Minnesota

Department of Health to work with the University of

Minnesota Adolescent Health Program (also funded

by the Office of Maternal and Child Health) to

establish a comprehensive adolescent health database in Minnesota for use by the State of Minnesota

and local Minnesota communities (327c). As part of

establishing such a database, the University of

Minnesota Adolescent Health Program conducted a

survey of over 36,000 public school students in

grades 7 through 12 in 86 Minnesota school districts

during the 1986-87 school year. As part of this

broad-ranging health survey, questions were asked

about the use of cigarettes, chewing tobacco, beer,

wine, hard liquor, and illicit drugs (any illicit drugs,

marijuana, cocaine, crack, amphetamines). This

survey is limited by being a self-report survey

representative only of Minnesota adolescents of

approximately ages 12 (7th grade) through 18 (12th

grade) who attend school, but its comprehensiveness

and large sample size may make it a useful model for

expansion into other groups of adolescents and

communities. 12

In general, local and national survey data would

be more useful if they reflected the use of multiple

drugs as well as the use of single drugs. Some studies

of limited numbers of adolescents suggest that

adolescents are likely to use more than a single drug,

but these studies do not report frequency of use. For

example, one Los Angeles County study reported

that 60 percent of high school and first-year-posthigh school respondents were multiple drug users,

but it did not report frequency of use; thus, individuals who may have used multiple drugs only one time

in the preceding 6 months would be included in the

60 percent (176).13

NIDA’s Drug Abuse Warning Network (DAWN)

System--NIDA’s DAWN system is a source of

information about alcohol and other drug use that is

potentially relevant to problem drug use by adolescents (302,304). NIDA’s DAWN system supports

the collection of data on emergency room visits and

deaths related to drug use. A sample of hospital

emergency rooms and medical examiner facilities

report to the DAWN system data for each ‘‘drug

abuse” patient or death encountered by medical

examiners. The DAWN system is designed primarily as an early warning system to monitor drug abuse

patterns and health hazards associated with drug use,

and to detect new abuse entities and new combinations of drugs of abuse.

One problem with DAWN data prior to 1990 was

that the data were collected from a nonrandom

sample of hospital emergency rooms and medical

examiner facilities in metropolitan areas selected

because of a high probability of problem drug use.14

Beginning in 1990, DAWN data were collected from

a national probability sample of emergency rooms

(304,327). This change will make DAWN data more

nationally representative, and make accurate national comparisons of data over time possible.

As noted in box 12-B, for the purpose of reporting

to the DAWN system, drug abuse is defined as ‘ ‘the

nonmedical use of a substance for. . . psychic effect,

dependence, or suicide attempt/gesture’ (302). Some

would agree that a limitation of the DAWN system

(apart from its being based in the past it on a rather

small and nonrandom sample of responding facilities) is its rather broad definition of nonmedical use

of drugs. Nonmedical use of drugs is defined as the

following:

●

●

●

The

the use of prescription drugs in a manner

inconsistent with accepted medical practice;

the use of over-the-counter drugs contrary to

approved labeling; or

the use of any other substance (heroin, marijuana, peyote, glue, aerosols, etc.) for psychic

effect, dependence, or suicide.

first two uses could be accidental and might not

be considered drug abuse by some definitions. To

]~VM1atlonS of he M~eso~ Sumey were administered by the University of Minnesota Adolescent Healfi ~ogr~ to adolcscen~ ‘n a ‘-&r ‘f

American Indian ,and Alaska Native communities. Reports from [he pilot phase of the Indian surveys can be found in OTA’s 1990 report Indian

Adolescent Mental Health (286).

13~1c National Adolescent CJtudcnt Health Sumcy ~Skcd adolescents whclhCr (hey had used alcohol iIl combination with other drugS, but lt did IIOt

report responses to this question (5).

14111 19g7, for ~xmp]c, data Were co]le~t~d from 610 ~mcrgency rooms ~d 75 mcdic~l examiner facilities in 27 large me~opohtan areas (e.g., Atl~tA

Baltimore, Boston, Buffalo, Chicago, Cleveland, New York, okhihoma City, Seattle, Washington, DC); these areas accounted for one-third of the U.S.

population (301). In addition, a “national panel” of 146 emergency rooms was newly added to the DAWN sample in 1987; the national sample was

not randomly sclecmd.
11-508. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

compensate, the DAWN system disaggregate episodes by motive (e.g., psychic effects, recreational

use, dependence, suicide) and type of drug, but the

breakdowns do not allow motives to be analyzed in

relation to types of drugs. A further limitation of

DAWN is that the drug mentions reported are not

necessarily the cause of the medical emergency.

Multiple drugs may be reported by a patient or

detected by the health care provider in the emergency room. Similarly, only one drug motive is

attached to an episode, and that motive is assigned

to each separate drug mentioned in the episode.

Thus, some caution must be exercised when attempting to relate drug mention patterns to specific

motives.

Federal Bureau of Investigation Data on Arrest Rates-As discussed elsewhere in this Report,

the Uniform Crime Reports program maintains

arrest data reported by local law enforcement

agencies to the Federal Bureau of Investigation in

the U.S. Department of Justice (323).15 Uniform

Crime Reports data offer several advantages-they

cover more types of offenses that data from other

sources, they cover offenses committed by individuals of all ages, and they are up-to-date and easy to

interpret. One limitation of these data, however, is

that they may be affected by underreporting by law

enforcement officials, particularly, underreporting

of less serious offenses (183). Another limitation is

that they may be affected by law enforcement

agencies’ bias toward the detection and arrest of

offenders from certain groups in society (e.g., black

male adolescents), and for certain categories of

offense (180a). Furthermore, the use of arrest rate

data to detect trends over time remains problematic.

One reason is that law enforcement agencies may

focus on different types of offenses in different

historical periods (e.g., a drug crisis may Limit

resources available for the detection of other types of

crimes); another reason is that changes may occur in

the definitions of offenses.

A problem related to these limitations is that the

category ‘drug abuse violations’ comprises a rather

broad range of offenses. Drug abuse violations are

State and local offenses related to the unlawful

possession, sale, use, growing, and manufacturing of

narcotic drugs (323). Because drug users may be a

different population than drug dealers and drug

dealers may sell to nonadolescents, arrest data are

not good overall indicators of adolescent drug use.16

Current Estimates of the Prevalence of

Psychoactive Substance Use Among U.S.

Adolescents Based on Self-Report Data

“Lifetime Use” of Psychoactive SubstancesCurrent data suggest that a substantial percentage of

U.S. adolescents will use alcohol, nicotine in the

form of cigarettes or smokeless tobacco, or some

other psychoactive substance, at least once during

adolescence. As shown in table 12-1, alcohol and

cigarettes are the two substances that U.S. adolescents are most likely to report ever having used.

About 50 percent of 12- to 17-year-olds responding

to the 1988 NIDA Household Survey on Drug

Abuse17 reported using alcohol at least once in their

lives (303); 90 percent of high school seniors

responding to the 1989 Monitoring the Future/High

School Seniors Survey reported using alcohol at

least once (288). Other than alcohol, tobacco is the

substance most likely to be tried by U.S. adolescents, with about two-thirds of high school seniors

in 1989 reporting having smoked cigarettes at least

once in their lives (288). Forty-four percent of high

school seniors in 1989 reported that they had tried

marijuana at least once; 19 percent had used

stimulants; 18 percent had used inhalants; 10 percent

had used cocaine; and 10 percent had used hallucinogens, primarily LSD (lysergic acid diethylamide),

(8.3 percent). Seven percent of high school seniors

15&x= Ch. 13, ‘ ‘Delinquency: Prevention and Services, ” in thk volume.

160~y ~lght sites @s ~geles, CA; Sm Diego, CA; sm Jose, CA; Portland, OR hhMpOk, ~; St. ~ui$ MO; clevel~dt OH; was-o~

DC) in the U.S. Department of Justice, OffIce of Justice Programs, National Institute of Justice’s Drug Use Forecasting system test juvenile arrestees

and detainees for the presence of drugs in their systems (323a). Hence, national estimates of drug use by juvenile amestees and detainees are not possible.

In the period April through June 1!390, from 8 percent (San Jose, CA) to 37 percent (Los Angeles, CA) of juvenile arrestee/detainees tested positive for

at least one of the following drugs: cocaine, opiates, PCP, marijuana, amphetamines, methadone, methaqualone, benz.odiazepines, barbiturates, and

propoxyphene. Some sites do not test for methadone, met.haqualone, and propoxyphene (323a). (Propoxyphene IDarvon@] is a prescription analgesic

structurally similar to methadone (147).) Other data, discussed in ch. 13, “Delinquency: Prevention and Services,” in this volume, suggest a high

prevalence of alcohol and drug abuse problems, and nearly universal use of tobacco among adolescents incarcerated in juvenile justice facilities. It is

important to note that drug use data from adolescents involved with the juvenile justice system pertain to arrests and incarcerations for many types of

offenses, not just drug use or drug sales.

170TA focused on adolescen~ ages 10 ~ough 18. ~A Household survey on Drug Abuse data are not readily available fOr thk age ~OUp ~d ~

therefore presented for individuals ages 12 to 17.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services .11-509

Table 12-l—Percentage of Surveyed U.S. Adolescents of Different Ages Reporting Ever Having Used Alcohol

or Other Types of Psychoactive Substances

Percentage of respondents reporting ever having used

NIDA Household Survey National Adolescent Monitoring the

on Drug Abuse, Student Health Future/High School

1988 Survey, 1987 Seniors Survey, 1989

12- to- 17 8th 10th High school

year-oldsa graders graders seniors

Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.20/ o

Cigarettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42.3

Marijuana/hashish . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.4

Smokeless tobacco/snuff . . . . . . . . . . . . . . . . . . . . . . . . . . 14.9

Inhalants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.8

Nonmedical use of stimulants . . . . . . . . . . . . . . . . . . . . . . . 4.2

Nonmedical use of analgesics . . . . . . . . . . . . . . . . . . . . . . 4.2

Hallucinogens (all forms) . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5

Cocaine (all forms) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4

Nonmedical use of sedatives . . . . . . . . . . . . . . . . . . . . . . . 2.4

Nonmedical use of tranquilizers . . . . . . . . . . . . . . . . . . . . . 2.0

PCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2

Crack cocaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.9

Heroin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.6

LSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA

Needle use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.4

77.4%

50.8

14.5

NA

20.6

9.0b

NA

2.6

3.6

NA

NA

NA

1.6

NA

NA

O.9c

88.8%

63.5

35.1

NA

20.6

15.7b

NA

6.7

7.7

NA

NA

NA

2.7

NA

NA

0.5c

90.7%

65.7

43.7

NA

17.6

19.1

NA

9.9

10.3

7.4

7.6

3.9

4.7

1.3

8.3

NA

KEY: NA-notavailable.

asample size is too smaii to disaggregate bysingle yearof age.

blncludes over-the%ounter as weii as prescription (e.g. amphetamines) drugs.

conformation m~ected onneedle use for injection ofcocaine only.

SOURCE: Office of Technology Assessment 1991, based on data fromthefoiiowing sources: NIDAHousehold Survey on Drug Abuse: U.S. Department

of Health and Human Services, Public Health Service, Alcahol, Drug Abuse, and Mental Health Adm inistration, National Institute on Drug Abuse,

Nationa/ Househo/d Survey on Drug Abuse: Main Findings 7988, DHHS Pub. No. (ADM) 90-1682 (Rockville, MD: 1989). National Molescent

Student Health Survey: American School Health Association, Association for the Advancement of Health Education, Society for Public Health

Education, Inc., The Nafiona/Ado/escent Student Hea/th Survey:A Report on the t-teahh of Amerka’s Youth (Oakland, CA: Third Party Publishing,

1989). Monitoring the Future/High School Seniors Survey: U.S. Department of Health and Human Services, data from the 1989 “Monitoring

the Future Survey” of drug abuse among U.S. high school seniors (conducted by the Institute for Sociai Research, University of Michigan, and

funded by the National institute on Drug Abuse), HHS News, Feb. 13, 1990.

reported that they had ever used sedatives and/or

tranquilizers nonmedically (288).18

Information collected with the support of the

CDC suggests that there may be considerable

variation by locale in the percentage of U.S.

adolescent students who have ever used drugs

intravenously. As shown in table 12-2, in 1988 in the

District of Columbia, for example, almost 5 percent

of female students and 9 percent of male students

ages 13 to 18 reported having administered drugs

(cocaine, heroin, or other illegal drugs) intravenously at some point in their lives (314). The

proportions were somewhat lower in schools in the

other localities that permitted their data to be

published. Because localities were permitted to

administer questionnaires to whichever schools and

students they deemed appropriate, it is difficult to

make comparisons among localities.

Frequent and Substantial Use of Psychoactive

Substances-As noted at the beginning of this

chapter, different segments of society differ with

respect to their conceptualizations of what constitutes substance abuse for adolescents (see box

12-B). Unless one believes that any use of psychoactive substances by adolescents is problem use or

abuse (310), it is important to determine when

substance use becomes problem use or abuse. Such

determinations are difficult. Typically, available

survey data are not particularly helpful in distinguishing occasional substance use from problem use

or abuse.

As shown in table 12-3, about one-third of high

school seniors reporting to the 1989 Monitoring the

18~e 1990 Mofitonng tie Fut~@High school sc,~ors Sumey found some sm~l, but st~tistical]y significant, decreases ~hveen 1989 and 1990 irl

the percentage of high school seniors reporting having ever used any illicit drugs, any illicit drug other than marijuana, marijuana/hashish, amyl and butyl

ni~ite, crack, stimulants, and sedatives (289).
II-51O . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 12-2—Percentage of U.S. Adolescent Students in Selected Cities and States

Reporting Ever Having Used Drugs Intravenously, by Sex, Age Group, 1988

Percentage reporting ever having used drugs intravenously

Gender Age group (yrs)

City/State Total Female Male 13-14 15-16 17-18

California . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 % 2.6%. 5.7% 2.8% 3.9% 4.3%

Washington,DC................,.. 6.3 4.6 8.7 ●

4.0 8.9

Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . 2.8 2.1 3.4 3.2 3.2 1.3

San Francisco, . . . . . . . . . . . . . . . . . . . . 3.7 2.4 5.1 1.4 3.9 2.4

● Less than 5 percent of subgroup in sample.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control,

“HIV-Related Beliefs, Knowledge, and Behaviors Among High School Students,” Morbidity and Morta/ity

Weekly Repoti37;71 7-721, Dec. 2, 1988.

Table 12-3—Current Estimates of Heavy Use of Alcohol Among

U.S. Adolescent Studentsa

Percentage of respondents reporting

National Adolescent Student Monitoring the

Health Survey, 1987 Future/High School

Number of times in the past 2 weeks 8th 10th Total Seniors Survey, 1989

had five or more drinksb

graders graders sample High school seniors

O times . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73.8% 61.8% 67.6% 67.O%

1 time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.5 15.8 14.3 11,1

2 times . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.4 7.8 7.2 8.3

3-5 times . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 8.5 6.4 9.0

6-9 times . . . . . . . . . . . . . . . . . . . . . . . . . 1.4 3.0 2.2 2.7

10+ tires . . . . . . . . . . . . . . . . . . . . . . . . . 1.7 3.0 2.2 1.9

aln the 1988 National Household Survey on Drug Abuse, NIDA defined “heavy use of alcohol” as drinldng five or more

drinks on the same occasion (i.e., within a few hours) on 5 or more days in the past 30 days.

b~ewording ish~ five ormoredrinks “on one occasion” inthe National Adolescent Student Health Survey; it is having

had five or more drinks “in a row” in the Monitoring the Future/High School Seniors Survey.

SOURCE

Future/High School

Office of Technology Assessment, 1991, based on data from the following sources: National Adolescent

Student Health Survey: American School Health Association, Association for the Advancement of Health

Education, Society for Public Health Education, Inc., l%e National kblescerrt Student Health Survey: A

Report on tha Hea/th of America’s Yith (Oakland, CA: Third Party Publishing, 1989). Monitodng the

Future/High School Seniors Survey: U.S. Department of Health and Human Services, data from the 1989

“Monitoring the Future Survey” of drug abuse among U.S. high school seniors (conducted by the Institute

for Social Research, University of Michigan, and funded by the National Institute on Drug Abuse), HHS

News, Feb. 13, 1990.

Seniors Survey and a similar

proportion of the 8th and 10th graders reporting to

the 1987 National Adolescent Student Health Survey said that they had had five or more alcoholic

drinks on at least one occasion in the 2 weeks prior

to the survey period (5,304). Many of the students

surveyed-7.2 percent of the 8th graders (5), 14.5

percent of 10th graders (5), and 13.9 percent of the

high school seniors (304 )-reported having had five

or more drinks on three or more occasions in the

previous 2 weeks. Apparently, such patterns of

consumption have led some adolescents themselves

to assert that alcohol use is the most prevalent

problem among students (3).

Nicotine is used by a significant number of

adolescents—most commonly in the form of cigarettes. As shown in table 12-4, nearly 6 percent of

10th graders surveyed in the 1987 National Adolescent Student Health Survey reported smoking more

than five packs of cigarettes a month. Nineteen

percent of high school seniors surveyed in 1989

reported some cigarette smoking on a daily basis

(from one cigarette per day [7.7 percent] to two

packs or more per day [0.3 percent]).

Some adolescents use nicotine in the form of

smokeless tobacco. Although the regular use of

smokeless tobacco can have significant health consequences (320), national surveys such as NIDA’s

Household Survey on Drug Abuse and the Monitoring the Future/High School Seniors Survey do not

request information about smokeless tobacco use.

As shown in table 12-5, the one-time National
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services ● II-511

Table 12-4-Current Estimates of Heavy Cigarette Smoking Among

U.S. Adolescent Students

Percentage of respondents reporting

National Adolescent Student Monitoring the

Health Survey, 1987 Future/High School

8th 10th Total Seniors Survey, 1989

Cigarettes smoked in past month graders graders sample High school seniors

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83.9°/0 73.6% 78.60/0 71 .4°/0

1-4 total for month . . . . . . . . . . . . . . . . . 7.7 9.1 8.4 NA

5-19 total for month . . . . . . . . . . . . . . . . 3.1 4.9 4.0 NA

1-5 packs total for month . . . . . . . . . . . 2.9 6.5 4.8 NA

>5 packs total for month . . . . . . . . . . . 2.4 5.9 4.2 NA

Less than 1 cigarette a day . . . . . . . . . NA NA NA 9.7

1-5 cigarettes per day . . . . . . . . . . . . . . NA NA NA 7.7

About 1/2 pack/day . . . . . . . . . . . . . . . . NA NA NA 5.4

About 1 pack/day . . . . . . . . . . . . . . . . . . NA NA NA 4.4

About 1 1/2 packs/day . . . . . . . . . . . . . . NA NA NA 1.1

Two packs or more/day . . . . . . . . . . . . NA NA NA 0.3

KEY: NA - not available.

SOURCE: Office of Technology Assessment, 1991, based on data from the following sources: Nationai Adolescent

Student Heaith Survey: American Schooi Heaith Association, Association for the Advancement of Health

Education, Inc., The National Adolescent Student Health Survey:A Report on the Health of Ametica’s Youth

(Oaidand, CA: Third Party Publishing, 1989): Monitoring the Future/High School Seniors Survey: U.S.

Department of Health and Human Services, data from the 1989 “Monitoring the Future Survey” of drug

abuse among U.S. high school seniors (conducted by the Institute for Social Research, University of

Michigan, and funded by the National Institute on Drug Abuse), HHS News, Feb. 13, 1990.

Adolescent School Health Survey found that an

average of 4.4 percent of 10th grade males (2.4

percent of 10th grade males and females combined)

used smokeless tobacco daily (5). The University of

Minnesota’s 1986-87 Adolescent Health Survey

found that 15 percent of male students in the 12th

grade were using smokeless tobacco daily (191).

Most U.S. adolescents do not use illicit drugs19

with great frequency. If one considers daily use of a

psychoactive substance as an indicator of problem

use, for example, one finds that less than 1 percent

of adolescent students report using any illicit drug

other than marijuana on a daily basis (see table

12-5). 20 For example, from 0.3 to 0.6 percent of

respondents reported using cocaine in any form

daily in the last month or year in various surveys

during the 1987-89 period. In 1989, 2.9 percent of

high school seniors reported using marijuana on a

daily basis. The fact that less than 1 percent of

adolescents appear to be using any specific illicit

drug other than marijuana on a daily basis should not

be dismissed lightly, however; 0.5 percent of 12- to

17-year-olds in 1988 was equal to 100,000 adolescents.

Not surprisingly, somewhat more U.S. adolescents report using an illicit drug less frequently than

daily but more than “ever.” For example:

●

●

●

●

3.9 percent of 12-to 17-year-old respondents to

the 1988 NIDA Household Survey and 5.5

percent of respondents to the 1988-89 National

PRIDE Survey reported having used marijuana

once a week or more in the past year.

Three-tenths of 1 percent of 10th graders and

high school seniors had used crack cocaine 20

or more times in the past month.

From 0.9 percent to 1.4 percent of respondents

(depending on the survey) had used crack

cocaine at least once in the month preceding the

survey.

From 0.6 to 2.2 percent of student respondents,

depending on the survey, had used hallucinogens 10 to 12 or more times in the year

preceding the surveys.

lqF~r~u~~~es of ~i~ Repofl, ~d t. bc con~lstent ~~ usage in tie ~AHousChold s~ey on Dmg Abuse (303) ~d the Motitofig the FutureJHi@

School Seniors Survey (300), the term illicit drugs refers to drugs that arc illegal for everyone in the United States and the nonmedical use of prescription

drugs. Illicit drugs include mtijuana, inhalants, cocaine, hallucinogens, heroin and the nonrnedical use of psychotherapeutics (sedatives, tranquilizers,

stimulants, or analgesics) (303).

mlt may& fipo~mt t. note ~al the data in tab[e 12.5 come from s~cys of adolescents in school. The NIDA Household Survey on Dmg Abuse,

which is population-based rather than school-based, does not ask respondents about daily use.
//-512 . Adolescent Health—Volume Ii: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 12-5-Summary of Daily Use of Alcohol, Tobacco, and Illicit Drugs by U.S. Adolescent Students of Various Ages

National Surveysb

Junior high school Senior high school High school seniors onlyg Regional/local surveys

PRIDEC PRIDEC Monitoring the Future/ Minnesota Adolescent

survey NASHSd e survey NASH SO f High School Seniors Health Survey

Druga

(1988-89) (1987) (1988-89) (1987) Survey (1989) (1986-87) —

Alcohol . . . . . . . . . . . . . . . . . . . . . . . . .

Cigarettes . . . . . . . . . . . . . . . . . . . . . . .

Marijuana/hashish . . . . . . . . . . . . . . .

Smokeless tobacco/snuff . . . . . . . . .

inhalants . . . . . . . . . . . . . . . . . . . . . . . .

Nonmedical use of stimulantsk . . . .

Nonmedical use of analgesicsk 

. . . .

Hallucinogens (all forms) . . . . . . . . .

Cocaine (all forms) . . . . . . . . . . . . . . .

Nonmedical use of sedatives . . . . .

Nonmedical use of tranquilizersk 

. . .

PCP . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Crack cocaine . . . . . . . . . . . . . . . . . . .

Heroin . . . . . . . . . . . . . . . . . . . . . . . . . .

LSD . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Amyl or butyl nitrite . . . . . . . . . . . . . .

Combinations of alcohol and other

drugs . . . . . . . . . . . . . . . . . . . . . . . .

“Other drugs” . . . . . . . . . . . . . . . . . . .

0.8

5.70/0

0.8

NA

0.6

0.5m

NA

0.4

:::1

—1

NA

NA

NA

NA

NA

NA

1.8

0.6%

NA

0.4

1.31

0.6

0.3n

0.4”

0.4P

NA

0.4

0.3

NA

NA

NA

0.1

NA

NA

0.6

NA

NA

1.1

10.60/0

2.3

NA

0.6

0.8M

NA

0.5

0.6

0.5l

J

NA

NA

NA

NA

NA

NA

2.0

2.0%

NA

2.1

2.4l

0.6

0.4n

0.3”

0.6P

:$

0.4

NA

NA

NA

0.3

NA

NA

0.4

NA

NA

4.2

18.90/oh

2.9

NA

O.3b

0.3b

NA

0.3b

0.3

0.1

0.1

0.2

0.2

0.1

0.0

NA

NA

NA

NA

12.00/0

2.0

3.8

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

KEY: NA = not available; PRIDE - Parents’ Resource Institute for Drug Education; NASHS - National Adolescent Student Health Survey.

aDmg~ are listed in roughly the same order as in table 12-I, where drugs were listed to reflect the prevalence Of their use by U.S. adolescents ~ determined

in the 1988 NIDA Household Survey on Drug Abuse. The categories “Amyl or butyl nitrite,” “Combinations of alcmhol and other drugs,” and “Other drugs”

were not listed in table 12-1 and are therefore shown last in this table.

b“Adjusted” figures are used. Adjusted figures are higher than unadjusted fi9LJres.

cFigures shown are the average of grades 6 through 9. Interestingly, for almost all t ypes of drugs, daily use in 6th grade aPPeared higher than use in 7tht 8th~

or 9th grades. However, the number of respondents was lowest for 6\h graders (half or less than in any other grade except 12th), a factor which could affect

the statistical significance of any differences. In general, the survey method would not meet generally accepted standards, and no tests of statistical

significance were conducted.

*he figures shown are for eighth graders only.

eln the National Ad~les~ent Student Health Survey, respondents were not asked about daily use, but they were asked about the nurnbar Of OOXIsiOtls particlllar

drugs had been used in “the past month.” The percentage reporting either 20 to 39 times or 40+ times are included here as daily use.

~enth graders only.

gln the Monitoring the Future/High school Seniors Survey, “daily use” means daily use in the past 30 days.

hThi~ figure reflects any level of cigarette smoking on a daily basis, A total of 11.2 percent of high school seniors reported smoking half a pack of Cigarettes

or more per day.

iHighest fr~uency of use included in question was 20+ times in the paSt month.

jThe National Adolescent Student Health Survey used the term “psychedelics,” but the actual question included what the NIDA Household Survey on Drug

Abuse and other surveys refer to as hallucinogens (i.e., LSD, PCP, mescaline, peyote, psilocybin).

kThe National pRIDESurvey~idnO~, ad the Monitoring the Future/High wool Seniors Survey dj~ distinguish between medical and nonradical USe of d~gs.

IThe National pRIDE survey us~the term ‘idowners~’ Re~rted use is in~uded here under sedatives. The Monitoring the Future/High %hool SefliOrS %rVey

asked about both sedatives and tranquilizers (nonmedical use only).

mThe National pRIDE survey used the term “uppers.” it did not ask respondents to distinguish beween medical and nonmedical USe of dregs.

~his figure is for prescription amphetamines for nonmedical use.

~his figure is for nonprescription look-alike stimulants and pep pills sold legally in most States without a prescription, usually by mail.

PThis figure is for nonprescription stay-awake pills (e.g., No-DozR, VivarinR).

SOURCE: Office of Technolocrv Assessment, 1991, based on data from the following sources: National PRIDE Survey: National Parents’ Resource Institute

for Drug Educatio;; The PRIDE Questionnaire for Grades 6-12, Natio;al Database, 1988-1989 (Atlanta, GA: July 24, 1989). Monitoring the

Future/High School Seniors Survey: U.S. Department of Health and Human Services, data from the 1989 “Monitoring the Future Survey” of drug

use among high school seniors (conducted by the Institute for Social Research, University of Michigan and funded by the National Institute on Drug

Abuse), HHS News, Feb. 13, 1990. National Adolescent Student Health Survey: American School Health Association, Association for the

Advancement of Health Education, inc., and Society for Public Health Education, Inc., The Nationa/Ado/escwnt Student Hea/th Survey:A RepoH

on the Health of America’s Youth (Oakland, CA: Third Party Publishing, 1989).

● About 2 percent of high school seniors reported school seniors reported having used LSD at

using LSD in the month preceding the 1989 least once in the year prior to the survey.

Monitoring the Future/High School Seniors

Survey, but less than 0.5 percent reported Comparison of Psychoactive Substance Use by

having used LSD 20 or more times in the month Adolescents and Adults-There are few compariprior to the survey. Almost 5 percent of high sons of adolescents’ use of psychoactive substances
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-513

Figure 12-l—Use of Alcohol in the United States,

by Age, 1988

Percentage reporting use

100

8 0

6 0

40

20

0

—

Et 1.7 80.5

Ever used Used past year Used past month

Age of respondents (in years)

= 12-17 ~ 18-25 ~ 26-34 m 35 +

SOURCE: Office of Technology Assessment, 1991, based on data from

U.S. Department of Heath and Human Services, Public Health

Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse, National Household

Survey on Drug Abuse: Main Findings 1988, DHHS Pub No.

(ADM) 90-1682 (Rockville, MD: 1989).

with use of other age groups. Only the NIDA

Household Survey on Drug Abuse collects information about substance use from a broad sample of age

groups from age 12 and over.21

Comparing adolescent and adult drug use is

complicated because of the need to take both cohort

and contemporary effects into account. It is important to note that the age group 35 and over represents

a very diverse group in terms of drug use experience

and that an average for all those 35 and over is not

a valid comparison to the 12- to 17-year-old age

group. 22 Further, the number of individuals in the

population ages 35 and over (112 million in 1988

[287a]) is far greater than the number of individuals

in the population ages 12 to 17 (20.5 million [287a]).

Because the NIDA Household Survey on Drug

Abuse does not report on age groups with equivalent

population distributions, comparisons of rates of

drug use in widely varying age groups should be

made with caution.

Data from the 1988 NIDA Household Survey on

the use of alcohol, cigarettes, and illicit drugs

Figure 12-2—Use of Cigarettes in the United States,

by Age, 1988

‘oo~

60

40

20

0

I

Ever used Used past year Used past month

Age of respondents (in years)

= 12-17 ~ 18-25 = 26-34 = 35 +

SOURCE: Office of Technology Assessment, 1991, based on data from

U.S. Department of Heath and Human Services, Public Healt h

Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse, National Househo/d

Survey on Drug Abuse: Main Findings 1988, DHHS Pub No.

(ADM) 90-1682 (Rockville, MD: 1989).

reported by U.S. adolescents ages 12 to 17 and by

individuals in older population groups are summarized in figures 12-1, 12-2, and 12-3. The substance

reportedly used by the most respondents in all age

groups is alcohol, followed by cigarettes. As shown

in figures 12-1 and 12-2, U.S. adolescents are less

likely to report having used alcohol or cigarettes

than adults, whether the time frame is ever, the past

year, or the past month.

The 1988 NIDA HousehoId Survey on Drug

Abuse found that smaller percentages of individuals

in all age groups reported use of any illicit drug than

reported use of alcohol or cigarettes. As shown in

figure 12-3, adolescents were far less likely than

young adults ages 18 to 34 and about as likely as

adults age 35 and over to report ever having used any

illicit drug. About 25 percent of 12- to 17-year-olds

reported ever having used an illicit drug, as compared with roughly 60 percent of 18- to 34-year-olds

and 23 percent of those over age 34. When asked

about illicit drug use in the past month, 12- to

17-year-olds reported less use than young adults

ages 18 to 34 and more use than adults 35 and older.

21~ 1991, he Mofitonng he Fu~e/High school se~ors s~ey repofied dam on a sample of 19- to 28-y W-olds who had been followed Up frOm

high school for 1986 through 1990 (289).

22 For exmple, 1988 DAWN data show tit the distribution of drug abuse (as defined for the DAWN swey) ass~iated wi~ emergencY ‘Oom ‘isiw

is very variable for those 30 and over, with the following distribution: ages 30 to 39, 23,615 encounters; ages 40 to 49, 6,651 encounters; ages 50 to 59,

1,380 encounters; and 60 and older, 371 encounters (302). Imputed “motives” for drug use resulting in an emergency room encounter also vw by age.

For example, drug dependence as an inferred ‘motive’ for drug use rose with age from ages 10 through 39, and declined with age from age40 on (302).

If6- to 9-year-olds are not included, drug dependence as a motive was lowest among those 10 to 17 (7.8 percent) and 60 and older (16.3 percent) (302).
II-514 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 12-3-Use of Any Illicit Druga in the

United States, by Age, 1988

Percentage reporting use

100 - I

90

80 1 I

70“

6 0 -

5 0 -

4 0 -

3 0 -

2 0 -

lo0“

32

16.

1

Ever used Used past year Used past month

Age of respondent (in years)

= 12-17 ~ 18-25 ~ 26-34 = 35 +

aln the NIDA Household Survey on Drug Abuse, the term “any ill~it dreg”

is defined as marfjuana, inhalants, cocaine, hallucinogens, PCP, heroin,

or the nonmedical use of psychotherapeutics (i.e., prescription medications which ean be used illicitly to get high or for other mental effects).

SOURCE: Office of Technology Assessment, 1991, based on data from

U.S. Department of Heath and Human Serviees, Public Healt h

Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse, Nationa/ #ouseho/d

Survey on Drug Abuse: Main Findings 1988, DHHS Pub No.

(ADM) 90-1682 (Rockviile, MD: 1989).

Summary: Current Estimates of the Prevalence of Substance Use Among U.S. Adolescents

Based on Self-Report Data—The majority of

contemporary American adolescents report that they

have tried the substances that are legally available to

and widely used by adults-alcohol and cigarettes—

at least once during adolescence. A substantial

portion of adolescents appears to consume alcohol

heavily and frequently, and 1 out of 10 smokes half

a pack or more cigarettes a day. Available data from

household and student surveys suggest that the illicit

drug adolescents are most likely to try is marijuana,

followed by stimulants, inhalants, cocaine, and

hallucinogens. Few adolescents appear to use any

substance-licit or illicit-daily, but those few

represent a sizable minority of individuals.

Estimates of the Prevalence of Psychoactive

Substance Use Resulting in Death or the Need for

Emergency Medical Care

Extreme indicators of problem use of psychoactive substances are death or the need for emergency

medical care from substance abuse. In 1988, 13,975

U.S. adolescents ages 10 to 17 visiting the emergency rooms participating in NIDA’s DAWN system tested positive for drugs (302). DAWN is not a

very useful source of information on psychoactive

substance abuse by adolescents, because alcohol, the

most frequently used psychoactive drug among

adolescents, is mentioned only when it is used in

combination with another drug. The majority (61.8

percent) of these adolescents had used drugs to

attempt suicide; less than 20 percent experienced an

emergency as a result of using a drug for recreational

purposes (302). About 8 (7.8) percent of the 13,975

10- to 17-year-olds who tested positive for drugs did

so because of drug “dependence” (302).

Consistent with other evidence on suicide, DAWN

data show that female adolescent patients (black,

Hispanic, and white non-Hispanic) were much more

likely than male patients to have used drugs to

attempt suicide,23 while male patients (black, Hispanic, and white non-Hispanic) were more likely to

report having used the drugs for recreational purposes or because they were drug dependent (302).

Few U.S. adolescents die as a result of drug use

that is not accidental or associated with suicide. In

1987, 3 adolescents ages 10 to 14 and 109 adolescents ages 15 to 19 in this country died as a result of

drug poisoning not related to suicide (319).24 NIDA

reports that, of the 82 drug-related deaths among

10- to 17-year-olds reported to DAWN by medical

examiners, approximately 45 percent were classified

as suicides (307). The apparently nonsuicidal drug

poisoning mortality rates (per 100,000 population)

for 10- to 14-year-olds and 15- to 19-year-olds did

not change between 1979 and 1987 (319).

As shown in table 12-6, DAW emergency room

data by type of drug are reported for 6- to 17-yearolds in the aggregate, not for adolescents separately.

Since children ages 6 to 9 accounted for only 0.5

percent (77 of the cases) on which the 1987

drug-by-drug analysis was based (302), however,

most of the data pertain to adolescents. The majority

of the substances used by adolescents seen in

emergency rooms are licit substances like acetaminophen, alcohol in combination with other drugs, and

aspirin, which together accounted for about 43

percent of the substances mentioned by emergency

~s~cide and StiCi& attempts among U.S. adolescents are discussed inch. 11, “Mental Health Problems: Prevention and Services, ” in this volume.

~~ese dea~ include JnterMtiowl Clastificatiort of Diseases E-Codes 980.0 to 980.5, “Death From Poisoning by Drugs, Medicaments, and

Biological [not determined whether accidental or unintentional] and E-Codes 850 to 858, ‘‘Death From Poisoning by Dxugs, Medicaments, and

Biological: Accidental” (319).
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services ● II-515

Table 12-6-DAWN Emergency Room Data on Drug Use by Patients 6 to 17 Years of Age, 1987a

Number Percentage Number Percentage

of of total of of total

Drug name mentions b

episodes Drug name mentions a

episodes

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

23

25

26

27

28

29

30

30

32

33

34

35

36

37

38

39

39

41

41

43

43

43

46

47

48

49

50

50

2,137

2,084

2,057

1,311

1,153

942

681

490

387

376

336

271

252

245

227

181

172

168

167

154

150

148

145

145

141

122

113

110

105

98

98

93

91

87

84

83

82

78

76

76

71

71

68

68

68

64

63

62

59

58

58

14.80

14.44

t 4.25

9.08

7.99

6.52

4.72

3.39

2.68

3.60

2.33

1.88

1.75

1.17

1.57

1.25

1.19

1.16

1.16

1.07

1.04

1.03

1.00

1.00

0.98

0.85

0.78

0.76

0.73

0.68

0.68

0.64

0.63

0.60

0.58

0.57

0.57

0.54

0.53

0.53

0.49

0.49

0.47

0.47

0.47

0.44

0.44

0.43

0.41

0.40

0.40

52

53

54

54

56

56

56

59

59

61

61

61

64

65

66

66

68

68

70

71

72

72

72

75

75

77

77

79

80

81

82

82

84

85

86

87

88

88

88

91

91

93

93

93

96

96

98

98

98

98

57

53

52

52

51

51

51

49

49

47

47

47

44

43

41

41

40

40

38

37

36

36

36

35

35

34

34

33

32

31

30

30

29

28

28

26

25

25

25

24

25

23

23

23

22

22

20

20

20

20

0.39

0.37

0.36

0.36

0.35

0.35

0.35

0.34

0.34

0.33

0.33

0.33

0.30

0.30

0.28

0.28

0.28

0.28

0.26

0.26

0.25

0.25

0.25

0.24

0.24

0.24

0.24

0.23

0.22

0.21

0.21

0.21

0.20

0.19

0.19

0.18

0.17

0.17

0.17

0.17

0.17

0.16

0.16

0.16

0.15

0.15

0.14

0.14

0.14

0.14

aThe &ta in this table are from the Dmg Abuse Warning Network (DAWN) of the National Institute on Drug Abuse within the U.S. Department Of Health and

Human Services.

bData are based on raw frwuencie~ of dmg mentions and a total raw emergenq room episode ~unt of 14,437 for patients 6 to 17 years C)f age. Ifl USiflg this

table, the reader should be aware that individual drugs are frequently mentioned in combination with other drugs and that the population at risk of an adverse

consequence relating to the abuse of any particular drug is unknown, i.e., the number of people abusing a particular substance, either alone or in any

combination, is unknown. Thus the relative frequency of mentions of any drug pertains only to the DAWN system and not the larger population at risk.

cpcp refers to phencyclidine.

dLSD refers to lysergic acid diethylamide.

eOTC dregs are drugs sold “over the counter, “ i.e., without a prescription,

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute

on Drug Abuse, Data From the Drug Abuse Warning Network DAWN: Annual Data 1987, DHHS Pub. No. (ADM) 88-15S4 (Rockville, MD: 1988).
//-516 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 12-7—Arrest Rates for Drug Abuse Violations in the United States,

by Age and Sex, 1965-88n

Number of arrests for drug abuse violations per 100,000 population

Under age 18 Age 18 and over

Year Total Male Female Total Male Female

1965 . . . . . . . . . . . . 11.7

1966 . . . . . . . . . . . . 18.9

1967 . . . . . . . . . . . . 44.6

1968 . . . . . . . . . . . . 91.2

20.2

31.7

73.5

145.0

2.9

5.5

14.6

35,4

50.4

62.8

91.5

135.1

90.7

113.1

166.5

246.1

13.2

16.8

23.4

34.6

1969 . . . . . . . . . . . . 122,4

1970 . . . . . . . . . . . . 160.3

1971 . . . . . . . . . . . . 177.1

1972 . . . . . . . . . . . . 190.7

189.9

244.7

271.3

300.9

52.4

72.7

79.2

76.1

199.1

285.3

319.4

320.4

361.6

516.6

575.1

577.8

52.2

76.0

87.6

86.3

1973 . . . . . . . . . . . . 263.2

1974 . . . . . . . . . . . . 305.7

1975 . . . . . . . . . . . . 245.0

1976 . . . . . . . . . . . . 242.8

423.2

496.4

401.0

398.5

96.7

107.2

82.7

80.7

355.6

398.6

339.9

342.0

648.9

727.4

621.9

624.0

88.9

99.6

83.6

85.7

1977 . . . . . . . . . . . . 237.2

1978 . . . . . . . . . . . . 242.4

1979 . . . . . . . . . . . . 202.3

1980 . . . . . . . . . . . . 184.7

388.6

396.0

330.9

301.5

79.4

82.2

67.9

62.7

334.1

321.0

289.3

306.9

608.0

587.9

530.7

565.8

85.1

78.6

69.9

74.7

1981 . . . . . . . . . . . . 173.6

1982 . . . . . . . . . . . . 150.1

1983 . . . . . . . . . . . . 135.4

1984 . . . . . . . . . . . . 139.2

285.1

246.2

222.0

231.3

56.9

49.7

44.9

42.7

332.8

358.0

370.2

380.9

610.5

651.8

670.2

690.0

80.2

90.5

96.8

99.4

1985 . . . . . . . . . . . . 153.1

1986 . . . . . . . . . . . . 135.5

1987 . . . . . . . . . . . . 143.9

1988 . . . . . . . . . . . . 158.3

255.4

227.6

244.3

271.0

45.8

39.0

38.6

40.0

423.3

440.3

491.6

552.6

766.1

789.2

872.6

973.7

110.0

121.0

142.6

166.5

ane Federal Bureau of Investigation’s Uniform Crime Reports defines tig abuse violations as Sta!e and IOCal

offenses related tothe unlawful possession, sale, use, growing, and manufacturing of nar@icdrugs( 323).

SOURCE: U.S. Department of Justice, Federal Bureau of Investigation, Age-Specific Arrest Rates and Race-Sp~’fic

Arrest Rates for Se/ected Offenses 1965-1988 (Washington, DC: April 1990).

rooms as being used by 6- to 17-year-olds. Unfortunately, it is not possible to pair these substances with

the motive or reason for the emergency room visit in

this age group (301).

Another increase in arrest rates for drug abuse

violations occurred in 1985, a year when the use of

cocaine increased among high school seniors.25

Somewhat anomalously, arrest rates for drug abuse

violations among individuals under age 18 increased

Arrests as an Indicator of Psychoactive Substance in 1988, despite the fact that drug use was down,

Use and Substance Use Problems

Arrests Related to Alcohol—Federal Bureau of

Investigation Part II offenses26 related to the drinking of alcohol are categorized three different ways:

In general, sources of data on arrests related to

drug abuse violations by U.S. adolescents have

tracked declines in use. Arrests related to alcohol use

have shown a more complicated pattern (182). . driving under the influence,

Arrests Related to Illicit Drugs-Arrest rates

for drug abuse violations among individuals under

age 18 rose somewhat steadily between 1965 and

1974, when they began to decline (see table 12-7).

. drunkenness (excluding driving under the influence), and

. State and local liquor law violations.

tiAs noted above, ~g ~~e ~ong ~gh school sefiors is often t~en ~ aII ~dicator of tig use among u adolescents. DHHS phtrls tO COlleCt

information on substance use from a broader range of adolescents (including nonstudents) in the future (326,327).

XSM ch. 13, ‘‘Del~ency: Prevention and seI_ViCeS, ‘‘ in this volume for explanation of different types of offenses.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-517

Menard analyzed differences in arrests of adolescents for drunkenness and liquor law violations

between 1976 and 1987 for OTA (182). While

arrests for drunkenness declined from 1.36 to 0.69

per 1,000 11- to 17-year-olds between 1976 and

1987, arrests for liquor law violations rose from 3.74

to 4.55 per 1,000 11- to 17-year-olds. Menard

suggested that these differences may reflect recent

decreases in the availability of alcohol to minors

(182). 27

Demographic Differences in Psychoactive

Substance Use by Adolescents

Racial and Ethnic Differences in Substance

Use—While a popular assumption may be that

substance use is most prevalent among black adolescents in the United States, self-report data from

recent NIDA Household Surveys on Drug Abuse

indicate that black adolescents ages 12 to 17 are less

likely than adolescents from any other racial or

ethnic groups to report the use of any illicit

drug-whether the measure is lifetime, annual, or

past-30-days use (303). NIDA Household Survey on

Drug Abuse data indicate that Hispanic adolescents

are slightly less likely than non-Hispanic white

adolescents (but more likely than black adolescents)

to use illicit drugs. In the case of cocaine and crack

cocaine, however, Hispanic adolescents report slightly

more use than non-Hispanic white adolescents.

Hispanic adolescents are also less likely than

non-Hispanic white adolescents (but more likely

than black adolescents) to report use of alcohol,

cigarettes, and smokeless tobacco.

The NIDA Household Survey on Drug Abuse and

the Monitoring the Future/High School Seniors

Survey involve different populations (adolescents in

households, high school seniors), but both are

limited by having only small annual samples of

adolescents in racial and ethnic minority groups.

Bachman and his colleagues performed an analysis

that sought to compensate for the Monitoring the

Future/High School Seniors Survey’s small annual

sample sizes by combining data from 1976 through

1989 into three groups (1976-79, 1980-84, and

1985-89) (15). This analysis provided somewhat

more information than the NIDA Household Surveys on Drug Abuse, because it allowed information

on Native American and Asian American high

school seniors, in addition to that for white, black,

and Hispanic high school seniors, to be disaggregated. Bachman and his colleagues found results

from the Monitoring the Future/High School Seniors

Survey that were generally similar to those of the

NIDA Household Surveys (15). Native American

high school seniors had the highest prevalence rates

for the use of cigarettes, alcohol, and most illicit

drugs. White non-Hispanic high school seniors had

the next highest prevalence rates for the use of most

drugs; Hispanic high school seniors had the next

highest prevalence rates (except for relatively high

cocaine use among Hispanic males) (15). Asian

American and black high school seniors had the

lowest prevalence rates (15).

It may be important to note that NIDA and other

self-report data on racial and ethnic differences in

substance use by adolescents do not appear to be

consistent with differences indicated by DAWN data

or arrest rates for drug abuse violations (182,301,

303,306,322). 28 For example, black adolescents

accounted for 20 percent, Hispanic adolescents

accounted for 12 percent, and white non-Hispanic

adolescents accounted for 55 percent of the DAWN

episodes among 10- to 17-year-olds in 1988 (302).

Arrests for drug abuse violations are disproportionately high among black adolescents (182).

Social Class and Income Differences in Substance Use--Only limited information is available

about social class and income differences in psychoactive substance use by adolescents. In this

chapter, social class refers to the socioeconomic

status of adolescents’ families of origin (most

adolescents live with their families), and income

refers to the adolescents’ own income. These indicators may or may not be related. Both measures may

be relevant to explaining adolescents’ use of substances because both may make substances more

270f ~omse, ~coho] ~a~ not ~eg~ly av~lable t. finors ~der age 18 in 1976, but presumably ]aws res~ctingalcoho] to hose ages 21 and over had

an impact on its availability to those under age 18 as well.

~Discrepancics ~tween self-report data and arrest data are a topic addressed in ch. 13, ‘‘Delinquency: Prevention and Sewices, ’ in this volume.
II-518 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

available to an adolescent, but not necessarily in the

same ways.

Further, the effect of income and social class may

differ for different substances. For example, since

crack is less expensive than powder cocaine, crack

may be more likely to be available to low-income

adolescents and powder cocaine to middle- and

high-income adolescents.

Very little research has examined the relationship

between substance use and income among adolescents, perhaps because adolescents do not typically

have a regular substantial income (176). Current

population-based surveys of self-reported substance

use by adolescents cannot be used to disaggregate

use by socioeconomic status. For example, the

Monitoring the Future/High School Seniors Survey

reports data by sex, college plans, region, and

population density, but not by socioeconomic status

(289). Similarly, the DAWN form does not require

information related to income level to be reported

(302).

Elliott and his colleagues analyzed data from the

National Youth Survey29 (a survey conducted on the

same cohort of adolescents from 1976 to the present)

and found that in 3 of the 4 years of their study,

working class adolescents30 were no more likely to

use drugs than middle class adolescents (81,83).

Several other studies that have examined the

availability of spending money and the use of

psychoactive substances by adolescents have found

that having disposable income is positively related

to substance use (190). Maddahian, Newcomb, and

Bentler also found that alcohol and cigarette use

increased with greater earned income; money from

allowances and other given income was related to

nontherapeutic use of prescription drugs-but no

relationship between income and other drugs was

demonstrated (176). In another analysis, Maddahian, Newcomb, and Bentler found that earned

income was a significant predictor of cigarette

smoking and alcohol consumption (assuming equal

availability), but availability (measured as friends

having given the respondent the substance and

perceived ease of acquisition) “drastically” decreased the effects of earned income (and ethnicity)

(175).

Age Differences in Substance Use-The detection of age differences in adolescent substance use is

made difficult by the scarcity of national data on

younger adolescents. Data such as those from the

NIDA Household Survey on Drug Abuse that

average information from a relatively wide range of

adolescent ages should be interpreted with caution

(306). Most available data do suggest that the

tendency to use drugs, except for inhalants, generally increases with age (table 12-1, table 12-2, table

12-5). Inhalants (e.g., gasoline, airplane glue) may

be easier for young adolescents to obtain and use.

As it is with other problem behaviors, the age at

which an adolescent begins to use substances maybe

an important indicator of the likely occurrence of

problem or continued use. Hirschi and Gottfredson

point out a very straightforward interpretation for

this pattern: at ages when very few people have a

given behavior, its appearance will be concentrated

among those people who are most strongly disposed

to that behavior (129). In other words, if 85 percent

of high school seniors and 10 percent of seventh

graders consume alcohol on a regular basis, then the

fact that an individual consumes alcohol says more

about a person who is a seventh grader than about a

person who is a high school senior.

Several analyses have found that the earlier the

use of psychoactive substances, the more likely it is

to result in problem use (235,272). These studies

have differed, however, in what they mean by

‘‘early’ use-for example, one study considers use

either before 15 or before 18 early (235), while

another study considers use before age 12 early

(272). Furthermore, it may be important to view

findings about early use in terms of cohort effects. In

recent years, substance use by Americans has been

occurring earlier in life. In 1975, 47 percent of the

high school seniors who reported smoking cigarettes

daily reported that they had begun smoking before

the 10th grade, but by 1984, the figure had risen to

Z9~e Natio~ youth Smey used a probabili~ smple of households iII the ~n~en~ Ufited States. The 1976 sample included adolescents ages

11 to 17; participants were found to be representative of the total 11- to 17-year-old population in the United States at that time as established by the

U.S. Census Bureau (81,83).

30wor~g ~las~ adole~ents were those whose Pwents were o~e~ of .s@l bus~esses, cleti~ workers, ~d persons h sales or skilled ]~ud

occupations with high school or some college completed; middle class adolescents were those whose principal wage-ewning parent was in a professional

or managerial occupation with a college educatiow and those whose parents were in semiskilled and unskilled manual occupations and had a high school

or lower level of education were designated lower class.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services II-519

63 percent (145). What was “early onset” in one

decade may become the norm in another. Nevertheless, the age of an adolescent or preadolescent’s

initial use of alcohol or other drugs may be a

predictor of future problem use.

Recent Trends in the Use of Psychoactive

Substances by U.S. Adolescents

Few data are available on trends in the use of

psychoactive substances by U.S. adolescents. As

noted earlier in this chapter, the NIDA Household

Survey on Drug Abuse has been conducted since

1971 (303).31 The Monitoring the Future/High

School Seniors Survey has been conducted by the

University of Michigan’s Institute for Social Research every year since 1975 (288). Other surveys,

including the National Adolescent School Health

Survey and the National PRIDE Survey, have been

conducted on a one-time only basis (5,206). Recently, CDC within the Public Health Service of

DHHS has begun to support the regular collection of

data on drug use and other behavioral risk factors

from students (316), but trend data are not yet

available from those surveys.

The Monitoring the Future/High School Seniors

Survey shows a net decline since 1975 in the

lifetime, annual, and current use32 by U.S. adolescents of any illicit drug (see figure 12-4, table 12-8).

Although the Monitoring the Future/High School

Seniors Survey found that the lifetime, annual, and

current use of any illicit drug reported by U.S. high

school seniors rose somewhat in the late 1970s, these

indicators declined quite steadily (except for an

increase in 1985) throughout the 1980s to rates

lower than those found in 1975 (300). The Monitoring the Future/High School Seniors Survey found

that lifetime, annual, and current cocaine use by U.S.

high school seniors increased between 1975 and

1979, then again between 1983 and 1985, and has

Figure 12-4—Use of Any Illicit Druga by U.S.

High School Seniors, 1975-89

Percentage reporting use

100 -T - ‘

—- ‘—- ‘“- ‘-- —--”-” ‘- —

80 J

65.4 60.6 60. 55.2 .- 53.1 Lifetime -

-- 50. 9

45.0

40 30.7 -- — —/ —— ————— —--—--- 29-7

/

— Past month — ‘ -

l9. 7

20 \

L

~

o ~ ~– ‘- ‘-- r “‘- ‘ ‘–– ‘ “ T T i

1975 1980 1985 1989

aln the Monitoring the Future/High School Seniors Survey, the term “any

illicit drug” is defined as marijuana, cocaine, heroin, or any use which is not

under a doctor’s orders of other opiates, stimulants, sedatives, or

tranquilizers.

SOURCE: U.S. Department of Health and Human Services, data from the

1989 “Monitoring the Future Survey” of drug abuse among U.S.

high school seniors (conducted by the Institute for Social

Research, University of Michigan, and funded by the National

Institute on Drug Abuse), H/+S News, Feb. 13, 1990.

steadily declined since then to approximately the

1975 levels (see figure 12-5).

The Monitoring the Future/High School Seniors

Survey found that U.S. high school seniors’ daily

use of marijuana, alcohol, and cigarettes declined

between 1975 and 1989 (see table 12-8). In 1975, for

example, 6 percent of the high school seniors

surveyed reported daily use of marijuana, and the

number rose until 1982. Beginning with the class of

1983, daily use of marijuana fell slightly, until a

slight (but not statistically significant) increase

among the class of 1989. The only statistically

significant difference between the classes of 1988

and 1989 was an increase of 0.2 percent in daily use

of hallucinogens to 0.3 percent of respondents

(about the same as it was in 1985 and 1986).33

JIAccordlng t. the Offlce of Nati~nal Drug Control Strategy (ONDCS), tie NrDA Natio~ Household Survey on Drug Abuse WaS tO h! conducted

annually beginning in 1990 (327).

32cWcn( use ~ his context means use ~m ~c Past ‘on*.

ssRe~ul[~ of ~e 1990 High s~h~l senlors~onitoring tie Fut~e s~ey (289) were report~ too late to be included in detail in MS Report.

Nonetheless, the findings of the 1990 survey, like those of the 1990 NIDA National Household Survey on Drug Abuse, were encouraging. me 1990

survey of high school seniors found that 47.9 percent of high school seniors had used an illicit drug at least once in their lives (289). It found statistically

significant declines between rates of use in 1989 and 1990 in lifetime prevalence (ever used) for any illicit drug, any illicit drug other than marijuana,

arnyl and butyl nitrites, crack stimulants, and sedatives; annual pre>’alence (use in the last year) for any illicit drug, any illicit drug other than rnarijuan~

rnarijuandhashish inhalants, PCP, cocaine, crack stimulants, sedatives, and alcohol; for use in (he last 30 days for illicit drug, any illicit drug other than

marijuan~ marijuam#hashish, inhalants, PCP, cocaine, crack methaquatone, and atcohol; and for alai/y use of marijuandhashish, cocaine, and crack

(289). Of 20 types of drugs selected for analysis by NIDA, only one (inhalants) showed a statistically significant increase in use in the last yeas (i.e.,

use of inhalan(s in the last year [before adjustment] increased 1 percent).
11-520. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

20

15

10

5

0

Figure 12-5-Use of Cocaine by U.S. High School

Seniors, 1975-89

Percentage reporting use

—–—”T

I

17.3

,5.7- . . . ‘“ “‘-‘ ~ .

Lifetime

,.

,, 12.3 13.1 ‘ ~ Past year 9.0 / “

.-

,-

5.6 6.7

/

Past month

1 .9/ ~

/

1975 1980 1985 1989

SOURCE: U.S. Department of Health and Human Services, data from the

1989 “Monitoring the Future Survey” of drug abuse among U.S.

high school seniors (conducted by the Institute for Social

Research, University of Michigan, and funded by the National

Institute on Drug Abuse), HHS News, Feb. 13, 1990.

Comparisons of NIDA Household Survey on

Drug Abuse results over the most recent 10-year

period show results consistent with the Monitoring

the Future/High School Seniors Survey. Average

use by 12- to 17-year-olds of almost all drugs at least

once in the last year (so-called annual prevalence)

declined between 1979 and 1988 (303).34

Summary of Data on the Use of Psychoactive

Substances by U.S. Adolescents

Self-report data indicate that most contemporary

U.S. adolescents are likely to try alcohol at least

once during their adolescence, and the majority are

likely to try tobacco. A significant minority of

adolescents are likely to try some illicit drug (most

commonly marijuana). Some of the adolescents who

try psychoactive substances go on to use them

regularly or in large quantities. Alcohol and tobacco

are the psychoactive substances that are most likely

to be used regularly or in large quantities by U.S.

adolescents (e.g., one-third of adolescent respondents to recent student surveys say they have had

five or more drinks on at least one occasion in the

previous 2 weeks). In recent years, the use of most

illicit drugs has declined considerably among U.S.

adolescents (as it has among individuals in other age

groups). National self-report data suggest that only

a small percentage (between 0.3 and 3 percent) of

today’s U.S. adolescents use some illicit drug (e.g.,

cocaine, PCP, or marijuana) on a daily basis.

In general, white adolescents and adolescents

with income (to whom substances are available) are

most likely to report use of both illicit and licit

substances, although there are differences by substance. Older adolescents are more likely to use

psychoactive substances than younger ones, but a

substantial number of very young adolescents do

appear to be using substances such as alcohol,

cigarettes, and inhalants. Unfortunately, few data

have been collected on adolescents younger than 12;

even the numbers of adolescents 12 and above who

are surveyed regularly are quite small. There appear

to be substantial regional variations in drug use by

adolescents.

Factors Associated With Psychoactive

Substance Use and Abuse by Adolescents

As discussed below, many American adolescents

use alcohol, tobacco, or some other psychoactive

substance at least once, but not all of these adolescents go on to use these substances heavily or

frequently. Efforts to understand the psychological

and social factors that lead adolescents to use

psychoactive substances are fairly recent. Unfortunately, the fruits of these efforts are often difficult to

interpret because of methodological limitations and

differences among studies.

Methodological Issues

Studies of risk and protective factors in adolescent

drug use exhibit methodological limitations and

differences such as the lack of a uniform definition

of the outcome variable (e.g., initiation of drug use,

occasional use, frequent but low-quantity use, and

chronic, heavy use); reliance on self-report data

without biochemical validation; the use of crosssectional surveys that cannot establish causality; the

use of questionnaires that have not been validated or

standardized for use with adolescents; and little

urn 1990, ~A conducted ~o&a Natio~ HouSehold s~ey on D~g Abuse (3~), but the findings of the 1990 survey were not published i.rl time

to be included in detail in this Report. DHHS reports that the 1990 Household Survey on Drug Abuse generally found that recent declines in drug use

among adolescents continued in 1990. The estimated number of U.S. adolescents ages 12 to 17 who reported ever having used any illicit drugs fell 13

percent between 1988 and 1990, from 1.866 million to 1.622 million (306).
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-521

Table 12-8—Trends in the 30-Day Prevalence of Daily Use of 18 Types of Drugs Among

U.S. High School Seniors, 1975-89

Percentage who used daily in last 30 days

Class Class Class Class Class class Class Class Class

of

1975

Drugs Approx. no= (9,400)

Marijuana/hashish . . . . . . . . . . . . . .

Inhalantsa 

. . . . . . . . . . . . . . . . . . . . . .

Inhalants adjustedb 

. . . . . . . . . . . . .

Amyl and butyl nitritesc d. . . . . .

Hallucinogens . . . . . . . . . . . . . . . . . .

Hallucinogens adjustede . . . . . . . .

LSD . . . . . . . . . . . . . . . . . . . . . . . . .

PCPcd . . . . . . . . . . . . . . . . . . . . .

Cocaine . . . . . . . . . . . . . . . . . . . . . . .

Crack cocainef 

. . . . . . . . . . . . . . .

Other cocaineg . . . . . . . . . . . . . . .

Heroin . . . . . . . . . . . . . . . . . . . . . . . . .

Other opiatesg . . . . . . . . . . . . . . . . .

Stimulants . . . . . . . . . . . . . . . . . . . . .

Stimulants adjusteg h. . . . . . . . . . .

Sedatives . . . . . . . . . . . . . . . . . . . . .

Barbiturates. . . . . . . . . . . . . . . . .

Methaqualone g 

. . . . . . . . . . . . . . .

Tranquilizers. . . . . . . . . . . . . . . . . . .

Alcohol

Daily . . . . . . . . . . . . . . . . . . . . . . . .

Five or more drinks in a row

in the last 2 weeks . . . . . . . . .

of of of of of of of of

1977 1979 1981 1983 1985 1987 1988 1989 1988-89

(17,100) (15,500) (17,500) (16,300) (16,000) (16,300) (16,300) (16,700) % change

6.0

NA

NA

NA

0.1

NA

0.0

NA

0.1

NA

NA

0.1

0.1

0.5

NA

0.3

0.1

0.0

0.1

5.7

36.8

26.9

17.9

9.1 10.3

0.0

NA

NA

0.1

NA

0.0

NA

0.1

NA

NA

0.0

0.2

0.5

NA

0.2

0.2

0.0

0.3

6.1

39.4

28.8

19.4

0.0

0.1

0.0

0.1

0.2

0.0

0.1

0.2

NA

NA

0.0

0.0

0.6

NA

0.1

0.0

0.0

0.1

6.9

41.2

25.4

16.5

7.0

0.1

0.2

0.1

0.1

0.1

0.1

0.1

0.3

NA

NA

0.0

0.1

1.2

NA

0.2

0.1

0.1

0.1

6.0

41.4

20.3

13.5

5.5

0.1

0.2

0.2

0.1

0.2

0.1

0.1

0.2

NA

NA

0.1

0.1

1.1

0.8

0.2

0.1

0.0

0.1

5.5

40.8

21.2

13.8

4.9

0.2

0.4

0.3

0.1

0.3

0.1

0.3

0.4

NA

NA

0.0

0.1

NA

0.4

0.1

0.1

0.0

0.0

5.0

36.7

19.5

12.5

3.3

0.1

0.4

0.3

0.1

0.2

0.1

0.3

0.3

0.1

0.2

0.0

0.1

NA

0.3

0.1

0.1

0.0

0.1

4.8

37.5

18.7

11.4

2.7

0.2

0.3

0.1

0.0

0.0

0.0

0.1

0.2

0.1

0.2

0.0

0.1

NA

0.3

0.1

0.0

0.1

0.0

4.2

34.7

18.1

10.6

2.9

0.2

0.3

0.3

0.1

0.3

0.0

0.2

0.3

0.2

0.1

0.1

0.2

NA

0.3

0,1

0.1

0.0

0.1

4.2

33.0

18.9

11.2

Cigarettes

Daily . . . . . . . . . . . . . . . . . . . . . . . .

Half-pack or more per day....

KEY: NA= notavailable.

NOTE:

aData are based On four questionnaire forms in 197&1988; the number of respondents to this item (n) is four-fifths of the total sample SiZe indicated at the

top of the column (N). Data are based on five questionnaire forms in 1989; n is five-sixths of N indicated.

bFigures are adjusted for underreporting of amyl and butyi nitrite.

cData are bas~ on a single questionnaire form; n is one-fifth of N indicated in 1979-1988 and one-sixth of N indicated in 1989.

d@estion text changed slightly in 1987.

eFigures are adjusted for underreporting of PCF’.

fData are based on two questionnaire forms; n is two-fifths of N indicated in 1987-1988 and two-sixths of N indicated in 1989.

gOnly drug use which was not under a doctor’s orders is included here.

hFigures are ~sed on the data f rom the revis~ question, which attempts to exc[ude the inappropriate reporting of noIlpreSCription Stimulants.

iAny apparent inmnsistency ~~een the change estimate and the prevalence estimates for the two mOSt recent classes is due to rounding error.

JDifference is statistically significant (p<.01 ).

+0.2

0.0

0.0

+0.2

0.0

+0.2i J

0.0

+0.1

+0.1

+0.1

-0.1

+0.1

0.0

NA

0.0

+0.1 

0.0

0.0

O.0

0.0

-1.7

+0.8

+0.6

SOURCE: U.S. Department of Health and Human Services, data from the 1989“Monitoringthe Future Survey” of drug abuse among U.S. high school seniors

(conducted by the Institute for Social Research, University of Michigan, and funded by the National Institute on Drug Abuse), /-#lSIVews, Feb. 13,

1990.

attempt to correct for confounding effects (189).35 approached globally, and heavy users and those for

Furthermore, because different drugs have different whom drug use is causing a problem typically are

effects on the body, it is important to understand not separated from those who use substances less

whether there are specific risk factors for individual frequently. Because alcohol is the most frequently

drugs. Unfortunately, much of the research that has used drug, analyses that combine drug use of all

been conducted with adolescents does not allow kinds are unlikely to be informative about the risk

such a fine-grained analysis. Drug use is often factors for use of specific drugs. While there is

35~ ~~dltlon, psychoactive su&tmceS of ~hoi~e ~ong users may ~hange over time. when such Changes occur, research normally lags behhd the

new usc patterns. For example, the body of existing research literature is relatively rich with studies of drugs that have been in use in American culture

for a considerable period of time (e.g., alcohol, tobacco, marijuana), while studies of the newer psychoactive substances such as *’crack” or “ice” are

uncommon.
II-522 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

considerable evidence that adolescents who use one

substance are also likely to use another, use of any

one substance does not inevitably mean that other

substances are being used (216).36

Several factors that are believed to lead to drug

use among adolescents have been investigated more

thoroughly than others. The more heavily researched

factors include having a substance-abusing parent

(163), other parental behavior as discussed under

“family factors” below (25,26), associating with

substance-using peers (189), and unconventionality

(139,140). Most recently, considerable attention has

been devoted to research on possible biological

factors in addiction. The most interesting and

valuable studies have investigated the influence of a

variety of factors using a longitudinal design (e.g.,

208). However, even the longitudinal studies are

limited because they have relied on adolescents’

self-reports and have not examined biological propensities to addiction. Further, even the most advanced statistical methods are limited in the number

of factors they can analyze simultaneously.

Much less research has been conducted on the

impact of specific drugs themselves and on the

impact of school, work, and other broader societal

environments on adolescents’ use of psychoactive

substances. A 1990 report by OSAP in DHHS

recently listed 65 “widely identified’ risk factors

and 39 ‘‘widely identified’ protective factors for

adolescent drug abuse (312). A previous OSAP

report summarized many of the most widely identified risk factors in a figure (see figure 12-6).37

This section reviews evidence on the following

risk and factors for substance use in general: family

factors; factors related to peers; personal characteristics of adolescent substance users; school, work, and

societal impacts; and appetitive drug effects. Then it

reviews some of the evidence for factors associated

with adolescents’ use of the specific substances

tobacco/cigarettes and alcohol. Readers are advised

that research into risk factors for adolescent drug use

and abuse is deservedly a rapidly growing field

(312). Good evidence on risk factors is needed for

the design of effective preventive interventions.

Family Factors Associated With Psychoactive

Substance Use by Adolescents

Any examination of the influence of family (or

any other social variable) on adolescent substance

use must recognize that the factors under consideration usually are not determinative. Adolescents who,

to all outward appearances, are at ‘‘high-risk” of

becoming psychoactive substance users may never

use such substances, while others theoretically

isolated from significant ‘‘risks’ may indulge heavily. Researchers are examining this phenomenon,

which has been variously termed “invulnerability”

or “resiliency,‘‘ in an effort to identify protective

factors which help to immunize an individual against

the risk of a negative life outcome (171,178,239,333).

Substance-Abusing Parents-Most of the research on having substance-abusing parents as a risk

factor for adolescent drug use has focused on

children of alcoholic parents and may not always be

generalizable to parents who use other drugs. Still it

appears that children of substance-abusing parents

are more likely than other children to use psychoactive substances (163,285). Whether this finding

reflects inherited biological factors or factors related

to living with substance-abusing parents is an

unresolved issue (100,163).

In a recent review for NIDA, Kumpfer drew the

following conclusion:

Biomedical research in this area [children of

substance abusers] is still in its infancy, and the few

existing studies need additional replication; but a

consistent picture is beginning to emerge of 1)

differences in metabolism and reaction to alcohol

and other drugs, 2) predisposing temperament and

psychological characteristics, 3) neurological and

biochemical differences, and 4) psychological and

cognitive differences that could make a child more

vulnerable to substance abuse (163).

The strongest evidence of biological vulnerability

has come from research on alcoholic fathers and

361n ~ ~evlewof he literatwe on ~ov~ation ~ ~olescents’ use of v~ous subs~~s, Osgood ad Wilson found correlation coefficients ranging from

0.30 to 0.68 (216).

N’~e tem~ used fi tie lg90 OS~ rqo~ (312) were somew~t different from hose in he ewlier OSAP report (3 10), although they Cm be made

to correspond. The 1990 OSAP report used the terms ecological environment (e.g., poverty, living in an economically depressed area with high

unemployment); family environment; constitutional vulnerability/strengths of the child; early behavior pmbIems/personality of the child; adolescent

problems (e.g., school failure and dropout); and negative adolescent behavior and experiences (e.g., resistance to authority, strong need for independence,

hopelessness, vulnerability to peer pressure) (312).

~SK~pfer notes mere is some, but not much research on heroin-abusing mothers md their Chikkn (163).
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-523

Figure 12-6—Factors That May Influence Alcohol,

by Adolescents

Tobacco, and Other Drug Use

ENVIRONMENTAL

INFLUENCES INTERPERSONAL

\

AND SOCIETAL

INFLUENCES

INDIVIDUAL

INFLUENCES

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental

Health Administration, Office for Substance Abuse Prevention, Prevention Plus 1/, DHHS Pub. No. (ADM)

89-1649 (Roekville, MD: 1989).

their sons.38 Recent research on the effects of

serotonin uptake inhibitors (fluoxetine and fluvoxamine) and norepinephrine uptake inhibitors (desipramine) on alcohol and food intake suggest that problem

alcohol users (and overeaters) may be selfmedicating for neurotransmitter deficiencies (163).

Whether these neurotransmitter deficiencies are

inherited is unknown.39

Existing research on the behavior of substanceusing parents is scanty and not systematic (163).

Nevertheless, the work that has been done suggests

that such a parent is typically self-involved and

lacking in parenting and family management skills.

The lack of parental supervision and training in

appropriate behavior often results in poor home and

school behaviors (temper tantrums, crying, aggression, sadistic behaviors, lying, screaming, noncompliance, absence from school, lateness) and social

isolation (163). Such children may be more vulnerable to the use of substances to self-medicate. This

chain of events is more likely to occur if the child has

special needs that may occur as a result of substance

use during pregnancy or inherited biochemical

deficiencies (163). In addition to being more vulnerable to deficits that may lead them to abuse

substances, children of substance users are more

39A complete review of tie evidence for biological issues in psychoactive substance use and abuse among adolescents is beyond tie scope of ~S

Report.
II-524 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

likely to be directly exposed to substances and even

to be encouraged or permitted by their parents to use

substances (25).

Other Parental Behavior Associated With Substance Abuse Among Adolescents-A recently

completed longitudinal study of children and their

parents by Baumrind demonstrates the impact of

parents on psychoactive substance use and abuse

(26). Baumrind’s study is impressive for its method

and intensiveness: experienced psychologists made

comprehensive ratings of both child and parent when

the children were ages 4, 9, and 15. In addition,

Baumrind examined different levels of substance

use and assessed the relationships between substance use and other adolescent behaviors, both

desirable and undesirable.40

Baumrind found that a variety of family types

protected their adolescents from problem use of

substances, but in different ways and with different

consequences. Her findings included the following:

●

●

●

‘‘Authoritative’ (but not authoritarian) families, in which parents are firm and committed

but also embrace some nontraditional beliefs,

were able to protect their adolescents from

problem drug use and generate competence.41

Children from “democratic” homes, in which

parents value freedom highly, were as competent as children from authoritative families

during adolescence, but more (not all) of the

children from democratic homes were heavy

users of marijuana or alcohol.

Children from directive homes, in which parents are considerate and supportive and value

control highly, avoided drugs altogether but

were not as competent as the adolescents from

democratic and authoritative homes.

Unlike adolescents who experimented with psychoactive substances, Baumrind found that adolescents whose drug use indicated dependence had

come from families that were quite dysfunctional

(26). Similarly, a study by Newcomb and Bentler

suggested that there were relationships between

family disruption in year 1 (junior high school), lack

of social conformity in year 5 (high school), and

problem drug use in year 9 (early twenties) (208).42

Peer-Related Factors Associated With

Psychoactive Substance Use by Adolescents

Use of drugs by peers has been the most consistent

factor associated with adolescents’ use of substances

(189). Robinson and his colleagues found, for

example, that perceptions of friends’ use of marijuana (the only substance chosen for inclusion in the

analysis) accounted for 41 percent of the total

variance in a group of 10th graders’ use of various

substances (including tobacco, alcohol, marijuana,

cocaine, LSD, and heroin) (237). However, findings

of peer influence are typically confounded by

researchers’ use of cross-sectional research designs.

In other words, at least some of the adolescents who

use drugs may be choosing peers who also use drugs.

The importance of a longitudinal research design

is shown in Stein, Newcomb, and Bentler’s analysis

of data collected over an 8-year period beginning

when respondents were in junior high school (261).

Analyses done within any particular year supported

the findings of previous research on the importance

of peer influences on adolescent substance use. In

analyses of substance use done across time, however, only prior drug use and lack of social conformity43 were found to be significantly related to

adolescents’ drug use. Among junior high school

students, for example, the less the social conformity

of the young adolescents, the more likely they were

to think that their peers and adults they knew were

using drugs or alcohol and that the community they

lived in approved of drug use.

Stein, Newcomb, and Bentler, in contrast to

Robinson and colleagues, examined the differential

impact of adolescents’ perceptions about adult and

peer use of different drugs (261). The study found

that adolescents’ perceptions of adult drug use

generally exerted an influence on their own alcohol

‘However, Baurnrind’s work was limited to an essentially white middle-class population and the findings may not apply to families from other ethnic,

racial, or economic backgrounds.

dlFor tier discussion of authoritative parenting and other ftilyWs,see ch. 3, ‘‘Parents and Families’ Influence on Adolescent Hedt.lL’ in this

volume.

qz~e potm~ fipact of family disruption (measured as whether the parents Were married to each other) was not measured until year 5 of the study.

However, in their model, the researchers include family disruption as a variable present in year 1, apparently because they assume that if the parents were

not married to each other in year 5, disruption was present in year 1. This maybe a reasonable assumptio% but it was not tested empirically in the study.

43SWM confo~~ was mwm~ by obedience to law, consematis~ and religious commitment (261).
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-525

use, and perceptions of peer drug use exerted an

influence on their marijuana and other drug use.

Unfortunately, Stein, Newcomb, and Bentler did not

take into account the difference between use and

problem use until year 9 of their study, when

respondents were in the their early twenties. Nevertheless, they did find a statistically significant

relationship between disruptive drug use in year 9

(defined as drinking or using drugs at school or at

work) and any drug use in year 5. Stein, Newcomb,

and Bentler’s work is limited by their reliance on

respondent self-reports, but the study’s use of a

longitudinal design and its interactionist perspective

make it a model for future research.

Personal Characteristics of Adolescent

Substance Users

Is there a type of adolescent who is more likely to

become a substance user? While adolescent substance use cuts across age, gender, racial, ethnic, and

geographic lines, some intriguing research has

explored the possibility that there may be clusters of

personality traits and ways in which some adolescents perceive their environments that indicate a

heightened risk of problem use of psychoactive

substances, as well as other ‘‘problem behaviors. ’

Starting from the premise that certain behaviors

(including marijuana use, problem drinking, and

cigarette smoking) are problem behaviors, Jessor

and colleagues have developed a theory to account

for such behaviors among adolescents (139,140).44

In their model, personality factors combine with an

adolescent’s view of peers and adults to predict

problem behaviors. The personality factors may be

a function of antecedent or background variables

(142). In testing problem behavior theory, Jessor and

his colleagues have found that adolescents who are

more likely to use marijuana or become involved

with drinking place a high value on being critical of

society, a low value on academic achievement, and

a high value on independence; tolerate deviant

behavior; and have lower religiosity (140).

Using both longitudinal and cross-sectional analyses, Jessor and colleagues found that such ‘‘psychosocial unconventionality’ accounted for about a

quarter of the variance in marijuana use (140).

Another set of factors—lower perceived controls by

friends, lower compatibility between what friends

expect and what parents expect, greater influence

from friends than parents, and (most strongly)

greater perceived approval of and models for marijuana use and other problem behaviors among

fiends-accounted for about a third of the variance

in marijuana use (140). Jessor found that problem

drinking 45 had predictors markedly similar to those

of marijuana use—an expected result given the high

correlation between marijuana use and problem . . drinking (139).

Similar associations have been found with other

behavioral factors. Robinson and his colleagues

found that the use of unhealthful weight control

practices (use of diet pills, laxatives, and diuretics

for both boys and girls and self-induced vomiting for

weight control among girls) were also significantly

(although weakly) associated with substance use for

both boys and girls (237).

These findings derived from problem behavior

theory have been instrumental in advancing understanding of the covariation between substance use

and other problems. Nonetheless, problem behavior

theory suffers from several limitations. It provides

only a partial accounting of problem behaviors,

leaving many such behaviors without explanation. It

does not empirically examine the restricted set of

sociological and demographic factors that are its

foundation. But most importantly, the focus on

behaviors, perceived environment, and personality

factors may result in victim blaming and the

channeling of interventions too narrowly toward

individuals and their behavior, to the exclusion of

other possibilities.~

Generally, Baumrind found that adolescent substance use was better predicted by parental behavior

~AIso see D.W, Osgood and J.K. Wilsom “Covariation of Adolescent Health Problems, ” 1990 (216).

45TW0 ~ca~wes of problem Ming ~cre used for ~ese amlyses: fr~uency of d~enness in the past year and drinking-related negatiVe SOCid

consequences.

~~ addition, fic term ‘problem behaviors’ carries an unfortunate comotation and may in some respects be historically and culturally bound, as well

as oriented to adult conceptions of adolescent problcms. For example, ‘‘activist protest” was initially examined as a problem behavior (142); at other

times, or by other analysts, student apathy might legitimately be considered a problem behavior, and activism an indicator of ‘social health’ (96,224).

It is interesting to note that activist protest was not found to fit the explanatory profile for problem behavior (142). Jessor sometimes uses the term

‘ ‘transition proneness’ instead of ‘problem behavior’ to connote that what are termed problem behaviors among adolescents are sometimes reflective

of precocious transitions to adult behaviors, such as the initiation of drinking or sexual intercourse (139). Sometimes, of cou~e, hey tie illegitimate

or problcm behaviors for all ages (e.g., tijuana use, problem drinking).
II-526 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

than by the personal characteristics and early behavior of the adolescents (26). Nevertheless, Baumrind

found that some personal characteristics were associated with substance use. Characteristics of children that Baumrind found to be associated with later

substance use included lack of social confidence

(shyness), as well as problem behavior at age 9.

Baumrind’s findings concerning shyness are consistent with Kellam’s earlier findings (26,157,158).

Attributes of adolescents that Baumrind found to be

related to substance use included low cognitive

competence, concern about peer approval, and lack

of concern about adult approval (26).

Relationship Between Mental Health Problems and

Use of Psychoactive Substances by Adolescents

Do adolescents use and abuse alcohol and other

drugs because they have emotional or other mental

health problems? Little research has addressed this

important question, and the results are inconclusive

(26).

Observers of clinical populations have often

reported a co-occurrence of drug use and other

mental disorders among adolescents (e.g., 249). A

1979 review by Jessor concluded that adolescents’

marijuana use was not related to psychopathology or

maladjustment (136), but some studies have shown

that substance use has been preceded by depressed

mood (153,209). Data from the National Institute of

Mental Health’s Epidemiologic Catchment Area

study suggest that individuals who had a depressive

or anxiety disorder before age 20 were twice as

likely to have a substance use disorder in young

adulthood (60,230). Although this finding does not

necessarily mean that adolescents who use substances have mental health problems, another analysis from the Epidemiological Catchment Area study

found that individuals who reported having used

drugs early (before age 15) also reported a number

of mental health problems at an early age (237).

School, Work, and Societal Impacts on

Psychoactive Substance Use by Adolescents

In comparison to the amount of research on

families and personal characteristics of adolescents,

there has been little empirical research to test the

specific impacts of schools, work, and society on

psychoactive substance use. However, reasonable

hypotheses have been developed based on observations of how these environments affect other aspects

of adolescent development, behavior, and health.

Schools-Schools exert both direct and indirect

influences on patterns of drug and alcohol use (262).

In particular, schools are influential in the kind of

self-concept an adolescent develops.47 Schools influence whom adolescents come into contact with

and help structure the activities of the adolescent

over the course of the week (262). Adolescents

typically make at least two school transitions that

may put them at risk for substance use and abuse: the

elementary to junior or middle high school transition, and the junior or middle high school to high

school transition. Each of these transitions is likely

to take the adolescent from a more to a less personal

and protected school environment (86,89,254). In

addition, school environments differ in exposure to

and acceptability of drugs and alcohol. Young

adolescents who attend school with older teenagers

are more likely than are young adolescents who are

more segregated from older teenagers to be exposed

at an early age to substance use (262).

Some adolescents (e.g., those with prior academic

difficulties, prior psychosocial problems, or who

lose a large number of friends during the school

transition) are at increased risk for adaptational

difficulties (30,240).

Work-Over the past 100 years, adolescents’

access to legitimate adult roles has been increasingly

constrained. Some substance use has been seen as

behavior ‘engaged in out of frustration or alienation

from adult values’ or as behavior ‘‘that affirms in a

distinctively adolescent fashion, teenagers’ desire to

be adultlike” (262). Hence, one might expect

working to decrease substance abuse by adolescents

because it would help them feel more adultlike. The

research evidence suggests that, in fact, work may

increase substance abuse. Several studies indicate

that teenagers who work, especially those who work

long hours, are more likely than are their counterparts who do not work or who work fewer hours to

use and abuse cigarettes, alcohol, and illicit drugs

(121). No studies indicate that working deters drug

and alcohol use by adolescents (96).

Steinberg suggests that some of the same factors

that may increase adolescent substance use at school

transitions-less adult supervision, increased exposure to older adolescents, and stress-may also

47For f~er discussion of tie evidence on how schools affect adolescent heala see ch. 4, “Schools ad Discretionary Time, ” iII Ws vOhIfne.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . //-527

increase working adolescents’ use of psychoactive

substances (262). In addition, paid work provides

increasing financial autonomy and income to buy

alcohol and drugs, and it may diminish school

involvement. It is important to note, however, that

the number of hours worked maybe more predictive

of substance use than whether the adolescent works

or not. According to Steinberg, the evidence is fairly

consistent in indicating that working in excess of 15

hours weekly for high school freshmen and sophomores, and in excess of 20 hours weekly for juniors

and seniors, places adolescents at greatest risk for

work-related problems such as drug abuse (262).

Society—It is ironic that at the same time

adolescents are exposed to public service announcements deploring drug use, they are also exposed to

advertisements and other media presentations that

glorify the use of alcohol and other drugs (107). As

Steinberg notes, ‘ ‘It is difficult indeed for program

developers to persuade adolescents that using drugs

and alcohol is undesirable when these same young

people are bombarded daily with messages designed

to persuade them that they are mood- and imageenhancing” (262).

Other commentators have noted an overall trend

of using more substances as society becomes more

advanced and more complex (213).

Appetitive Effects of Drugs48

Most studies of risk factors for adolescent substance use have addressed the initiation of drug use.

Studies that have looked at what makes adolescents

persist after first using drugs have tended to ignore

the effects of the drugs themselves. A recent

overview of research on models of addiction noted

that theorists were beginning to recognize the

appetitive effects of drugs as important motivators

for drug use (17). This recognition departs from

earlier models of drug motivation that stressed the

reduction of aversive withdrawal symptoms as the

core motivation for addictive drug use (17). Furthermore, it has potential implications for drug abuse

treatment and possibly for prevention:

Conceivably, the person currently experiencing

pleasurable drug effects may be relatively immune to

concerns about potential untoward consequences,

may be especially ‘primed’ to redose with the drug,

may attribute various positive events to the drug, and

so on (17).

The appetitive effects of drugs have not been a

particular focus of explanation for adolescent substance use.

Factors Associated With Adolescents’ Use of

Alcohol and Cigarettes

Factors Associated With Use of Alcohol—

Using survey data collected from 499 10th, 11th, and

12th graders in four large suburban public high

schools, Kline and his colleagues found several

variables related to higher levels of drinking and to

problem drinking behavior:

●

●

●

●

●

adolescents’ ratings of high levels of family

disengagement and poor intrafamily communications;

adolescents’ ratings of peer approval of alcohol

use;

parental approval of alcohol use;

poor social skills;

positive expectancies for alcohol use (161a).

Despite the sophisticated model for statistical analysis Kline and his colleagues used, it is important to

keep in mind that their data were collected in a

cross-sectional survey. Thus, some or all of the

variables-poor social skills, positive expectancies

for alcohol use, peer approval, even poor family

functioning and perceived parental approval---could

have been effects of greater alcohol use rather than

causes. Furthermore, the data were collected from a

student population that was 96 percent white and

may apply only to this population.

Jessor’s research on initiation of drinking suggests that significant psychosocial risk factors (e.g.,

value on academic achievement) can be identified

among adolescents who have not yet begun to drink

(139).

Factors Associated With Use of CigarettesMiller and Slap recently reviewed evidence for the

factors associated with cigarette smoking by adolescents (189). Although hundreds of associations have

been reported in the literature, Miller and Slap’s

review found that the weight of the literature

supported strong and consistent associations of

smoking with only three variables:

48Appe~jn”},e ~ect~ is tic tcm for “s~lly pica.~~able sensations or fwlings such as euphoria—instill a craving (or appetite) for continu~ use of a

substance in order to prolong or re-create the desired effects.
II-528 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

● parental smoking,

● peer smoking, and

● sibling smoking (189).

The variables they found not to have strong and

consistent associations with smoking by adolescents

were knowledge and attitudes about smoking, demographic factors, school activities, and psychologic

factors. Miller and Slap noted, however, that several

flaws in the research methods used to investigate

risk factors for smoking limit interpretation of all

such data, and they concluded that the research

evidence had little utility for the design of interventions.

Summary: Factors Associated With Psychoactive

Substance Use and Abuse by Adolescents

The epidemiological evidence on the prevalence

of psychoactive substance use by adolescents and

the evidence on risk factors suggest that the use of

alcohol or other drugs by adolescents cannot be

considered a single behavior with a simple cause. To

some extent, one-time use of some psychoactive

substances (especially alcohol and tobacco, but

perhaps even marijuana) is common among contemporary U.S. adolescents, but one-time use does not

necessarily suggest the presence of some untoward

risk factor. For very low levels of use of some

substances, it would be difficult to distinguish

between the characteristics and social circumstances

of users and nonusers.

On the other hand, a number of risk factors have

been associated with frequent or heavy use of

psychoactive substances (with such use defined

differently in different studies for different substances). These risk factors for frequent or heavy use

include substance-abusing parents, dysfunctional

families, placing a low value on academic achievement, having low cognitive competence, early

problem behaviors, being shy, having non-drugrelated mental health problems, and association with

drug-using peers.

Much of what is known about risk factors for

adolescents’ abuse of alcohol and other drugs and

the implications for the prevention of such abuse is

summed up by Steinberg, in his review for OSAP in

DHHS (263). In that review, Steinberg concluded:

. . . the young person who approaches adulthood

with a sense of confidence and purpose and with

well-developed social and instrumental competencies; who associates with peers who value achievement and responsible behavior and who devalue

drug and alcohol use; and who spends time in

settings which are adequately supervised by adults is

at relatively low risk for substance abuse. In contrast,

the young person who has few present skills and little

hope for the future; who associates with peers who

embrace an antisocial or a pro-drug lifestyle; and

who spends a large part of his or her day isolated

from adults runs the risk of developing drug and

alcohol problems (263).

One policy dilemma may lie in deciding how to

allocate resources among different approaches to the

problems of psychoactive substance use by adolescents. Alternatives include reducing the supply of

drugs, 49 reducing the demand for drugs (e.g., by

efforts to prevent any use of any psychoactive

substance by any adolescent or to prevent use that

results in injury, incapacity, dysfunctionality, destruction, or damage to self or others), and treating

adolescents with substance use problems who appear to be in the most trouble. Unfortunately, as the

preceding discussion on risk factors and the discussion below on consequences of adolescent drug use

suggest, available research provides only partial

guidance on this question.

Consequences of Psychoactive Substance Use

by Adolescents

Given concerns about the harmful consequences

of psychoactive substance use, it is surprising that

the research literature on the short-term and longer

term effects on adolescents is so sparse (25,152). As

Newcomb and Bentler have stated, “Following the

area of treatment, consequences of teenage drug use

are the second least understood and researched area

of child and teenage substance use’ (208). The

research literature on adolescent substance use is

replete with studies on risk factors, age of onset, and

incidence and prevalence, but the implications of use

for the mental, physical, and social development of

49supp/y Sj~e prevention effo~ ~ve ~cluded le@51ative effom to prohibit the sale and consumption of alcoholic beverages (e.g., tie 181h amendment

to the U.S. Constitution minimum drinlun‘ g age laws); to restrict access to pharmacologic agents (e.g., interdictio~ treaties on psychotropic drugs, the

Uniform Controlled Substances Act [Public Law 91-513; 21 U.S.C. 800 et seq. and 21 U.S.C. 100 et seq]); and to regulate the availability of tobacco

products and alcohol (e.g., advertising codes, laws banning cigarette vending machines). Supply side prevention efforts have tended to be oriented toward

law enforcement, regulation, and punitive measures imposed on violators (195). Demund side prevention has sought methods of deterring use through

information+ Persuasion development of alternatives, and the enhancement of individual and family resistance to potential abuse.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services ● II-529

adolescents are only recently receiving the attention

of serious investigators. Kandel notes:

Despite the initiation of a relatively large number

of longitudinal studies in the last decade, more is

known at this time about the antecedents of initiation

of drug use than about the consequences of use either

in adolescence or in young adulthood. Very little is

known about how patterns of drug use affect health,

psychological well-being, and adult participation in

the labor force, marriage, or parenthood (152),

In addition, most of what is known establishes the

coexistence of certain adolescent health problems

(e.g., delinquent behavior, drug use, pregnancy

[216]), but not that one problem causes another.50

This section will examine briefly the association

between adolescent substance use and subsequent

physical and mental health problems, educational

achievement and employment, adolescent sexual

activity and pregnancy, marriage and divorce, and

delinquency.

Physical Health Consequences

 51 The pharmacologic effects of various psychoactive substances on the human body have been widely

studied. Box 12-A, presented earlier in this chapter,

notes some of the pharmacologic actions of major

classes of psychoactive substances. Few studies

have been done on the effects of psychoactive

substances on adolescents.

In addition to the properties of drugs noted in box

12-A, the mode of ingestion clearly has health

implications. For example, the ingestion of nicotine

by smoking tobacco has different effects than the

chewing of smokeless tobacco does (317,320).

Similarly, the ingestion of cocaine by smoking

freebase has effects that differ from the effects of

snorting powder cocaine. The hazards to adolescents

of human immunodeficiency virus (HIV) infection

associated with the sharing of dirty needles or other

intravenous drug use equipment are well-established.52 Inhalation of solvents or aerosols can cause

liver damage, cardiac arrest, or neurological damage

(62,68).53 Another mode of death is through suffocation due to inhalation of a solvent in a closed space

(i.e., a plastic garment bag).

As noted above, relatively few adolescents die

from unintentional drug poisoning. In 1988, the

NIDA DAWN system reported that 9 adolescents

between 10 and 14 years of age and 79 15- to

17-year-olds died as a result of drug toxicity (302).

Suicide attempts, however, are a different story. Of

the 13,975 adolescents between 10 and 17 years of

age who were brought to emergency medical services responding to the DAWN survey in 1988, 61.8

percent were suicide-related drug cases (302). Thus,

intentional overdose is a more serious threat to life

than unintentional poisoning from a lethal dosage.

While alcohol has been extensively studied in

connection with accidental injuries,54 other drugs

have not (202). No systematic epidemiological

studies have been conducted to identify what role

other drugs may play in various injury events.

Nonetheless, it is likely that substances other than

alcohol share some common traits which increase

risk of accidental injury or death. Thus, it may be

instructive for future research to examine what is

known about the consequences of illicit and other

drug use on adolescent accidents and injuries.

It is well established that alcohol use contributes

to a significant number of adolescent accidents and

injuries. The most obvious examples of alcohol’s

role in adolescent injuries are automobile accidents

in which alcohol is a factor. Adolescents are at

higher risk than adults of becoming involved in a

motor vehicle accident if they have been drinking

(167). In 1984, for example, 15- to 24-year-olds

constituted 20 percent of the population but accounted for 35 percent of drinking driver deaths. In

~For a fuller exploration of tie significance of covariation among selected health compromising behaviors, see D.W. Osgood ~d J.T. WilsoL

“Covariation of Adolescent Health Problems, ” 1990 (216).

slf’har~coz~gic means related to the nature, chemistry, effects, ~d uses of tigs.

52 For f~er infomtion on ~-mission of tie MV “lms, acquir~ immunodeficiency syndrome (AIDs), and AIDs-related complex, S(X ch. 9,

“AIDS and Sexually Transmitted Diseases: Prevention and Services, ’ in this volume.

s~Ac~ordlng t. Cohen (62), some of tie “olatlle solvents are known poisons, including carbon tetracldoride, benzene, hexane, ~d leaded gasoline.

Hcxanc and leaded gasoline can cause polyneuritis, and the latter can produce encephalopathy. Toluene has been linked to disorders of the kidney,

nervous system, and bone marrow. Sudden sniffing death may result when a solvent or aerosol propellant is inhaled and the oxygen content of the blood

is reduced. Ventricular fibrillation or other arrhythmia occurs and the person dies abruptly (62). Inhalants tend to be subject to “fad’ use. Gasoline,

vegetable oil spray, tmnsmission fluid, liquid shoe polish, amyl nitrite, isobutyl nitrite, gold or bronze paint sprays, paint thinners, and model airplane

glue have been used at various times.

5’$For further discussion, see ch. 5, “Accidental Injuries: Prevention and Services, ” in this volume.
//-530 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

1988, 3,158 adolescents ages 15 to 19 died in

alcohol-related crashes (324).

Alcohol is also involved in nearly 40 percent of

adolescent drownings (132,215,217,259,335). And,

when fatal pedestrian and bicycle accidents are

evaluated, alcohol again assumes a major role. In

1988, nearly a third of the victims of fatal pedestrian

or bicycle accidents had a blood alcohol content of

0.01 percent or more, and approximately a quarter of

those victims had blood alcohol concentrations in

excess of 0.10 percent (324). Thus, as discussed

elsewhere in this Report, it appears to take less

alcohol to precipitate accidents among young people

than among older adults.55

Mental Health Consequences

Just as mental health problems as predictors of

adolescent drug use have not been studied extensively, the mental health consequences of adolescent

drug use have received little attention. In a 1986

study by Kandel and her colleagues, adolescent

smoking predicted elevated depressive mood scores

among female young adults and elevated scores on

a psychosomaticism scale among male young adults

(152). Illicit drug use also predicted greater likelihood of consultation with a mental health professional (particularly among females). “Thus,” the

authors conclude, ‘‘while use of cigarettes predicted

dysphoric mood, only illicit drug use predicted

discomfort severe enough to seek help from a

professional” (152).

Newcomb and Bentler’s research also suggests

that specific types of drugs produce different mental

health consequences (208). For example, frequent

use of cocaine among the adolescents they studied

increased loneliness, suicidal thinking, and psychotic behavior, while decreasing the user’s social

supports. On the other hand, alcohol (when used by

itself) reduced loneliness, increased social support,

and enhanced the drinker’s positive self-feelings

(208).

Educational Consequences

In 1988, Mensch and Kandel examined the

relationship between drug use and the likelihood an

adolescent would drop out of school (184). Using

event-history analysis (which specifies the dynamic

relationship between the use of drugs and completion of one’s education), they examined data from

the National Longitudinal Survey of Young Adults,

which interviewed over 12,000 subjects aged 19 to

27 in 1984, 5 years after the initial survey. They

found that prior use of cigarettes,56 marijuana, 57 

or

other illicit drugs58 increased the propensity of both

sexes to drop out of school. The earlier an adolescent

was initiated into use (of alcohol, marijuana, or other

illicit drugs for males or cigarettes and marijuana for

females), 59 the more likely it was that he or she

would not have graduated from school by the time of

the survey. In their multivariate analysis, Mensch

and Kandel controlled for various factors (e.g.,

parental education, family intactness, self-esteem)

that could influence both drug use and dropping out

of school, leading them to the conclusion that

dropping out is a partial function of drug use itself.

At the same time, however, Mensch and Kandel

found that early intercourse and pregnancy among

females were both very highly related to dropping

out of school and were more likely to lead to

dropping out than was early drug use (184).60

In an earlier analysis based on data from 1,004

men and women interviewed when they were 15 or

16 and then reinterviewed in 1980-1981 at age 25,

Kandel and her colleagues found that substance use

during adolescence61 had very little effect on the

level of education attained by young adulthood

(339). The most predictive factor related to eventual

educational level was the educational aspiration of

the adolescent.

Employment-Related Consequences

Using life and drug histories of 1,325 young

adults aged 24 and 25 in 1980-1981, Kandel and

Yamaguchi found that those interviewed who were

S5S~ ch. 5, “~ciden~ Injuries: Prevention and Services, ” in t.hk vOhlme.

SsM~ures of use: Ever, last year, or 100 or more times ever.

sTM~ures of use: Ever, last year, or one or more packs per day in the hM 30 @ys.

ssM~ures of use: Ever, last year, or 40 or more times ever.

sgMemch ~d Kmdel a~bute tie gender differences to differences in tie soci~ impfi~tio~ of these subswcti fOr IlldeS ad femd~ (184).

60Ch. I(), ‘‘pre~cy and PMentig: Prevention and SerViCeS, “ in this volume, considers risk factors for, and consequences of, adolescent sexual

activity and pregnancy.

Slsuch use was defin~ as use of any of 12 classes of drugs 10 or more times in a lifethe.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-531

ever illicit drug users in adolescence tended to have

greater difficulty in obtaining and holding a job

(155). These young adults also had a higher rate of

unemployment and had experienced greater turnover than their cohorts who had not used drugs in the

10th and 11th grades. However, Kandel and Yamaguchi point out that the causal order between job

turnover and drug use is far from clear (152,155).

There may be preexisting differences among individuals who start using drugs, and the relationships

among employment problems and drug use may be

attributable to these underlying variables rather than

to the drugs themselves.

Sexual Activity, Pregnancy, and

Pregnancy Outcomes

The use of drugs-including cigarettes and alcohol—

by adolescents has been associated with early sexual

experimentation and permissive attitudes about

sexual behavior (216,338).62 Various studies have

revealed a clustering of the variables of early sexual

behavior in adolescents and early onset of the use of

alcohol and tobacco (137, 141 ,216), The Institute of

Medicine cautions, however, that a causal link

between alcohol use and early sexual activity has not

been proven, despite the disinhibitory effects of

alcohol (200).

Studies have varied as to whether there is a

relationship between the use of illicit drugs and

premarital pregnancy (216). A 1980-81 study of 706

New York women who had participated in an earlier

adolescent survey in 1971-72 indicated that women

currently or formerly using illicit drugs other than

marijuana were about twice as likely as other women

to become pregnant before marriage (338), Similarly, Elster and his colleagues found that male and

female adolescents who used marijuana and other

drugs were about twice as likely as nonusers to

become parents during adolescence (84a). In reviewing these and other findings, Osgood and

Wilson noted that the findings relating substance use

to adolescent parenthood and pregnancy were roughly

evenly divided between significant positive associations and statistically insignificant relationships

(216). Those relationships that were found (e.g.,

84a,338) were generally weak (216). A more recent

study by the U.S. General Accounting Office (GAO)

came to the same conclusions (283).

Poor pregnancy outcomes have been associated

with smoking and other drug use in several studies

of adult mothers (185,210,226,328). For example,

mothers who smoke risk preterm delivery, premature detachment of the placenta with adverse consequences for the mother, placenta previa,63 bleeding

during pregnancy, and prolonged premature rupture

of membranes, as well as exposing their infants to

low birthweight and impaired physical and intellectual development (185,317). The use of alcohol

(286) and crack cocaine (283a) by pregnant women

can have serious consequences for their infants.

In addition, some studies have found a relationship between drug use and the presence of a sexually

transmitted disease (216).

Marriage and Divorce

Young adults aged 24 to 25 who used drugs as

10th and 11th graders were found, in two studies, to

be more likely than nonusers to become separated or

divorced from their spouses (152,339). Newcomb

and Bentler ascribe these consequences to stunted

maturation:

Childhood and adolescence are critical periods for

the development of both personal and interpersonal

competence, coping skills, and responsible decisionmaking. Drug use is a manner of coping that can

interfere with or preclude the necessary development

of these other critical skills if it is engaged in

regularly at a young age. For instance, if a young

teenager learns to use alcohol as a way to reduce

distress, he or she may never learn other coping skills

to ameliorate distress. Thus, teenage drug use may

truncate, interfere with, or circumvent essential

maturational processes and development that typically occur during adolescence. As one result,

teenage drug users enter adult roles of marriage and

work prematurely and without adequate socioemotional growth and often experience greater failure in

these adult roles (208).

GzSee ch. 9, “AIDS and Other Sexually Transmitted Diseases: Prevention and Services, ” and ch. 10, ‘‘Pregnancy and Parenting: Prevention and

Services, ’ both in this volume, for a discussion of U.S. adolescents’ sexual behavior and issues related to pregnancy and parenting among U.S.

adolescents.

63p/acen[a *reL,ia is a condition ~ which tie placenta develops in the lower uterine segment, in the zone of dilatation, so hat it cove~ or adjoins the

internal OS. Painless hemorrhage may result.
//-532 . Adolescent Health—Volume //: Background and the Effectiveness of Selected Prevention and Treatment Services

Delinquency

The link between drug use and other forms of

adolescent delinquent behavior64 is well established

(82,84,143,278), although far from every drug-using

adolescent engages in other forms of delinquent

behavior (216).65 For example, in 1970, Robins and

colleagues found that men who were marijuana users

in adolescence were more likely as young adults to

be violent, have police records, and to fail to

graduate from high school (234). But the nature of

that association is more elusive, despite the popular

notion of the individual led into a life of crime by

drugs. A basic question is whether drug use and

delinquency are part of a single syndrome or whether

developmental stages can be identified when each of

these problems emerge (146,236). Examining a

national sample of adolescents, Elliott and Huizinga

found that delinquent activities preceded experimentation with illicit drugs in about half of the

subjects involved with both substance use and

delinquency (82). The question of a common etiology remained unresolved.

Kandel, Davies, and others looked into this issue

in 1986 and found that there was a predictive

association between adolescent involvement with

illicit drugs and subsequent engagement in theft

among both males and females (339). They did not

find a similar correlation between drug use and

interpersonal aggression (fighting). Yamaguchi and

Kandel found that any marijuana use in the period

from adolescence to early adulthood predicts interpersonal aggression (for women) and use of other

illicit drugs predicts participation in theft (339).

What Level of Psychoactive Substance Use Is

Harmful to Adolescents?

While the preceding review of research on psychoactive substance use suggests that there are

potentially harmful consequences associated with

adolescent use of alcohol and other drugs, some

investigators have challenged the notion that any

substance use, however limited, will typically produce negative effects. These researchers suggest that

experimental use of psychoactive substances66 by

adolescents is not necessarily harmful (25,208,252).67

In fact, Newcomb and Bentler argue, “Infrequent,

intermittent, or occasional use of drugs by a basically healthy teenager probably has few short-term

and no long-term negative or adverse consequences

(25). Baumrind echoes a similar sentiment, seeing

adolescent experimentation of various kinds as

being more “health-enhancing” than are riskavoidant behaviors that are phobic or sedentary (25).

For example, Baumrind cautions,

We have yet to subject to rigorous empirical tests

the various hypotheses proposing that adolescent

experimentation with psychoactive drugs has dysfunctional consequences. Thus, in my opinion, we

still cannot show that regular marijuana use is

implicated in a causal nexus which produces drug

dependence or a dropout mentality, or lack of

motivation to achieve and develop, or cognitive

decrements relative to a previous level of functioning (25).

As evidence for this perspective, Baumrind points to

studies that show that experimental or Light marijuana use in nondelinquent populations is associated

with such positive attributes as independence, friendliness, self-confidence, and intelligence (25).68 New64s= Ch. 13, “Del@ u~cy: Prevention and Semices, ” for a detailed discussion of delinquent behavior during adolescence.

65~ ~e~ ~cvlew for OTA, Osgood ~d Wilson fo~d co~elation coefficients for tie relatio~p be~een tiolescent delinquency ~d the use Of

various substances ranging from 0.23 (tobacco and delinquency, males) to 0.53 (alcohol and delinquency, males) (216). While all correlation coefficients

reported in the literature were statistically significant (that is, they were more likely to reflect a “real” relationship than to reflect a chance occurrence)

and positive (that is, the more likely there was to be use of alcohol, other drugs, or tobacco, the more [rather than less] likely there was to be involvement

in delinquent activities), the correlations were not perfect. A perfect correlation is reflected by a coefficient of 1.0. Correlation coefficients can be negative

or positive.

fiExpen”menfa/ ~~e refers t. tie act of using a psychoactive substance and experiencing its effw~ ~ a novel~ prompted by fiosi~.

67However , some reww~he~ believe tit mere is a cle~ sequen~ ord~ of pmfy~sion from childhood or adolescent klvolvement wiIh SUbS@llCCS

that are legal for adults (e.g., alcohol, tobacco) to illegal drugs ( 155). In their view, use of one substance opens the ‘gate’ to another. As Newcomb and

Bentler explained:

“Past behavior is often the best predictor of future behavior, and in drug use this consistency extends to variants of the behavior in which similar

but less serious types of drug use are good predictors of subsequent use of more serious drugs. A typical progression maybe starting with coffee

and tea, beer or wine, or cigarettes, moving to hard liquor and marijuana, and subsequently moving on to other illicit drugs such as amphetamines,

cocaine, or heroin” (153).

However, Newcomb and Bentler caution that the gateway drug theory should not be overinterpreted: ‘‘Involvement atone stage does not necessarily

lead to involvement at the next stage; rather, involvement at the next stage is unlikely without prior involvement in the previous stage” (208).

~These s~dies demo~mte covariance but not causation.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . //-533

comb and Bentler found that in the quantities

typically used by normal adolescents, cigarettes

were more harmful to adolescent health than alcohol, marijuana, or most other drugs over a 4-year

period (208).

Other researchers suggest that alcohol or other

drug use during adolescence does not necessarily

mean that drug use will be continued later in life

(e.g., 139,208). For example, among the adolescents

studied by Jessor, half (51 percent) of the males who

were problem drinkers in 1972 were also problem

drinkers in 1979 to 1981, while half (49 percent)

were nonproblem drinkers (74,139). For females, the

decline in problem drinking was more pronounced—

26 percent of the problem drinkers in 1972 were

problem drinkers in 1979 to 1981.

Similarly, the ‘ ‘sniffing” of psychoactive solvents (many of which are extremely toxic) is an

abusive behavior that also seems to be abandoned by

most users as they grow older. Research suggests

that users often ‘‘mature out’ of solvent inhalation

(62,68).

The seeming contradiction between research showing that drug use can have harmful effects during

adolescence and afterward and studies showing no

harmful (and even some positive) effects may

reflect, at least in part, the differential consequences

of using different study populations, different levels

of drug use, and different research designs in the

available studies (216). For example, Baumrind

generally uses a higher level of drug involvement

than the “any use” standard employed by Kandel

and her colleagues to define drug users (26).

Similarly, Baumrind would remove such “heavy

users” from the pool of research subjects when

analyzing the effects of ‘ ‘experimental use” on

adolescents. Thus, design distinctions cart profoundly alter the database and permit or prevent

discrete analysis of selected categories-thereby

giving rise to results which appear to be in conflict

with related data developed through a different

approach. The lack of uniform definitions and

consistent controlled variables, differences in populations (e.g., by age, geographic region, racial and

ethnic composition), the inclusion or exclusion of

particular substances-all combine to make analyses across studies exceedingly difficult and cloud

efforts to measure the consequences of adolescent

drug use.

Economic Costs of Drug Abuse by Adolescents

The economic costs to society of use and abuse of

alcohol, tobacco, and drugs by U.S. adolescents ages

10 to 18 have not been estimated. The closest current

estimates of some of the economic costs to society

come from a report by Rice and her colleagues to

ADAMHA’s Office of Financing and Coverage

Policy in DHHS (233).

In their report, Rice and her colleagues were able

to estimate 1985 core costs—i.e., ‘‘all costs directly

related to the treatment and support of persons with

[alcohol and drug abuse] disorders as well as the

indirect costs associated with these disorders’ ‘—for

alcohol and drug abuse problems for individuals

under age 15 and ages 15 to 44 (233).6970 71 Rice and

her colleagues did not include the costs of smoking

or other tobacco use in this study.

Rice and her colleagues estimated core costs

related to alcohol abuse to be $58.1 billion, of which

$796 million (1 percent) could be allocated to

individuals under 15 and $34.9 billion (60 percent)

to individuals ages 15 to 44 (233). Core costs related

to illicit drug abuse were estimated to be $10.6

billion, of which $98 million (1 percent) could be

allocated to individuals under 15 and $7.2 billion (68

percent) to individuals ages 15 to 44 (233). In

addition to estimating core costs related to alcohol

and drug abuse, Rice and her colleagues estimated

other related costs. Other related costs included

direct [related] costs of crime, motor vehicle crashes,

social welfare program administrative costs, and

costs associated with the destruction of property by

69Direcr ~oSIS inc]u~ed by Rice and Collmgues were the amounts spent in 1985 for personal health care for persons suffering from alcohol ~d drug

abuse disorders, including hospital and nursing home care, physician and other professional services, and prescription drugs. Also included indirect costs

were support costs related to the treatment of alcohol and drug abuse disorders, such as expenditures for research, training costs for physicians and nurses,

program administratio~ and net cost of private insurance, Indirect costs were the value of lost output resulting from reduced productivity, lost work and

housekeeping days, and losses due to premature death from alcohol and drug abuse disorders. For all ages together, core costs accounted for 83 percent

of total alcohol abuse costs and 24 percent of drug abuse costs (233).

7oR1ce notes tit ~c under age 15 Woup inc]udes costs for 15. to lv-yem-olds for sever~ cost categories (including alcohol, drug abuse, and sp~lalty

institu[iom and Federal providers); thus, the costs of the under age 15 group are overstated, and the costs for the 15 to 44 age group are correspondingly

understated m some instances (233).

T] Total econo~c costs (lnc]udlng core ,md noncore costs) Were ~s(fi:it~ at $7~,3 billion for alcohol abuse and $44.1 billion for drug abuse (233).
II-534 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

free. They also included indirect [related] costs of

productivity losses for victims of crime, incarceration, crime careers, and time spent to care for family

members because of their. . illness” (233). Other

related costs of alcohol and illicit drug abuse could

not be estimated separately for individuals under 15

(233).

Prevention of Alcohol, Tobacco, and

Drug Use and Abuse by Adolescents

Drawing from the common view that “an ounce

of prevention is worth a pound of cure, ’ numerous

strategies have been devised to prevent psychoactive

substance abuse within American society .72

Primary and secondary prevention efforts have

included both efforts to reduce the supply of drugs

(e.g., minimum drinking age laws, drug interdiction

efforts, laws banning cigarette vending machines)

and efforts to curb demand for drugs (e.g., educational efforts, alternatives programs, resistance

skills training). The discussion that follows focuses

primarily on demand side prevention approaches but

also considers some supply side approaches.

Demand Side Prevention Efforts

Historical Perspectives

Some of the frost demand side prevention efforts

emphasized the harmful effects of substances of

different kinds (197a). At the turn of the century,

Carrie Nation popularized the “home-wrecking”

potential of ‘Demon Rum.’ An anticigarette league

was active in the 1920s, and films like “Reefer

Madness’ in the 1930s associated marijuana use

with depravity, Scare tactics are still employed

today, despite the fact that a considerable body of

research has demonstrated they are ineffective and

can sometimes stimulate experimentation

(20,36,116,125,160,228, 241,266).

In large part, confidence in the fear-based appeals

of the nascent prevention movement yielded to

reliance on knowledge-based programs designed to

disseminate factual information about drugs and

their adverse consequences and “affective education ‘‘ intended to clarify values and improve selfesteem and interpersonal social skills. As public

concern about adolescent substance use grew in the

1970s, combinations of information and affective

education programs were increasingly employed as

prevention measures (19).

More recently, approaches to prevention variously termed social influence (227), psychosocial

(36), or risk factor (53a) models have been devised

to counteract environmental messages and peer

behaviors which promote adolescent substance use.

These approaches seek to “inoculate” a person

against the social pressures which lead to undesirable substance use. They stress techniques for “saying no’ to inducements to use a substance (“resistance skills”) (113) and may also include more

general life skills and social assertiveness training

(36,40,128,220,221).

At the same time these individually targeted,

psychosocial approaches are being developed and

tested, informational approaches, such as those

using mass media, have continued (e.g., 24,33,34).

Most recently, so-called systemic, broad-based, or

comprehensive approaches to prevent adolescent

drug use have been implemented (e.g., 220,221,223,

311). In these approaches, multiple members of local

communities (e.g., business, political, and other

community leaders, parents, teachers) and multiple

channels (e.g., media, school curricula) are used in

the prevention effort (113,313).

Categorizing Contemporary Demand Side

Prevention Programs

Substance use prevention programs for adolescents can be categorized in a number of different

ways, and the absence of a uniform typology can be

confusing. One way of categorizing demand side

prevention programs is to examine what strategies

are used to produce a desired outcome—the ‘‘how’

of the programs. Another way is to distinguish

among the kinds of sites where activities occur—the

‘‘where of program delivery. A third way is to

examine what groups are their intended participants—

the “who” of the programs.

Prevention Strategies--Using the first approach—

categorizing prevention programs by examining

TzPn”mV ~reven~on s~atc@es tie efforts to stop or modify the initial use of substances like idcohol, tobacco, tigs, md ~~ts. ~ec~n~~~

prevention strategies are efforls to shorten the course of an illness or conditiou or end a bebavior after it has been initiated, usually by early identifkation

and rapid intervention. In the field of drug abuse preventio~ primary and secondary prevention efforts are often difficult to distinguish in practice, because

target groups (e.g., groups of adolescent students, communities) may include some drug users. Early intervention efforts, such as student assistance

programs, are discussed in the treatment section, below.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-535

what strategies are used to produce a desired

outcome-one finds some of the major models of

demand side prevention programs identified in the

literature to be the following:

●

●

●

●

●

●

u

Knowledge/attitudes-based model—This assumes

that increased knowledge about the consequences of substance use will increase negative

attitudes and thereby reduce the likelihood of

use (195).

Normative education—This aims to correct

misperceptions about high levels of drug use by

others (1 19).

Affective education model (sometimes called a

‘ ‘values/decisionmaking model)---This focuses

on the individual and teaches self-examination

and responsible decisionmaking consistent with

one’s values (195).

Resistance skills model-This helps adolescents identify sources of pressure to conform

and teaches methods of countering negative

influences (1 13,195,227).

Life skills training model—This combines drugspecific resistance skills training with training

in more generic personal and social skills

(36,37).

Alternative program model—This is designed

to provide adolescents with constructive community activities and opportunities for recognition or to offer high-risk adolescents special

opportunities to compensate for the environmental deficits in their lives (274).

Sites--Using the second approach-categorizing

prevention programs by the kinds of sites where

activities occur-one finds that schools frequently

have served as delivery sites. Schools have been the

most popular location of programs in part because

they offer a‘ ‘captive’ audience and convenience of

administration.

One of the factors that may influence site location

outside of a school setting is the target population.

For example, if a program is intended to reach school

dropouts, a school-based initiative may not be the

most conducive to encouraging participation.

Family, peer, and community-based efforts have

been less common than traditional school-based

programs led by a teacher or primary prevention

staff, although they are growing in acceptance

(1 13,195). Family educational efforts may be provided in the school, home, or in a community

facility. These programs typically provide parent

education and training. Similarly, peer-based programs (i.e., programs which emphasize peer interaction and are sometimes led by adolescent peer role

models)--while often implemented in the school

setting---an be based in adolescent recreational

programs or other places where young people gather.

Churches, mental health centers, social clubs, hospitals, and work sites are also used on occasion as

community-based sites for adolescent primary prevention activities. On occasion, site selection also

may be based on facilities used by ethnic social

networks.

Media campaigns have been a popular means of

disseminating information through television, radio,

posters, and newspapers and magazines. While they

are not site-specific in the same manner as school or

community-based programs, media campaign materials may emphasize certain distribution channels

over other available alternatives (e.g., posters on

buses, pamphlets in certain locations frequented by

adolescents, advertisements placed in selected publications or television time slots).

Target Populations----Using the third way—

categorizing prevention programs through an examination of the groups who are their intended participants-one finds that some programs target all

adolescents---either with or without specific age

groupings. Others focus on adolescents they consider to be at “high risk” for substance use

(frequently school dropouts, youth from disadvantaged homes, or minorities) or a particular peer

group. Parents or families of adolescents may also

become the focal points of prevention programs.

And, finally, broad-based prevention programs may

target an entire community for environmental or

attitudinal change.

Summary—While these various methods of conceptualizing demand side prevention programs all

provide some insights, the reality is that many

programs, even those cited in the research literature,

‘‘mix-and-match’ components in permutations that

defy categorization. One seldom finds a “pure”

model. Analyzing the types of preventive interventions being used in schools and communities across

the country is even more difficult, because of the

variety of approaches being used. A review of recent

innovative projects (see below) illustrates this point.
//-536 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Effectiveness of Demand Side Substance Use

Prevention Efforts

As noted above and in table 12-9, current demand

side prevention programs targeting (for the most

part) individual adolescents can be categorized as

information-based approaches, programs with a

resistance skills emphasis, life skills training programs, comprehensive community programming

with an initial focus on school-based resistance

skills training, comprehensive health education and

alternatives approaches. In addition to programs

targeting adolescents, noncoercive prevention programs have targeted parents of adolescents.

Mass Media Prevention Programs--Mass media

has been one of the Nation’s most predominant

channels for antidrug messages in the late 1980s and

early 1990s. Programs of this type are among the

most difficult to evaluate systematically because

there are few ways to control exposure to the

message, Further, at the same time individuals are

exposed to antidrug media campaigns, they may be

receiving numerous other messages, both consistent

and conflicting with antidrug themes. Perhaps for

this reason, the evidence on the effectiveness of

mass media campaigns in reducing or preventing

drug use and abuse is—and will probably remain—

inconclusive.

One example of a national mass media approach

to prevention is the Partnership for a Drug-Free

America (33,34). The Partnership has saturated the

electronic and print media with negative messages

about drugs in order to create an environment that is

hostile to substance-abusing behavior by influencing community attitudes (33,34). Partnership ads are

designed to reverse positive perceptions about

marijuana, cocaine, and crack and to dispel the

notion that drug users are popular. Many of the ads

appear on prime time television, and many use scare

tactics. According to Black, the Partnership for a

Drug-Free America is the largest advertising effort

ever undertaken in the United States (34).

There have been no rigorous tests of the effectiveness of the Partnership for a Drug-Free America

campaign. An evaluation of the Partnership for a

Drug-Free America campaign reported by Black

attempted to distinguish between ‘‘high exposure’

and other media markets, but there appear to have

been problems making this distinction (34). In

addition, no tests of statistical significance were

reported (34). Black did conclude, however, that

13- to 17-year-olds surveyed as part of the evaluation were the age group least likely to appear to have

been influenced by Partnership ads (34).

Bauman and colleagues recently found that radio

and television antismoking campaigns targeted towards adolescents in the Southeast United States

were not successful in reducing smoking (24).

On the other hand, analyses by Bachman and his

colleagues of trends in behavioral change (i.e.,

reported drug use) and perceptions related to drug

use (i.e., perceived health risks, perceived social

disapproval, availability of drugs) suggest that

fear-based campaigns such as the Partnership’s

(which saturated many media from spring 1987 on)

may be at least somewhat influential in reducing

drug use (1 1,12). Bachman and his colleagues have

found that as high school seniors’ perceptions of

risks associated with marijuana and cocaine use

increased, their use of these drugs declined (1 1,12).

Adolescent Alcohol Prevention Trial (AAPT)-

In addition to information delivered through the

mass media, information-based approaches to prevention are delivered as part of classroom-based

prevention strategies.73 One example is AAPT,

which was designed in part to test the effectiveness

of an alcohol abuse prevention curriculum based on

normative education (119). The AAPT curriculum is

based on research indicating that adolescents overestimate the prevalence of substance use, and it

consists of eight sessions devoted to correcting

misperceptions about adolescents’ use of alcohol

and other drugs (with an emphasis on alcohol) and

about the acceptability of drug use by adolescents.

Graham and colleagues performed a l-year followup study designed to test AAPT’s effectiveness

with respect to seventh graders’ use of alcohol,

cigarettes, and marijuana. Defining success in terms

of participants’ probability of remaining in ‘‘no

use’ status, as compared to a comparison group,

Graham and his colleagues found that the program

was most successful with students who had not tried

any of the study drugs at the beginning of seventh

grade. It was least successful with students who had

tried tobacco by the beginning of the seventh grade

73A~ noted by Good~~dt ~d ~tche~, tie provision of some ~nd of ~g.related ~o~tion is pm of every school-based dlllg education prO~am

(113).
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services ● II-537

Table 12-9-Overview of Selected Substance Abuse Prevention Programs

Target Target Approach/ Representative

Programa population substances setting studies b

Information-based approaches

1. Mass media Community at Marijuana

large Cocaine

Tobacco

2. AAPT 7th grade Alcohol

Tobacco

Resistance skills emphasis

Project SMART

DARE Program

Project ALERT

Life skills training

7th grade Alcohol

Tobacco

Marijuana

5th & 6th Drugs

grades Alcohol

Tobacco

7th grade Tobacco

Alcohol

Marijuana

7th to 10th grades Tobacco

Marijuana

Alcohol

Comprehensive community programming with an initial focus

on school-based resistance skills training

Project STAR 6th or 7th grade (grade Tobacco

of transition to middle or Marijuana

junior high school) Cocaine

Comprehensive health education

Kindergarten through All unhealthful

12th grade life-styles including substance

abuse

Parent education

Parents Varied

Information/fear

Normative education.

Resistance skills, affective education.

Peer pressure resistance training delivered in classrooms

by police officers.

Information, normative education, resistance skills in a

school setting.

Personal and social skills (e.g.,

resistance skills, assertiveness, self-control, cognitive

skills) taught through a combination of instruction, demonstration, feedback, reinforcement, behavioral rehearsal (practice during

class), and extended

practice.

Psychological consequences,

normative education, resistance skills training for adolescents, plus parent involvement in homework,

media coverage.

Information/affective

education.

Varied

plus

Black, 1991; Bauman, 1991

Graham, Collins, Wugalter, et

al., 1991

Hansen, Malotte, and Fielding,

1988; Graham, et al., 1990

DeJong, 1987; Aniskiewicz and

Wysong, 1 990; Clayton, Cattarello, Day, 1991

Ellickson, Bell, Thomas, et al.,

1988; Ellickson and Bell,

1990

Connell, Turner, and Mason,

1985; Christenson, Gold, Katz,

et al., 1985

Shah, Suurvali, and Kilty, 1980;

Grady, Gersick, and Steinberg, 1985

aKEY: ~pT = Adole=ent Al~~hol prevention Trial; ALERT = Adolescent ~~periences in Resistance Training; DARE - Drug Abuse Resistance Education;

STAR - Students Taught Awareness and Resistance; SMART = Self-Management and Resistance Training.

bFull citations are listed at the end of this chapter.

SOURCE: Office of Technology Assessment, 1991.

(1 19). Graham and his colleagues suggested that program that takes a resistance skills approach to

adolescents who begin smoking in the seventh grade drug abuse prevention. Project SMART includes a

may be most rejecting of adult values and thus most 12-session program intended primarily to give

resistant to drug prevention education (119). students social skills for resisting offers of alcohol,

Project SMART-Project SMART (Self-Man- cigarettes, and marijuana (120). Social skills sesagement and Resistance Training) is a school-based sions include teaching students about the various

<~l”; (f 10 (11 ) - (J1 , \
II-538 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

sources of social pressure to use drugs, techniques

for resisting them, and role-play opportunities for

practicing the resistance techniques. Affective education sessions focus more generically on personal

decisionmaking, values clarification, and stress management techniques. Seventh graders have been the

target population for Project SMART.

In a 1988 evaluation of Project SMART, Hansen,

Johnson, Flay, Graham, and Sobel found that the

social skills portion of the program-but not the

affective part—was effective in reducing the onset

of cigarette, alcohol, and marijuana use (123a). A

subsequent evaluation by Graham and his colleagues investigated differential effects74 of Project

SMART by type of drug, gender, and racial/ethnic

group (as compared to the usual school curriculum

on drugs and alcohol) (120). Overall, the program

was found to be effective for females, but not for

males, and for Asians, but not for blacks, whites, or

Hispanics (120).75 As did Botvin’s Life Skills

Training programs and other prevention programs

(see below), Project SMART had its strongest

effects on cigarette use. It showed some statistically

significant effects for alcohol use, but no effects on

marijuana use.

Drug Abuse Resistance Education (DARE)

Program—The DARE program is different from

school-based interactive education programs such as

Project SMART in that it uses specially trained

police officers to teach fifth and sixth grade students

about drug use (61). Police officers are believed to

be an especially credible source of information for

young adolescents. In addition, the training the

police officers receive (80 hours) is more extensive

than that given to many others who deliver prevention programs, such as peers or teachers (61). In 16

or 17 sessions, the DARE program teaches students

self-management and refusal skills and instructs

them in personal safety techniques. Graduates take

an antidrug pledge during a formal graduation

ceremony.

Evaluations of DARE have shown mixed results.

According to DeJong, the program has some impact

on boys, but not on girls, and only on the use of hard

liquor and cigarettes (70). Clayton and colleagues

found DeJong’s evaluation to be seriously flawed,

but one other evaluation reported in Clayton and his

colleagues found no reductions in self-reported drug

use or intentions to use drugs after the DARE

program was implemented in 10 randomly chosen

North Carolina schools (233a). Clayton et al. ’s own

evaluation of DARE among Kentucky sixth graders

was also noteworthy for using random assignment to

conditions (61). However, consistent with previous

evaluations, Clayton and colleagues found no differences in self-reported cigarette, alcohol, or marijuana use shortly after completion of the DARE

program, although DARE did achieve some small

changes in students’ attitudes towards drug use

(61).76 A fourth evaluation of a DARE program in

Kokomo, Indiana, found reason to be “cautiously

optimistic,” but the Kokomo evaluation did not

measure actual drug use (7).

Project ALERT—Project ALERT (Adolescent

Experiences in Resistance Training) was a 7-year

longitudinal resistance skills training study involving 30 Oregon and California schools (78,79).

Teachers in Project ALERT led eight once-a-week

sessions with seventh graders-including minorities, economically disadvantaged children, and children from disrupted families-with the intention of

preventing alcohol, tobacco, and drug use. Three

booster sessions were provided in the eighth grade.

In an evaluation of Project ALERT published in

1990, Ellickson and Bell reported that the outcome

of the program differed somewhat depending on the

drug evaluated (78). For example, Ellickson and Bell

found modest short-term effects, but no effects at a

15-month followup, for alcohol use (78). Students

who were experimenting with cigarette smoking at

the beginning of the seventh grade intervention were

more affected by the program (in a health-enhancing

direction) than were nonsmokers or heavier users.

74As in many Other evaluations, methodological considerations make it impossible to discern the proportion of students who resisted drug use entkely

as a result of Project SMART. Effectiveness in Graham et al. ’s 1990 study was measured in terms of differences between program and con~ol students

on an index of average drug use.

TSGraham et al. suggested several possible reasons that Project SMART may have been more effective with females, ~clu~g: 1) seventi Wade

females may be more receptive to antidrug messages; 2) seventh grade females may fmd social skills training more relevant to them; 3) the project health

educators were all female; and 4) females had lower pretest drug use to begin with (120). Ethnic minority students also had lower pretest drug use (120).

76~e ev~mtors hypothesized titthe fmfig of no diffe~nces could IX due to an init~ly low base rate of drug use among the students, but it cotdd

also be a result of the comparison group also receiving some drug education as part of the existing science curriculum. The evaluation reported by Clayton

and his colleagues was the first phase of a 5-year evaluation, so the opportunity exists to test for long-term effects on drug use behavior (61).
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-539

But students who were not users of marijuana or

cigarettes at the beginning of the project were most

affected in terms of subsequent marijuana use. There

were no consistent differences in effectiveness of

programs led by older adolescents v. adult health

educators. There also were no consistent differences

in effectiveness of programs for racial and ethnic

minorities v. whites.

Ellickson and Bell’s evaluation report is particularly useful because it permits detection of the fact

that, despite the program, substance use in both the

experimental and control groups did increase on

average; reported ‘‘reductions’ or “effects’ were

relative to the substance use experience of students

in the control group (78). For example, by month 15

(after the three booster sessions in eighth grade),

about 57 percent of experimental group students had

‘‘ever’ drunk alcohol, 30 percent had at least tried

cigarettes, and 8 percent had used marijuana at least

once (78). In addition, some potentially important

changes (such as the percent of ‘ ‘alcohol experimenters’ who had used alcohol in the past month)

were not in the desired direction. For example, the

benefits of changes in the desired directions (e.g., the

greater proportion in the experimental condition of

moderate cigarette smokers who had apparently

‘“quit’ smoking) would have to be weighed against

apparent ‘‘boomerang’ effects to obtain a net

benefit (92). The differences between experimental

and control group students that were statistically

significant were small, and their practical significance would require additional analysis.

Life Skills Training Programs--The programs

known widely as life skills training have also been

referred to by Botvin as ‘‘personal and social skills

training” (36) and “generic cognitive-behavioral

drug abuse prevention” (37). According to Botvin,

the programs’ distinguishing feature is their emphasis on the acquisition of generic personal and social

skills.77 These generic skills are applied specifically

to drug-related situations; the skills are generally

taught using a combination of instruction, demonstration, feedback, reinforcement, behavioral rehearsal (practice during class), and extended practice through behavioral homework assignments

(36).

Life skills training programs have differed in the

age group targeted (mostly 7th graders, but some

6th, 8th, 9th, and 10th graders), program length

(from as few as 7 to as many as 20 sessions),

frequency of sessions (from 1 to 2 class sessions per

week), providers (mostly adults, but some peers),

and the inclusion or not of booster sessions.

Early studies of the life skills training approach

focused on prevention of smoking among young

(e.g., seventh grade) white adolescents and generally

found statistically significant--but generally small—

reductions, particularly when booster sessions were

employed (37,39,40,41 ,42,43,44,45). Some observers, however, questioned whether the results of this

early research were generalizable to other substances, to nonwhite students, and in nonresearch

settings (37). Further, life skills training (and other

prevention research) had been criticized on methodological grounds, including the exclusive use of

self-report data, inappropriate research designs,

inappropriate statistical analysis, lack of demonstrated pretest equivalence in experimental and

comparison groups, failure to examine attrition

effects, failure to examine the extent of faithful

implementation of the program model, and failure to

examine changes in theoretically important mediating variables (19,37,97,1 13,241,274).

In a recent study designed to overcome methodological and other criticisms, Botvin and his colleagues implemented their approach among almost

5,000 junior high school students in 56 schools

across New York State (37,38). Fidelity to program

criteria was assessed, and only students who received at least 60 percent of the prevention program

were included in the 3-year evaluation (37). A major

focus of the evaluation was a comparison between an

intervention providing formal provider training (more

costly) and an implementation with videotaped

provider training and no feedback (less costly); a no

treatment group was also included (37).

~According t. B~tvin tie ~rlmq dis(in*iShing fea~re of tie life skills tmining approaches is ~[ *&ey typicdy attempt tO develop WO Or mOre

,

of the following skills: 1) general problemsolving and decisionmaking skills (e.g., brainstorming, systematic decisionrnaking techniques); 2) general

cognitive skills for resisting interpersonal or media influences (e.g., identifying persuasive advertising appeals, formulating counterarguments); 3) skills

for increasing self-control and self-esteem (e.g., self-instruction self-reinforcement, goal setting, principles of self-change); 4) adaptive coping strategies

for relieving stress and anxiety through the use of cognitive coping skills or behavioral relaxation techniques; 5) general interpersonal skills (e.g.,

initiating social interactions, complimenting, conversational skills); 6) general assertive skills (e.g., making requests, saying no, expressing feelings and

opinions (36). The theoretical bases of the life skills training approach include social 1 earning theory (18) and problem behavior theory (139,142,224).
11-540 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Over a 3-year period (1 year of full program

implementation and booster sessions in 2 succeeding school years), statistically significant effects for

smoking and marijuana use were found for both

training conditions, compared with the comparison

condition (37). Effects were measured in terms of

comparison and experimental group differences in

average drug use scores on a post-test (37). No

differences between experimental and control

groups were found in overall drinking frequency or

. . drinking amounts in any group, although there was

a reduction in the frequency of getting drunk in the

group with videotape-trained teachers (37). When a

more conservative school-level analysis of the data

was performed, significant effects for reductions in

cigarette smoking (only) were retained.

This study’s measures for testing the development

of theoretically predicted skills were limited to

self-reports by students of their confidence in their

ability to use specific personal and social skills, and

their knowledge of communication and general

social skills (37). Only communication and interpersonal skills showed improvement (37). According to

Botvin and his colleagues, this evaluation provided

further evidence that life skills training is effective

in at least delaying the use of substances other than

tobacco and demonstrated for the first time the

feasibility and effectiveness of the life skills training

approach in typical classroom situations (37). However, the broad test of the life skills training approach

reported in 1990 by Botvin and his colleagues was

somewhat limited by having a sample that was 91

percent white and mostly suburban and rural.

Previous research by Botvin and his colleagues with

urban black (39) and Hispanic (41) students provided only tentative support for the effectiveness of

life skills training with nonwhite adolescents (37).

Project STAR—Project STAR (Students Taught

Awareness and Resistance)--part of the Midwest

Prevention Project-is widely known as a broadbased, comprehensive community-based drug prevention intervention (220,221). The target group

includes the entire adolescent population in 50

schools of the 15 communities comprising the

Kansas City (Kansas and Missouri) metropolitan

area. Begun in 1984, Project STAR sequentially

attempted to involve the media, community organizations, and families in drug prevention in the

Kansas City area, but the cornerstone of the program

is a school-based education curriculum with an

emphasis on resistance skills.

Photo credit: Education Week

Project STAR is an example of a contemporary schoolbased drug abuse prevention program that attempts to

teach young adolescents the kinds of skills that will

help them resist pressures to use drugs. These Kansas

City students are participating in part of the

Project STAR curriculum.

The Project STAR drug use prevention model

builds upon earlier efforts to reduce adolescent

pregnancy and cigarette smoking and to prevent

heart disease. Its agenda covers tobacco, alcohol,

and marijuana and the program focuses on sixth and

seventh graders. In the first 2 years of the project,

22,500 sixth and seventh grade students participated

in the school-based educational component. Other

components (i.e., parent education, community organization, and health policy changes at the community level) have been added to the project sequentially-approximately one each year. Boosters are

provided on a yearly basis through the 12th grade.

Annual assessments are made of adolescent drug use

in schools assigned to immediate intervention or

delayed intervention control conditions.

Evaluation of broad-based community programs

and mass media campaigns is exceedingly difficult

and subject to numerous methodological problems

(77), and reported results for Project STAR have

varied somewhat. In a report on a l-year followup,

Pentz and her colleagues reported modestly, but

statistically significantly, reduced rates of increase

in cigarette, alcohol, and marijuana use by experimental v. control students in the week and month

prior to the followup survey (220). In another

analysis of l-year followup data that used a smaller

sample and different statistical methods, Dwyer,

MacKinnon, Pentz, and their colleagues reported

reduced rates of increase for cigarette smoking,
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . //-541

mixed evidence for effects on marijuana use (depending on whether schools or students were used as

the unit of analysis), and no evidence of an effect on

alcohol use (77).

Another study compared the effects on high- v.

low-risk adolescents78 of 3 years of Project STAR

(144). By 3 years into the project, experimental

schools had been exposed to a parent organization

program, parent-child communication skills training, initial training of community leaders in the

organization of a drug abuse prevention task force,

and mass media coverage, as well as the l-year,

10-session, resistance skills curriculum for students.

The comparison groups were exposed only to the

initial training of community leaders in the organization of a drug abuse prevention task force and the

media elements of Project STAR (144). Overall, this

analysis found generally lower rates of increase for

tobacco and marijuana use, but not for alcohol use,

in program schools than in control schools. The only

difference between high and low risk groups of

students was a greater reduction in the rate of

increase in cigarette smoking in those students

exposed to the program during a 6th rather than 7th

grade school transition.

Other studies by Pentz and her colleagues suggest

reasons for variations in results across schools other

than method of statistical analysis (77). Pentz,

Trebow, Hansen and colleagues found, for example,

that the greater the amount of the school-based

portion of the program actually delivered to students

in Project STAR schools, the less was the increase

in drug use after a year (223). In one of six

comparisons, there was an actual decrease in drug

use among project students with more extensive

exposure to the curriculum (223).

The Project STAR effort in Kansas City was

evaluated with a quasi-experimental design. A

replication in Indianapolis, Indiana (Project ISTAR), is being evaluated with a true experimental

design.

Comprehensive Health Education—As prevention programs, comprehensive health education

efforts are premised on the belief that children and

adolescents can benefit from instruction in all phases

of healthy living. Thus, sequential curricula have

been developed for prekindergarten through the 12th

grade, focusing on developmentally appropriate

subjects. The prevention of psychoactive substance

use can be either a separate segment within the

instructional sequence or integrated throughout the

health curricula (247).

In a 1985 evaluation of four comprehensive health

education curricula for grades 4 through 7, based on

a survey of 1,000 classroom programs in 20 States,

the School Health Curriculum Project was identified

as the most effective health education program (66).

The School Health Curriculum Project is highly

structured and emphasizes ‘‘hands-on’ activities

but requires significant teacher in-service training

and student classroom time. The program appears to

have been successful in deterring sixth and seventh

graders from smoking, but its impact on other

substance use has not been assessed (59,65).

Parent Education Programs—Parent education

programs attempt to influence adolescent behavior

by altering the interactions that occur within a

family. Parents attend seminars or courses designed

to help them encourage and support appropriate

behavior in their adolescent family member. Typically, a program will provide factual information

and training in discipline, communication, and other

parenting skills. Sometimes, parent education programs are held in conjunction with programs for

adolescents.

Parent education programs specifically geared

toward substance use concerns have not been widely

tested. Schaps and his colleagues found that only 4

percent of 127 drug education programs included in

their review used a family involvement strategy

(241). Nearly a decade later, Moskowitz found very

few family-oriented educational programs targeted

toward adolescent alcohol or drug problems in his

review of the literature (195). Of those adolescent

substance use/parent involvement programs that do

exist, only two have been evaluated. The first, a

20-hour Parent Effectiveness Training program,

which emphasized communications and problemsolving skills for parents, was examined in a 4-year,

quasi-experimental study that showed short-term

improvements in parenting skills but also revealed

an increase in alcohol use among the children of

participants (251).

TsHigh risk students were defined as those students: 1) who had previously used a so-called ‘gateway drug” (tobacco, alcohol, ~~~Jw); 2) whose

parent(s) used tobacco, alcohol, or Mjuan% 3) with higher numbers of friends perceived as having used tobacco, alcohol, or marijuana (cutoff not

given); and 4) of higher age (measured as grade level). Gender was also used as an indicator of relative risk.
II-542 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

The second study looked at a program that

combined drug education for students and 12 hours

of parent training on drugs, adolescent development,

decisionmaking, and communication(118). Preliminary results showed some improvement in parenting, but recruitment and attrition problems limit

inferences about the validity of the findings.

Other studies of parent education programs which

were not targeted toward substance use issues have

tended to support the conclusion that these programs

can improve parents’ attitudes and skills, but that

they have limited impact on an adolescent’s behavior—

including substance use (72).

Alternatives Programs—The provision of alternatives to alcohol and other drug use have had a long

history in prevention efforts (1 13). According to

Botvin, the original model for alternatives programs

took the form of establishing youth centers in the

community to provide a particular activity or set of

activities:

The underlying assumption of this approach was

that adolescents could be provided with real-life

experiences that would be as appealing as substance

use and, therefore, involvement in these activities

would actually take the place of involvement with

substance abuse (36).

Examples of this approach, which provided a

predetermined single set of activities for all participants, include Outward Bound (36). A second type

of alternatives approach involves attempting to

match specific alternatives with an individual’s

unfulfilled needs (36), For example, interpersonal

needs, such as gaining peer acceptance, might be

satisfied through participation in sensitivity training

or encounter groups (36,274). Another way to

categorize alternatives approaches is as 1 ) efforts to

provide positive activities more appealing than drug

use; and 2) efforts aimed at developing competence

to overcome individual deficits in basic life skills,

low self-worth, and limited experiences that place

them at risk (1 13,274).

The provision of alternatives to psychoactive

substance use is intuitively appealing and has been

one of the approaches used in the contemporary

“War on Drugs” (see below). As noted above, at

least some the predominant risk factors for substance

abuse (e.g., dysfunctional families, association with

drug-using peers, school transitions) appear to be

those that could be amenable to the alternatives

approach. Unfortunately, however, there is little

systematic research that can be used to evaluate

whether alternatives work in preventing drug use

and abuse by adolescents (36,1 13,241,242,274). For

example, in a 1986 quantitative review of studies

covering the period 1972 through 1984, Tobler

found only 11 alternatives programs that had adequate evaluation data, and not all of the evaluations

measured drug use by adolescents (274). In a

subsequent meta-analysis of the same studies,

Tobler limited her review to studies using drug use

outcomes (274a) .79 In both meta-analyses, Tobler

found that alternatives programs had the second

greatest effects on drug use (274a) and related

outcomes (274), after resistance skills and life skills

training programs that involved peer interaction

(274,274a) .80 Tobler concluded that alternatives

programs were especially effective with “highrisk’ adolescents such as drug abusers, juvenile

delinquents, or students having school problems

(274),

Further examination of the components of successful alternatives programs seems to be in order.

For example, Swisher and Hu noted that some types

of activities have been associated with substance

abuse (e.g., entertainment, vocational, and social

activities), while others (e.g., religious activities)

have not (269a). Consequently, it is conceivable that

some alternatives programs could be counterproductive if the wrong type of activities were selected (36).

Feldman notes that it maybe important to mix both

troubled and nontroubled adolescents in alternative

activities (88a) and both Feldman and Tobler note

the importance of well-trained group leaders (88a,

274a).

Selected Supply Side Substance Use

Prevention Efforts

Health protection is an aspect of prevention that

acts through the passage of laws and regulations

limiting access to substances believed harmful to

health. Many of the psychoactive substances dis7qn ~ Subsqucnt ~evlew, Botv~ feud Ody IWO studies of alternatives (peer tutoring and working in a school store), nei~er of w~ch meas~ed ~g

use (36).

SO~ Tobler$s ~lcles, ~esis~ce ~~l]s ~d l~e stills ~a~ng pro~~ are ca~~ ‘ ‘peer pro~~’ ~cause peer interaction (not peer leadership) iS

the key component (274,274a).
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-543

cussed in this chapter are illegal for use by people of

all ages. As noted earlier, however, the psychoactive

substances used the most by U.S. adolescents—

alcohol and tobacco-are legally available for use

by older people. Some public health measures have

been taken to limit access to and use of these

substances by adolescents. Others are under consideration. Supply side substance use prevention efforts

discussed here are laws related to access by minors

(e.g., minimum drinking and smoking ages) and

some actions under consideration that would affect

not only adolescents but all individuals (e.g., additional limits on advertising, increased excise taxes

on cigarettes and alcohol). Relatively little research

has been done on the effects of health protection

efforts specifically on adolescents.

Minimum Ages for Drinking and Smoking—

Between 1970 and 1975, 29 States lowered their

drinking age to conform with a Federal shift in the

voting age from 21 to 18 in 1970 (123). By 1984,

however, 28 States had increased their legal drinking

age. In 1984, the U.S. Congress passed the Uniform

Minimum Drinking Age Act (Public Law 98-363).

Under this law, increasing percentages of Federal

highway funds would be withheld from States that

did not make the drinking age 21. Currently, all 50

States and the District of Columbia have a drinking

age of 21, although there are some exceptions to the

general rule (e.g., for employment, with parental

guidance, under medical supervision, and possession for purposes other than consumption) (123,290).

Age limits on possession of tobacco products are

more lenient than those on alcohol (317). Changes

are occurring, but the minimum age in most States

is 18 rather than 21 (315).

Limits on Advertising-Recognizing that antidrug education messages compete with advertising

that makes alcohol use appealing to adolescents

(180), there has been congressional interest in

limiting the advertising of alcohol and cigarettes

(169). Cigarettes and hard liquor are not advertised

on television or radio but can be advertised in

magazines81 and on billboards. Wine and beer can be

advertised in any medium.

Further passage of restrictive advertising laws is

problematic because of concerns about possible

infringements on advertisers’ constitutional rights.

On the one hand, there is precedent for such action.

The Public Health Cigarette Smoking Act of 1970

(Public Law 91-222), for example, banned prosmoking cigarette advertising on radio and television

beginning in 1971. On the other hand, Goodstadt and

Miller concluded that studies of the impact of

alcohol advertising have demonstrated little to no

effect on alcohol consumption (1 13). These studies

have not been specific to adolescents.

Excise Taxes--Economists suggest that adolescents’ use of alcohol and tobacco may be more

sensitive to increases in price than adult’s use of

alcohol and tobacco (123). One way to increase the

price of alcohol and tobacco is to increase excise

taxes. As of spring 1990, Federal excise taxes had

not been raised in real terms since 1951 (123). Beer,

a preferred alcoholic beverage of adolescents, is

taxed at one-third the rate of liquor.

In a simulation for ADAMHA’s National Institute

on Alcoholism and Alcohol Abuse (NIAAA), Grossman found that the raising of excise taxes on beer to

the same level as taxes on liquor would reduce motor

vehicle fatalities among 18- to 20-year-olds by 21

percent (123). Grossman found that an increased

excise tax would have a greater effect on reducing

fatalities than could be expected from increases in

the minimum drinking age because the minimum

drinking age can be evaded, at least in part.

Grossman notes, however, that these simulations

have not been tested empirically.

Simulations of the effects of excise taxes on

cigarette smoking have focused on reductions in

premature mortality as an outcome. Cigarette smoking generally does not result in fatalities until later

in life (although there are short-term health effects of

smoking for adolescents). Grossman’s analysis of an

increase in excise taxes on cigarettes found that over

800,000 premature deaths in the cohort of Americans 12 and over in 1984 would be averted.

Coincidentally, an earlier analysis by Warner suggested that raising the excise tax would discourage

approximately 800,000 adolescents from starting to

smoke (33 1).

S 1A check by OTA staff of scvc-al teen magazlncs suggested hat such mag~.incs do not tend [O advertise cigarettes Or alcohol.
II-544 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Conclusions About the Effectiveness of

Prevention of Psychoactive Substance Use

From the foregoing review of the research findings from selected contemporary efforts to prevent

or delay the onset of psychoactive substance use by

adolescents, and from the reviews summarized in

table 12-10, it is clear that most demand side

prevention programs targeted at individuals have yet

to make a compelling case for their effectiveness.

Some models show some positive effects in delaying

increases in drug use, but the effects are generally

small. Whether these models are of much practical

significance in reducing drug use among adolescents

is debatable, However, some programs may turn out

to be effective in other important respects, such as

enhancing adolescents’ general life skills (e.g.,

social competence, decisionmaking),

Recognizing the limited evidence for the effectiveness of traditional school-based drug prevention

efforts, as well as the wide variety of risk and

protective factors apparently involved in drug use

and abuse (see figure 12-6), some observers have

urged that drug abuse prevention efforts not be

limited to small-scale, time-limited, educational

interventions, although these interventions have

their place (36,1 13,172,273). Neither, say many

observers, should prevention be limited to coercive

supply side strategies such as minimum drinking

ages, limits on advertising, or excise taxes ( 113, 172).

Goodstadt and Mitchell, for example, recommend

that the Nation take a health promotion approach to

preventing alcohol and other drug use and abuse by

adolescents. The health promotion perspective permits greater acknowledgement of the fact that

psychoactive substance use problems may result

from: a) what the user/drinker does, b) the properties

of the drug, and c) the impact of social and physical

environments (1 13). According to Goodstadt and

Mitchell, ‘‘this appreciation for the diverse etiology

of problems should increase the range, appropriateness, and effectiveness of prevention measures’

because ‘‘problems with complex etiologies usually

require diverse or complex solutions’ (1 13). Further, “addressing the three elements would reduce

scapegoating of any single factor’:

9

Photo credit: Office of Technology Assessment

Current recommendations on preventing alcohol and other

drug abuse among adolescents suggest that prevention

efforts not be limited to efforts targeted at individual

potential users-although these maybe useful-but

that they also focus on adolescents’ environments.

It would no longer be appropriate to “blame the

victim” by attributing the abuse exclusively to the

abuser’s personal deficiency; nor would it be sufficient to condemn drugs as the cause of problems, or

strive for prohibition as the sole solution for abuse;

nor would individuals and communities be tolerant

of environmental conditions or social practices that

contribute to drug abuse (1 13).

The fact that these recommendations (and other

similar thoughts) were published by OSAP suggest

that a more comprehensive approach to psychoactive substance abuse prevention is possible (76,1 13,

313). Unfortunately, however, implementing systemic approaches may prove to be quite difficult

(172).

Substance Abuse Treatment Services

for Adolescents82

For some adolescents, the use of or experimentation with alcohol or other psychoactive substances

may progress to a point where the adolescents

develop physical, emotional, or social problems.

When substance use becomes fictionally incapacitating, health-threatening, or presents a danger to

self or others, professional services may be necessary to treat the condition. The broad goals of

substance abuse treatment can be defined as the

az~~ section is based on the paper by James Emshoff ~d Ronni MargoIin-Mankoff entitled ‘ ‘Treatment of Adolescent Substance Abuse: A N:Itionat

Review and Critique, ” which was prepared under contract to Carnegie Corporation of New York and the Carnegie Council on Adolescent Development

for OT.4’S adolescent health report (85).
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services ● II-545

Table 12-10—Summary of Reviews of Evaluation Literature on Demand Side Substance Use Prevention Programs

for Adolescents

Evaluations Method of Key findings and

study a

reviewed the study recommendations

Schaps, DiBartolo, 75

Palley, et al., 1978, (127 programs)

1981

Tobler, 1986

(9%studies)

Bangert-Drowns, 33

1988

Moskowitz, 1989 NA

Goodstadt and NA

Mitchell, 1990

Crosstabular and correlational analyses of primary

drug abuse prevention programs, using 70 dimensions; included all psychoactive drugs. Studies had to assess a planned intervention and use

drug-specific measures of effectiveness in terms

of use, intention to use, or attitude toward use.

Included unpublished manuscripts. Ninety percent of programs served target populations of

college age or younger; 56 percent served high

school age adolescents. Comparison groups

were not required.

Meta-analysis; reviewed substance abuse evaluations

of variety of program types; controlled for effect

size; included unpublished studies. Limited to

young adolescents. Five modalities were examined: knowledge, attitudes, use, skills, and

behavior; drugs, alcohol, tobacco, were included.

Control group was not required for some studies.

Meta-analysis; controlled for effect size; only schoolbased drug education programs were included.

Covered elementary through college level; limited

to publicly available studies; anti smoking studies

were excluded; only U.S./Canada studies were

reviewed. Control group was required,

Literature review/focus on alcohol issues. Four types

of interventions were examined, including primary prevention. Not oriented toward adolescents-general alcohol abuse review.

Narrative literature review of evidence on noncoercive

(drug education, mass media, and alternatives)

and coercive (legal deterrence) strategies, and

conceptual analysis of health promotion (concept

of Iifestyle, community-based health promotion,

community responsibility and empowerment) strategies.

Most evaluations were poorly done; most studies

ignored racial and ethnic characteristics; only 5

percent of programs were peer-led. lnformationonly programs were not effective; combination

programs hold promise, but data are unreliable.

More research is needed, particularity with regard

to minorities; greater use of peers and parents

should be explored; a repository for evaluation

reports should be created; evaluation must be

more rigorous and better documented.

Peer programs showed definite superiority in outcome across substance; alternative programs

successful for “high-risk” adolescents; “for knowledge-only and affective-only programs solid evidence exists for discontinuing their use.”

Most studies were of poor quality. Substance abuse

education may alter knowledge and attitudes but

is unsuccessful in changing drug-using behaviors

of students; peer-led and group discussion models were more effective in changing attitudes;

students who volunteered for programs reported

lower drug use than compulsory participants.

More rigorous research is needed but not on

effect of education on knowledge; substance use

education has not been effectively used in

schools to date.

There is little evidence that primary prevention programs are effective; additional research is needed

on affective education and social influence models; behavior is unlikely to be influenced by

education or media efforts; parent attitude changes

are not reflected in adolescent behavior; social

norms must change; some prevention programs

may actually increase problems; recommends

large-scale social experiments combining control

and prevention strategies.

Could not conclude with confidence that drug education (Including school-based education and nonschool-based parenting skills education) is either

effective or ineffective. Criteria for effective schoolbased drug education appear to include: targeting subpopulations with a uniform level of use, or

incorporating elements and processes that recognize the needs of varying subgroups; attending

to the major personal and social determinants of

human behavior; implementing programs with

adequate intensity of time and effort, staff training, and adequate administrative and community

support; integrating school-based programs into

the larger community. Studies of mass media

antidrug campaigns do not encourage optimism

about effectiveness. Laws and regulations play a

significant role in controlling average level of

alcohol use and abuse in a population, but

evidence for the effectiveness of legislation (legal

deterence) in controlling individuals’ drug use is

neither encouraging nor consistent.

Recommends a health promotion perspective, which

would develop policies to address the implications of the diverse causes of drug use problems

(i.e., behavior, properties of the drugs, and the

impact of the social and physical environment).

KEY: NA E not available.

aFull citations are listed at the end of this chapter.

hhis review’s evaluation of the alternatives approach summarized Tobler’s findings (274).

Continued on next page
II-546 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 12-10-Summary of Reviews of Evaluation Literature on Demand Side Substance Use Prevention Programs

for Adolescents-Continued

Evaluations Method of Key findings and

studya

reviewed the study recommendations

Botvin, 1990 35 interventions Narrative review of theoretical and evaluation litera- Except for the more recently implemented psychosoture on 4 approaches: informational, affective, cial approaches (resistance skills alone or in

alternative, psychosocial. combination with life stills training), primary prevention approaches targeting adolescents have

not been successful in reducing actual substance

use because they have not focused on documented risk factors. Some methodological and

dissemination/implementation problems with the

psychosocial approaches remain, but these psychosocial approaches should be further disseminated because they can reduce susceptibility or

vulnerability to environmental factors and reduce

potential intrapsychic motivations to use drugs.

They can be used as substitutes for widelyutilized school-based prevention programs that

rely on intervention strategies that have either

been found to be ineffective or have no scientifically defensible basis. Several additional levels of

intervention need to be adopted: at the broadest

societal level, eliminate or reduce environmental

influences promoting or facilitating smoking, drinking, and drug use; at the interpersonal level, go

beyond strategies that rely solely on schoolbased interventions; and, at the intrapsychic

level, reduce potential motivations to engage in

substance use.

SOURCE: Office of Technology Assessment, 1991.

elimination of chemical dependency and related

undesirable behaviors and the restoration of the

individual under treatment to a healthy and functionally appropriate status (201).

But despite a general consensus about the broad

goals of substance abuse treatment, substance abuse

treatment for adolescents is often fraught with

controversy. It is not always clear when---or if-an

adolescent requires treatment for substance use. In

addition, there remains disagreement about the

respective virtues of abstinence and responsible use

of psychoactive substances as treatment outcomes.

Nor is there agreement within the treatment community or its critics regarding the efficacy or effectiveness of various kinds of treatment, desirable length

of treatment, or criteria for matching individual

clients to particular treatment settings. In a comprehensive 1990 study on drug treatment, a committee

of the Institute of Medicine concluded that the state

of knowledge on drug treatment effectiveness was

worst with respect to treatment for adolescents, and

this committee recommended that drug treatment of

adolescents be studied intensively (201). Exploring

the variety of substance abuse treatment services

could illustrate the needs for additional research,

highlight some of these points of contention, and

provide a conceptual framework for future policy

deliberations on substance abuse treatment services

for adolescents.

The importance of such exploration becomes

clear when one considers the number of adolescents

whose lives are affected by treatment and how many

others might benefit if additional services were

available. However, assessing the number of U.S.

adolescents in substance abuse treatment is difficult

because of limitations in data sources. Several data

sources were used to gather the information presented below—the National Drug and Alcohol

Treatment Unit Survey (NDATUS) (308,309); the

Chemical Abuse Treatment outcome Research(CATOR)

network, which provides outcome data for private

treatment centers (126); and the Treatment Outcome

Prospective Study (TOPS) at the Research Triangle

Institute (134). Information was not always available regarding specific issues, in particular interactions between race and age.

The NDATUS census of private and public drug

abuse treatment provides a cross-sectional snapshot

of treatment on October 30, 1987, and not a count of

clients served in an entire year. Among other

problems with NDATUS is its low response rate: a

total of 22.5 percent of the surveyed treatment units

did not respond to the NIDA-sponsored survey.

Thus, OTA multiplied totals by 1.29 to reflect an
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-547

estimate of the numbers served by nonresponding

programs. This extrapolation seems to be a closer

representation of the total population served than the

number calculated by including only the 77.5

percent.

A second correction factor can be estimated in

order to convert the point prevalence data to yearly

totals served. Dividing the number of drug abuse

clients served in 12 months by the number in

treatment on October 31, 1987, one finds that 3.21

people were served in the 12-month period ending

on that date. The ratio of annual total served to the

total served in the point prevalence data for alcoholism treatment is 4.23. Applying these ratios to

subtotals based on age and setting yields the only

available estimate for total clients served by drug

and alcohol treatment programs in a 12-month

period.

Using these adjusted figures, an interesting picture emerges. Approximately 76,000 children and

adolescents under age 18 were in drug and alcohol

treatment programs on the day the most recent

NDATUS was taken in 1987 (308,309). An estimated 49,000 of these minors were in drug abuse

treatment (15 percent of the total population of all

ages in drug abuse treatment), and the other 27,000

were being treated for alcoholism (6 percent of the

alcohol treatment population of all ages). Over the

course of a year, it is estimated that nearly 272,000

adolescents are treated for substance use—157,000

for drugs and 115,000 for alcohol. Adolescent males

made up 55 percent of the adolescent drug treatment

population and 67 percent of the adolescent alcohol

treatment populations.

Substance abuse treatment services for adolescents, provided to adolescents after assessment and

referral, fall broadly into five sometimes overlapping categories (see table 12-11):

. self-help groups,

. outpatient treatment (including day treatment),

● residential treatment,

. inpatient treatment or hospitalization, and

. other.

Treatment is usually, but not always (e.g., self-help),

preceded by assessment and diagnosis.

In addition to there being overlap within these five

categories of substance abuse treatment services,

there may be some overlap between prevention

strategies and treatment. Thus, for example, prevention and treatment strategies may both use similar

techniques such as assertiveness, coping, and life

skills training; efforts to build self-esteem and

refusal skills; and group therapy.

Nonetheless, prevention and treatment efforts are

targeted toward different populations and also may

be distinguished by the focus of prevention on

deterrence of use and the focus of treatment on

recovery from abuse and its consequences. In

contrast to prevention programs, substance abuse

treatment programs are aimed at adolescents for

whom psychoactive substance use has progressed

past the stage of experimentation. Substance abuse

treatment programs are usually geared toward older

adolescents and include a variety of interventions

designed to restore an individual to physical and

mental health (267).

Adolescents seldom receive substance abuse treatment in age-specific settings. As likely as not, they

can be found mixed into programs designed for

adults or programs intended for children. There are

few drug treatment programs specifically for adolescents, and the adolescent-specific drug treatment

programs that do exist tend to serve a disproportionate share of the adolescents in treatment. Currently,

only 18 percent of all drug treatment programs are

adolescent-specific but nearly half of the adolescents in drug treatment are served by these programs

(308,309). Adolescents in treatment for alcohol use

problems are less likely to receive treatment in

special adolescent programs; about 15 percent of

adolescents being treated for alcohol use problems

are treated in special adolescent programs. Almost

one-fourth of adolescent alcohol treatment clients

were in programs in which less than 10 percent of the

client population were adolescents (21 1).

Self-Help Groups for Substance Abusers

Self-help groups for substance abusers often serve

as alternatives or adjuncts to professional treatment,

and many include programs not only for substance

abusers but for family members as well. Self-help

groups are widely used as a treatment of choice by

many professionals and nonprofessionals and are

frequently incorporated into professional substance

abuse treatment programs (267). In this context,
II-548 . Adolescent Health—Volume ii: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 12-1 l-Overview of Substance Abuse Treatment Services for Adolescents

Service Setting Target population Strategies

Assessment/referral Community agencies: schools,

medical settings, youth services agencies, juvenile justice,

mental health settings

Treatment:

Self-help groups Community settings

Outpatient treatment Mental health facilities, drug/

alcohol treatment centers

Residential treatment Group homes, drug/alcohol treatment centers

Inpatient treatment Hospitals (general, psychiatric, or

specialized)

Other Schools, juvenile justice system

Substance users, to determine level

of use/abuse and refer for treatment

Substance abusers, substance dependent (especially highly motivated, successful treatment completers)

Substance abusers, substance dependent (especially highly motivated, early abusers, with no

prior treatment history)

Substance abusers, substance dependent (especially less motivated, prior treatment failures,

limited support system)

Substance dependent (especially

less motivated, prior treatment

failures, poor support system,

medical risk, dually diagnosed)

Students; adolescents arrested for

delinquency offenses

Interviews, standardized tests

Education, group support

Counseling, social skills development, psychotherapy group

therapy, family therapy selfhelp

Milieu therapy, education, group

therapy, daily supervision, counseling, family therapy, self-help

Medical services, milieu therapy,

psychotherapy, counseling,

group therapy, family therapy,

education, daily supervisions,

self-help

Student assistance programs, diversion

SOURCE: Office of Technology Assessment, 1991.

self-help groups may serve as group therapy and/or

aftercare.83

The oldest, largest, and best-known self-help

group is Alcoholics Anonymous (AA), which was

formed to help recovering alcoholics maintain their

sobriety. As of 1986, AA included approximately

1.5 million participants (l). About 3 percent, or

47,000, were under the age of 20. In recent years,

participation in AA by adolescents has been increasing, at least in part because of the inclusion of AA

groups in formal treatment programs. Adolescents in

their mid-to-late teens are likely to attend two or

three meetings per week, slightly fewer than adults.

Adolescent alcoholics are far more likely than adult

alcoholics to also consider themselves addicted to

other drugs (80 percent of AA members in their late

teens, as compared with 30 percent age 40 or over).

Narcotics Anonymous—modeled after AA as a

self-help group for narcotics abusers—indicates that

its ‘fellowship’ of participants is generally younger

than that of AA, with most between the ages of 16

and 40 and approximately 10 percent under the age

of 20. Informal estimates indicate that about 18,000

adolescents participate in Narcotics Anonymous

meetings annually (199).

Although there are numerous formal and informal

self-help groups in the substance abuse field, most

use the 12-step model popularized by AA or some

variation on it. This model regards substance dependence as a chronic illness from which recovery

is an ongoing, lifetime process maintained solely by

total abstinence. The program involves acceptance

of the illness and one’s powerlessness in relation to

it; acknowledgement of the damage done by substance abuse; and commitments to make amends,

continue the recovery effort, and help others. A

strong spiritual, but nonsectarian, component is

essential in the 12-step program. Whereas 12-step

programs for adults have traditionally been voluntary, adolescents are often required to attend 12-step

groups.

Peer support is a primary aspect of the self-help

group approach. Most AA and Narcotics Anonymous groups include a “sponsor” system. Each

recovering addict is paired with a more experienced

partner (who, in the case of an adolescent, can be

either a peer or an adult) available for crisis

intervention and emotional support. The meeting

format usually involves first-person accounts of

drug and alcohol problems and recovery from them.

83&ercaTe ~efer~ t. ~ “~ety of ~emicm desi~ed to render ~sis~ce to ~ in~vid~ recove~ from subs~ce abuse fo~owing discharge frOm

a hospital or formal @eatment program, including such things as peer support and counseling, crisis services, job referral, or dropin centers.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-549

These inspirational testimonials help participants

feel less alone in their recovery struggles.

AA and Narcotics Anonymous have traditionally

been resistant to rigorous research studies, primarily

as a means of protecting the confidentiality an d

anonymity of their membership. AA’s own survey of

its membership indicated that 67 percent of its

members report having been sober for more than 1

year (1). Specific information regarding adolescen t

members is not available. Problems noted with the

AA model include high attrition rates, apparently

due to resistance to the spiritual component of AA

(47). Although clinical descriptions of the use of the

12-step model with adolescents are available (e.g. ,

28), it is notable that outcome research is no t

available, despite the almost universal inclusion o f

these groups in formal adolescent treatment pro -

grams.

Outpatient Substance Abuse Treatment

Programs for Adolescents

Outpatient substance abuse treatment programs

are oriented around counseling rather than medical

intervention. If a person needs medically managed

detoxification, that is handled in another setting

prior to the person’s entry in the outpatient drug-free

program. Outpatient substance abuse treatment programs seldom use medications on their clients,84

Some outpatient substance abuse treatment programs are integrated into comprehensive youth

service centers, family-planning services, or nutrition counseling (27).

The most intensive outpatient treatment programs

are day treatment programs, in which the participant

arrives early in the day and returns home only in the

evening. Parental involvement is considered ‘‘mandatory’ when available, in order to provide family

support for continued participation by the adolescent. Day treatment programs function much like

inpatient programs, with structured activities, onsite

education, and a variety of therapeutic programs for

adolescents and their families (131).

Outpatient substance abuse treatment programs

often serve as early aftercare services for inpatients

—.

(16). Although some of these programs are available

to low-income adolescents, they are frequently

associated with private for-profit organizations, and

can be quite costly—as much as $2,000 to $5,000 for

outpatient day care (337). Community mental health

centers also offer outpatient treatment as an alternative for low-income clients.85 One estimate suggested that about 30 percent of such programs are

associated with community mental health centers

(134).

Residential Substance Abuse Treatment

Programs for Adolescents

Residential substance abuse treatment programs

for adolescents offer 24-hour supervision by trained

adults and recovering peers, providing immediate

confrontation of substance-abusing or other selfdefeating behavior. Residential programs may have

locked units, employ nursing and counseling staff

very much like those in psychiatric hospitals, and

include structured daily routines, including a variety

of educational and therapeutic groups. They frequently operate on the 28-day model, with a high

level of structure in the initial stages and diminished

structure as the client earns privileges through

program participation and responsibility.

Residential treatment programs remove participating adolescents from peer or family environments

that may have encouraged or failed to prevent their

substance abuse. Some observers argue that such

removal not only limits the adolescent’s access to

drugs but also offers a positive environment in

which the adolescent can deal with his or her

substance abuse (207). Other observers, however,

dispute this view, suggesting that adolescents in

residential treatment are exposed adversely to more

peers with problems (95). Unfortunately, research

on the relative effectiveness of residential programs

in comparison with other treatment options is not

available to settle this issue.

Ideally, the halfway house model of’ residential

treatment offers adolescent participants supervision

coupled with participation in public school and

extracurricular activities. Located in neighborhoods

where residents can attend regular public schools,

— —

M~ss ~m g percent of adolescent clients in outpatient substance abuse programs are on maintenance m~i~tio~ ad less ~

 3 Wment ‘e k

detoxification programs (308,309).

85 CommuniV ~enral hea~tfi ~enrer$ we public or Pnvatc nonprofit ment~ heal~ clfics intended to serve the IOCd residents of a

community-generally on an outpatient basis. They are funded through a combination of fees, third party reimbursements, State and local government

contracts, and Federal alcohol, drug abuse, and mental health block grants.
11-550. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

halfway houses are often staffed by a live-in couple

who serve as “teaching parents. ’ They usually

include regularly scheduled group meetings focused

on interpersonal relations and individual goals.

Some are developed specifically as substance-abuse

treatment settings, and others are simply homes for

adolescents with any of a variety of problems-e. g.,

delinquency, emotional disturbance, homelessness.

In the therapeutic community model, residents

maintain the administrative and therapeutic functioning of the facility. Less emphasis is placed on

specific forms of therapy and more on global

changes in conduct, feelings, values, and attitudes

(71). In therapeutic community settings, household

responsibilities and privileges are often assigned

based on seniority and success in the program,

thereby providing motivation for individuals to

continue their participation. Although this model

has been used extensively with adult substance

abusers, it is less commonly available for adolescents. Therapeutic communities can be highly confrontational and may be difficult environments for

adolescents.

In wilderness-challenge programs, a group of

adolescent clients and counselors live together in a

‘‘primitive’ camp environment (274). Personal

challenges include mastering unfamiliar environmental conditions and learnin g survival skills.

Wilderness camps often operate on the therapeutic

community model. Although information regarding

the effectiveness of these models for treatment of

adolescent substance abuse is quite limited, Tobler,

in her meta-analysis of 143 adolescent drug prevention programs found alternative programs to be

highly successful among disadvantaged and high

risk adolescents (105,267,274).

A more recent type of residential program is the

“boot camp’ or “shock incarceration” concept for

young offenders (adolescent delinquents). According to the Institute of Medicine, boot camps vary in

nature: “Some are entirely militaristic environments

with few if any therapeutic staff or procedures;

others incorporate many drug treatment elements

that the more successful prison treatment efforts

display but lack still other requirements—

particularly continuity of care when the individual

returns to the community” (201). There have been

no rigorous evaluations of the effectiveness of boot

camps for drug-using offenders.

Inpatient Substance Abuse Treatment

Programs for Adolescents

Hospital inpatient programs offering treatment for

substance abuse include programs in independent

facilities specializing in addiction, psychiatric hospitals, and general hospitals (85,201). Only a few

States fund inpatient substance abuse programs

(especially for alcohol abuse) specifically for adolescents (85). More than one-half of all adolescents

treated for alcoholism are treated in settings serving

primarily adults (308,309).

Adolescents in inpatient treatment settings often

do not have the option of leaving. In 32 States,

adolescents can be admitted for substance abuse

treatment through “voluntary” commitment by

their parents, with varying degrees of legal safeguards against inappropriate hospitalization.86 Most

inpatient facilities include locked-door units.

Hospitals generally include medically managed

services, such as detoxification, as a part of treatment (13 1,203). In addition to medical services,

hospitals generally offer therapy groups, individual

therapy, and on-site educational facilities. These

services are typically provided by an interdisciplinary staff. Family information and therapy programs

are often available.

According to NDATUS, rehabilitation and recovery accounted for the largest percentage of inpatient

adolescent care for alcoholism (89 percent) in 1989

(308,309). Five percent were in medical detoxification, 2 percent received social detoxification, and 4

percent were in custodial care. An adolescent

receiving inpatient treatment for alcoholism had a

70-percent chance of being placed in a hospital,

while an adolescent requiring inpatient drug abuse

treatment was much more likely to be placed in a

residential treatment facility (308,309). The standard length of stay for inpatient facilities has been 28

days for adults and slightly longer for adolescents.

Adolescents are often assumed to need an even

longer separation from their previous environment

(193,267).

BbFor a fufier discussion of this topic, see ch. 17, “Consent and Confidentiality in Adolescent Health Care Decisio Ilmaking, ” in vol. m!
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-551

Issues Related to Substance Abuse

for Adolescents

Methodological Issues in Evaluation

Treatment

Interpretation of research in the field of substance

abuse treatment for adolescents has been hampered

by a number of factors. Several investigators have

reviewed relevant research literature between 1975

and

●

●

●

●

●

●

1988, resulting in the following conclusions:

Evaluations too often fail to distinguish among

age groups within adolescence or specify substances for which treatment is sought.

Reliable measures of abuse, dependence or

treatment success are not often used.

Outcome research is limited, with poorly defined variables.

Followup is rare and too brief.

Research is often poorly designed, with insufficient attention to controls and comparison

groups and factors associated with effectiveness.

Definitions of terms need to be standardized

(57,336).

Many programs report success rates only for those

who complete treatment. Yet the attrition rate of

clients (often as high as 50 percent, and sometimes

as much as 90 percent) in a particular treatment

program is in itself considered to be a valid practical

criterion of program success (126). Methods and

statistical procedures for dealing with clients lost to

followup also vary, creating opportunities for significant bias.

Thus, despite the conclusion of some evaluators

that adolescents who participate in treatment fare

better than those who do not, these groups have not

been systematically compared in long-term studies

(134). Further research, utilizing clearer measures,

stronger research designs, and a broader variety of

adolescent patients, is badly needed. There is a

significant gap in knowledge of treatment effectiveness in relation to adolescents, seriously hampering

the development of appropriate public policy (201).

Some of the characteristics of clients and programs which have been examined with varying

degrees of scientific rigor are presented below to

illustrate the paucity of substantive data available in

this area as well as to suggest directions for further

research development.

Client Characteristics Related to the Effectiveness

of Substance Abuse Treatment

Age--Laundergan, reporting on clients under age

25 in a private inpatient setting, found that younger

clients were less likely to consider themselves

‘‘chemically dependent” and more likely to use

drugs and alcohol at followup (164). This finding

may be important when coupled with another

finding that acceptance of chemical dependency is a

significant predictor of adolescent treatment success

(126).

In considering only residential clients, research

has been contradictory regarding the effect of age on

completion of a treatment program. One study found

that adolescents overage 15 were more likely to

complete treatment (94). One recent study found,

however, that ‘‘relatively younger” clients were

more likely to remain in treatment (103).

Ethnic Factors--Using race as an independent

variable, some studies indicate higher rates of

completion of treatment and reduction of drug use

for white adolescents compared with nonwhites

(238,248). Whites have also been found to be more

likely than nonwhites to reduce posttreatment drug

usage (103). Similarly, Jewish adolescents are more

likely than others to complete a day-treatment

program (94).

Pretreatment Behavior—Adolescents who initiate substance abuse early tend to experience more

family discord and other problems, including resistance to authority,87 and are less likely to complete

treatment (94,126,238). Adolescents who have a

history of educational failure or use multiple drugs

are more likely to drop out of treatment (126).

Mental Health Problems—Although adolescents who are depressed are more likely to drop out

of treatment, those with relatively severe psychopathology who do complete treatment seem to be more

successful at reducing subsequent drug use (102,126).

This interesting finding may reflect positive response to adjunctive treatment such as individual or

group therapy.

Substance Abuse History-Specific substances

used may be predictive of later treatment success.

87A ~au~e.md.effect relationship has not been dete~~ed.
II-552 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

One fairly consistent finding is that the two substances most commonly used by adolescents, alcohol and marijuana, are the most resistant to treatment

(103,135,292). Findings are less definitive regarding

other substances (57).

Program Characteristics Related to the

Effectiveness of Substance Abuse Treatment

Setting-Comparisons of inpatient v. outpatient

treatment offer no conclusive evidence that either

setting is clearly more effective in reducing substance use. In the two largest national studies-the

Drug Abuse Reporting Program (DARP) and the

previously mentioned Treatment Outcome Prospective Study (TOPS)--comparisons of inpatient v.

outpatient treatment resulted in contradictory results. Residential clients fared better in TOPS (135),

while outpatients fared slightly better in the DARP

study (248). These studies were both conducted with

adult patients. A study using random assignment

compared inpatient and outpatient services for

juveniles characterized as delinquent and substance

abusing and found improvement in both groups but

no differences between groups (6). These researchers suggest that maturation, and not treatment, was

responsible for change.

Time in Treatment—According to some studies,

time in outpatient treatment for adolescents is

negatively correlated with certain outcome measures, such as posttreatment productivity and frequent marijuana use (135,238). Hubbard looked at

clients ages 17 and under and found that residential

treatment was more successful for longer stays, but

adolescents in outpatient treatment were more successful if their course of treatment was shorter (135).

These findings were not true of 18- and 19-year-old

adolescent clients. However, another study suggests

that time in treatment positively correlates with

posttreatment reductions in drug use (103).

Types of Services-–Despite the emphasis in most

programs on the addiction model, the services most

clearly associated with positive treatment outcome

are those often considered “adjunctive” to substance abuse treatment, such as educational, recreational, and family therapy services and social skills

and assertiveness training. For example, a number of

researchers suggest that recreational programs such

as challenge-adventure courses are especially important because they teach adolescents alternative

discretionary time activities as well as enhance

self-esteem (102, 103, 126). Friedman and Glickman

found that provision of educational services, mandated in residential programs, are an effective

intervention in outpatient treatment as well (102).

Family involvement is also consistently found to

be a positive influence upon program cooperation

and treatment effectiveness-even more effective

than individual therapy (22,53,94,102,260). One

research team reports success in changing family

relationships by intervening with only one family

member (270). These findings may be particularly

helpful, given that mothers were much more likely

to be involved in their adolescents’ treatment than

fathers (126).

Program Climate-While counselors appear to

be poor judges of their own success according to one

study, their ratings of how explicitly they addressed

clients’ personal problems and feelings correlated

with reduction in drug use (103). Other important

correlates identified in this study were a practical

orientation towards preparation for release from the

program, measures of organization and order within

the program, and adolescent client ratings of program flexibility.

Voluntary Participation—Mandated treatment

is usually followed to completion, possibly because

of legal sanctions, but voluntary treatment is more

likely to be considered successful (71,23). An

adolescent’s perception of choice in treatment decisions is an effective predictor of treatment success.

The Economics of Substance Abuse Treatment

Substance abuse treatment for adolescents is

generally expensive, though the range is substantial.

Wright estimates the cost of a continuum of substance abuse care ranging from a primary prevention

alcohol education program through medically intensive rehabilitation (337). According to Sunshine and

Wright, a 1-month stay in a private hospital costs at

least $4,000 to $5,000, may average around $10,000,

and can be as high as $20,000 (267).

Publicly funded services are uniformly less expensive, with public hospitals costing between

$1,000 and $6,000 per month (267). Day treatment

is considerably less expensive than hospitalization—

around $3,000 per month for a private for-profit

program. Community mental health centers often

provide outpatient services which cost clients only

a few dollars, while the State reimburses the centers

approximately $30 per hour of client services. There
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-553

is no conclusive relationship between the cost and

effectiveness of services (267).

Costs for most substance use treatment services

can represent a considerable burden to adolescents,

their families, and to those health insurance plans

that cover such treatment. Medicaid coverage for

substance abuse treatment services is limited, and88

less than 20 percent of all treatment units serving

primarily adolescents accept Medicaid coverage

(308,309). Uninsured adolescents may seek treatment through community mental health centers or

private nonprofit agencies, which often operate on a

sliding-scale basis. Unfortunately, these agencies

often report long waiting lists and limited staffing.

State expenditures for alcohol and drug treatment

for persons of all ages exceeded $1.6 billion in 1988

(55). This represents a 61 percent increase over

1985. States provided funds to 6,926 treatment units

in 1988. While almost one-half of adolescent alcohol

clients received treatment in settings receiving some

public support, adolescent drug abuse clients are

served primarily in settings receiving no public

support (308,309).

Utilization of Substance Abuse Treatment

by Adolescents

According to data from NDATUS, the largest

number of treatment programs are offered by private, nonprofit facilities (65 percent of the total).

Utilization rates for these programs average 80

percent. Private, for-profit programs accounted for

14.4 percent of all programs surveyed by NDATUS

in 1987 and served 11.9 percent of the total

population in treatment (with an average 61-percent

utilization rate). On the other hand, State and local

governments own 17.3 percent of all treatment

facilities, yet they serve 24.6 percent of the population in treatment, maintaining a utilization rate of

almost 90 percent (308,309). These figures include

adult facilities and adult utilization. Adolescentspecific figures are not available.

While not conclusive, these numbers at least

suggest that available treatment may be underutilized in the private sector, creating a potential for

overtreating--especially in private, for-profit settings. At the same time, some observers have

suggested that adolescents who cannot afford private treatment may continue to be unserved, underserved, or inappropriately served (109,218).

Assessment and Referral of Adolescents With

Substance Abuse Problems

The identification and referral of an adolescent

with a substance abuse problem, although not

technically substance abuse treatment per se, are

usually the first steps in the treatment process. In

most cases, the initial identification of an adolescent

with a substance abuse problem is made by family

and fiends (126, 134). In fact, however, other

institutions or agencies—including schools, child

welfare agencies, juvenile courts, mental health

providers, medical settings, and community organizations—may be better informed and able to identify

adolescents in need. The role of these other institutions and agencies in referring adolescents to assessment or treatment is crucial. And referral is not

always a simple matter (see box 12-C). For this

reason, emphasis has been placed in recent years on

improving communications between treatment providers and these institutions.

The preliminary identification of an adolescent

with a substance abuse problem is normally followed by more detailed assessment of the suspected

substance use problem and the adolescents need for

particular services. Assessments can range from

observation and interviews through the use of

standardized tests to complete physical and psychological workups. A few assessment scales appropriate for adolescents have been developed, but the

extent of their use is not known.89 Schools and

nonspecialized community agencies generally do

not engage in elaborate assessment work themselves. They either rely on interviews and common

testing procedures or refer an adolescent to a mental

L38SW & 16, ‘Fmcial Access 10 Health services, ‘‘ in Vol. III for discussion of public (e.g., Medicaid) and private third-party payment for substance

abuse treatment services.

890De sc~e, tie Ad~]e~ent Alcohol Involvement SCale, measures ~ adolescent’s alcohol use o~y (179). Another Scale, the adolescent-SpWifiC

Addiction Severity Index, provides information regarding the seventy of an adolescent substance use problem as well M sociological and behavioral

information related to family, employment, medical, and personality factors (87), Another scale is a two-part instrument developed by Winters and

Henley to assess the extent and severity of chemical abuse (the Personal Experience With Chemicals Scale) and risk and maintenance factors (the Personal

Experience Scale) (336). Some standard tests include indicators of substance abuse. One of the most frequently used diagnostic tests, the Mimesota

Multiphasic Persomlity Inventory (MMPI), for example, includes a scale for substance abuse (the MacAndrews scale), which has been found to be a

valid index for adolescents (229).
II-554 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 12-C-Problems With Access to

Substance Abuse Treatment Services

in a Large Metropolitan Area

One large metropolitan area has at least eight

different inpatient and residential substance abuse

treatment facilities that serve adolescents. Seven of

these facilities require health insurance payment.

The eighth facility does offer an occasional “scholarship,’ ‘ but the criteria under which financial aid is

available are unclear.

For low-income adolescents in need of substance

abuse treatment who do not have health insurance,

the only other substance abuse treatment services

available in the area are outpatient services provided through community mental health centers.

The nearest publicly funded inpatient substance

abuse treatment facility is approximately 50 miles

away, treats only females, and reports a long

waiting list. Two nonprofit halfway houses are

available, but these are most frequently used as

aftercare or transitional facilities for adolescents

who have already been hospitalized They also

report waiting lists. One of the private hospitals that

claims a speciality in adolescent substance abuse

treatment has a referral list for low-income youth,

but fewer than one-quarter of the facilities on the list

actually serve adolescents.

SOURCE: ~. Emshoff and R. Margolin-Mankoff, ’’Treatment of

Adolescent Substance Abuse: A National Review

and ~qe,” paper prepared under contract to

Carnegie Corporation of New York and the Carnegie

Council on Adolescent Development for the (Mce

of Ikdmology Assessment U.S. Congress, Washington DC, 1990.

health or substance abuse professional for assess

ment. Data provided by these interviews, however,

have certain implicit difficulties in that some investigators have questioned the validity of such selfreporting. Researchers caution that assessment tests

should be part of a battery of evaluation techniques

that include intellectual and personality functioning,

family relationships, and other areas (336). Comprehensive psychological assessment is especially important when dual diagnosis (diagnosis of psychiatric disorder in addition to substance abuse) is known

or suspected, so that need for appropriate psychotherapeutic treatment is documented (186). NIDA

recently developed a comprehensive assessment and

referral manual for adolescents available for use and

further testing (307a).

Once an assessment is done, the adolescent may

be referred to a treatment program or service

provider. This is the point at which decisions are

made which affect patterns of utilization. Some of

the more common formal sources of assessment and

referral are examined below, followed by consideration of the need for standards for placement to guide

treatment decisions (2).

Schools--Schools have a significant stake in the

early identification and treatment of adolescent

substance abusers. In 1984, 21 percent of school

administrators surveyed nationally indicated that

substance abuse problems ranked second only to

discipline as a major problem (196). In addition,

schools are where most adolescents spend a large

part of their waking hours and, as discussed above,

schools have been a primary site for drug prevention

education. 90 Thus, these institutions provide convenient opportunities to observe behavioral changes

which may be associated with substance use problems. Academic performance may suffer when an

adolescent is using alcohol or drugs, and behavior

also may begin to affect others if classroom disruption ensues. As a consequence, teachers and peers

may be the first to recognize an emerging problem.

It is hardly surprising, then, that attempts have

been made to develop school-based programs for

identifying adolescent substance users and referring

them to treatment. An example of a school-based

program is substance abuse counseling-generally

known as a Student Assistance Program. Student

Assistance Programs are modeled on employee

assistance programs (188,192). They provide onsite, immediate intervention-identifying students

with problems, helping them to acknowledge their

difficulties, and making referrals to other services in

the community. In some cases, they use peer or

guidance counselors already involved with other

school programs. Student Assistance Programs often

use prevention techniques and may reach out to

students who are neither high risk nor active users.

In many communities, Student Assistance Programs

are among the only substance abuse intervention

services available to low-income adolescents.

90For d&-uSSiom of school env~oments and ~eir impact On health and of adolescents’ use Of discmtio~ ~e, ~ch. 4, ‘ ‘Schools ad

Discretionary Time,” in this volume.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . //-555

Despite efforts like Student Assistance programs,

school systems are often reluctant to become involved in substance abuse issues which may be seen

as health problems and not strictly educational

concerns. In addition, policies requiring suspension

for substance use may interfere with a school’s

ability to provide services onsite. Thus, one researcher argues that school personnel must make

more effective use of community treatment resources, rather than attempting to provide longrange counseling themselves (341). Some States

require schools to document efforts at coordination

and to specify agency responsibilities before funding school-based substance abuse intervention programs. Confidentiality, coordination of services for

multiproblem students, lack of parental involvement, and the advisability of increasing treatment

services may be problems when schools become

involved in identification and referral (275,341),

The scarce literature on Student Assistance Programs (1 13) has not addressed these issues, but there

have been reports of positive reception to Student

Assistance Programs by students (188).

Juvenile Justice Agencies--The incidence of

substance abuse problems among adolescents

served by the juvenile justice system is disproportionately high (127).91 Thus, the juvenile court can

be an important link in connecting adolescents with

substance abuse problems to needed treatment.

Generally, services provided in court settings focus

on assessment and referral for substance abuse

treatment. However, in some instances the court may

retain jurisdiction over a juvenile and actually

approve a treatment plan in coordination with

substance abuse or mental health agencies. This can

occur under a diversion plan before adjudication is

completed or afterwards, with treatment imposed as

a condition of probation (sometimes with provision

for expunging a record upon successful completion

of treatment).

In diversion, the juvenile justice system (i.e., the

court or a lower officer of the court) may redirect an

adolescent to a substance abuse treatment program

as an alternative to the adjudication process—

reducing the caseload of the court system while

providing rehabilitative services to adolescents (10).

By retaining jurisdiction pending completion of a

substance abuse program, a juvenile court may

provide the added leverage of potential sanctions for

noncompliance, thereby increasing cooperation with

treatment (148). Although some authors have questioned the appropriateness of court-ordered treatment for substance abuse problems (258), others

have shown that even mandated treatment can be

effective when some measure of decisionmaking is

available to the adolescent within the treatment

program (104).

Treatment Alternatives to Street Crime is a

Federal program that was developed for use in the

adult corrections system in the 1960s but now funds

programs for juvenile offenders as well (148). One

comprehensive evaluation and referral program

funded by Treatment Alternatives to Street Crime

screens all juveniles involved in complaints for

substance abuse (148). If initial screening reveals a

substance use history, a more comprehensive assessment is done. Subsequent referral for treatment is

then incorporated into conditions of probation.

The High-Intensity Treatment and Supervision

program reported by Swarm provides mandatory

counseling not only for substance abusing delinquents but also for their parents (269), This program

seeks to ‘‘empower’ parents whose children are out

of control by teaching parenting skills. Swarm

suggests that this program serves younger siblings in

these families as much as the delinquents themselves

(269).

Primary Health Care Services--Some observers have suggested that primary care physicians

should evaluate adolescents for a variety of ‘‘risky

behaviors,’ including substance abuse, at routine

examinations (51,93). Although most physicians are

willing to provide counseling and referral for

adolescents with substance abuse problems, they are

often quite poor in identifying drug users among

other medical patients (255).92

NIDA’s DAWN system, discussed earlier, documented 13,975 adolescents in 1988 who were

admitted to selected emergency rooms nationwide

for conditions involving the use of drugs. Most of

these encounters (61.8 percent) were related to

91~e @g abuse ~d ~~cr h~~ prob]ems of adolescents ~ tie juvenile justice system, as well as problems witi the health services available [0

such adolescents, are discussed in ch. 13, “Delinquency: Prevention and Services, ” in this volume.

%lFor a fuller discussion of p~mq hCa]th ~Me for adolescents, including, studies of physicians’ ability to detect subswce abuse problems in

adolescents, see ch. 15, ‘‘Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Services to Adolescents, ” in Vol. III.
II-556 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

suicide attempts (302). While the use of a drug in a

suicide attempt does not necessarily demonstrate the

existence of a continuing substance abuse problem,

the DAWN data do indicate that medical personnel

come into contact with adolescents at crucial moments and that these opportunities for substance

abuse treatment interventions are not being fully

utilized. One review of an emergency department of

a university hospital that was especially designated

as an alternative to incarceration for public drunkenness suggests that intensive and longer term intervention at the emergency-room level may be effective in reducing episodes of intoxication (264). In

this program, intoxicated adolescents were evaluated and observed closely for an extended period,

interviewed extensively, and scheduled for followup

appointments. At 13 months, only 13 percent of

these high-risk patients had come back to the

emergency department because they were intoxicated. The lack of a control group makes definitive

conclusions about the effectiveness of this intervention difficult. However, since emergency room

personnel rarely provide such interventions, specialized training in the provision of extensive counseling and followup seems warranted, and further

systematic study of such interventions would be

worthwhile.

Mental Health System-Considerable differences exist between professionals in the substance

abuse and mental health areas, mostly centering

upon appropriate identification of treatment needs

and services. These differences have sometimes

worked to the disadvantage of the adolescent seeking services. So, too, has the tendency in some areas

to maintain separate substance abuse and mental

health programs, even though certain clients may

have dual diagnoses and therefore be denied needed

treatment for one condition while enrolled in a

program for the other.

Given the documented incidence of mental health

problems in substance abusing adolescents, involvement by mental health providers is appropriate and

necessary (102,126). However, these professionals

need a basic knowledge of the substance abuse

process and treatment to be most effective. In fact,

a common complaint by substance abusers is that

those in the mental health professions fail to

recognize the severity of their problems (52). There

is a divergence in perspective between traditional

mental health professionals and those specializing in

substance abuse treatment based on their respective

philosophical frameworks. Mental health treatment

frequently emphasizes development of self-control

and searches for ‘‘underlying issues, ’ while substance abuse treatment stresses loss of control over

a substance and identifies the immediate symptom

(the substance abuse) as the primary problem for

treatment. In addition, traditional therapists may

have difficulty with the spiritual focus of 12-step

programs (52). While some mental health therapists

are increasing acceptance and involvement with

practitioners of the addiction model of substance

abuse, others continue to develop psychologically

oriented treatments especially focusing upon cognitivebehavioral and family approaches (52).

Standards for Placement of Adolescents With

Substance Abuse Problems

The need for criteria to guide placement decisions

for adolescents with substance abuse problems has

arisen from the “dilemma of recommending the

most appropriate treatment option from a proliferating array of choices” (131) and recent concerns

about the potential overuse of both inpatient and

outpatient treatment. In response, the substance

abuse treatment community has developed its own

placement standards, because the broad guidelines

of the Joint Commission on Accreditation of

Healthcare Organizations and the Commission on

Accreditation of Rehabilitation Facilities do not

offer sufficient assistance in admission decisions

(64). The “Cleveland Criteria” were developed in

1986 by the Chemical Abuse Treatment Outcome

Research (CATOR) network in collaboration with

several treatment centers and advisers. These criteria

offer standards for placement and treatment in six

levels of substance abuse services and cover six

levels of care, including separate guidelines for

adolescent clients. Other work is being done by the

National Association of Addiction Treatment Personnel (203). The Provisional Committee on Substance Abuse of the American Academy on Pediatrics has also developed guidelines for the selection

of substance abuse treatment programs (2).

The emergent criteria stress placement in the least

restrictive environment and seek to take adolescent

maturation levels, cognitive functioning, and developmental factors into account in placement decisions. The National Association of Addiction Treatment Personnel’s draft document suggests that

placements should be based on clinical functioning

rather than issues of sponsorship or payment.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-557

Preliminary standards suggested by both the National Association of Addiction Treatment Personnel and the Cleveland group require a DSM-III-R

diagnosis of a substance use or dependence disorder

for a client to be considered for treatment (4).

Placement decisions are also affected by medical,

psychiatric, and ‘‘environmental’ complications.

Interestingly, these criteria fail to address the

issues raised by many experts in the field of

substance abuse assessment. No mention is made of

standardized instruments (beyond the criteria themselves) or of incorporation of assessment procedures

into treatment planning. Furthermore, adherence to

these criteria is, at this point, entirely voluntary and

is not monitored at all.

Staffing of Substance Abuse Services

The credentialing of substance abuse treatment

professionals is an enduring problem. Some level of

standardization was recommended a decade ago, in

a 1980 General Accounting Office report that called

for a national system for accreditation of substance

abuse counselors (279). That report noted that

‘‘counselor competency is vital to proper treatment

(279). Despite such recommendations, however, no

nationally standardized system of accreditation has

yet been developed.

The substance abuse treatment community has

responded to this void by developing certification

criteria of its own in several different fields. For

example, the American Society of Addiction Medicine (ASAM) offers a certification examination to

board-certified physicians with at least one year’s

full-time involvement in the field of alcoholism and

other drug dependencies (3a).93 The National Association of Alcoholism and Drug Abuse Counselors

has developed certification criteria for National

Certified Addiction Counselors (204).94 All States

now provide (and most require) some form of

certification for substance abuse treatment professionals—usually identified as ‘‘certified alcohol

counselor, ’ ‘‘ certified drug counselor, ’ or a combined “certified addictions counselor’ ’-and, as of

1989, 36 States extended reciprocity for certification. But, as discussed elsewhere in this Report, the

number of health care providers trained specially to

provide health care to adolescents is very small.95

Staffing patterns also affect the quality of care in

adolescent substance abuse treatment programs and

substance abuse treatment programs in general

(201). Funding limitations may restrict staffing,

especially in public settings. Administrative personnel report that in many cases, due to funding

limitations, one staff member may provide several

different services. Within drug treatment outpatient

programs in which at least 75 percent of the clients

are adolescents, there are approximately 20 clients

per counselor. Each client has an average of only 1.7

scheduled appointments per week, including individual and group meetings (308,309).

In residential settings, psychiatrists or addiction

specialists may provide individual therapy and

paraprofessional staff provide milieu therapy and

supervision of client activities. Inpatient programs

are usually managed by physicians with training in

psychiatry or addictions. Nonetheless, physicians

may have limited contact with their clients, often

meeting with them only for brief sessions and

making decisions based on record reviews. Most

hospitals use a team approach in which a variety of

professionals share responsibility for patient care.

A complicating issue in evaluating staff requirements is the norm of hiring former substance abusers

as counselors, especially in residential programs. In

one study, about 40 percent of counselors in

residential programs and nearly half in outpatient

programs were described as recovering personnel

(134). An assessment involving adolescent treatment found no differences in selected client outcomes between programs using staff who were

former substance abusers and staff professionals

with no personal substance abuse history.

93ASAM iS not iLSelf ~ ~em~r of tie ~enm B~ard of M~iC~ Sp=idties, and thuS the ASAM cefification process is not a bored U~lGltiOn

(3a).

941n ord~ t. be ~efi~l~ as a National Cefified Addiction counselor, applicants must possess current State cetilcation or licensure &S MI alcoholism

and/or drug abuse (AODA) counselor, have 3 years’ full-time or 6,000 hours of supewised experience as an AODA counselor, 270 contact hours of

education and training in AODA or related counseling subjects, and pass a written examination administered by the National Association of Alcoholism

and Drug Abuse Counselors Certification Commission (204). The National Association of Alcoholism and Drug Abuse Counselors Certi!lcation

Commission defines addiction as ‘the condition or state wherein an individual is physiologically and/or psychologically dependent upon alcohol and/or

other drugs” (204).

gsSec ch. 15, ‘‘Major Issues in the Delivery of Primary and Comprehensive Health Semices to Adolescents, ’ in Vol. III.
II-558 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

The recent Institute of Medicine report on drug

treatment did not deal in depth with the issue of

staffing-and did not deal with staffing for facilities

and programs treating adolescents at all— but, with

respect to publicly funded treatment programs, it

concluded in general that “the competence, quality,

and continuity of care givers may well be a critical

element in explaining. . differential effectiveness’

(201). Overall, the Institute of Medicine report

recommended considerable upgrading of public

facilities. With respect to private facilities, the

Institute of Medicine suggested “the development

of soundly derived standards for admission, care,

and program performance” (201).

Conclusions About Substance Abuse Treatment

Services for Adolescents

Clearly, there is no one system for the treatment

of psychoactive substance use problems among U.S.

adolescents. Costs of services vary tremendously by

type of provider and setting. Adolescents from

affluent homes or those with insurance coverage are

likely to be seen in private settings that tend to offer

more intensive services.96 Low-income adolescents

are typically restricted to what local public services

may be available. Public services may vary tremendously from State to State, depending on the funds

available for inpatient and outpatient services, policies regarding the mandating of substance abuse

coverage in private health

use of Medicaid funds to

treatment.

The lack of standards

plague the field. Whether

insurance plans, and the

support substance abuse

and uniform definitions

one considers quality of

care standards, professional qualification standards,

or key conceptual terms like “abuse,” “need,” or

‘‘success, ’ confusion is more common than concurrence. Program accountability is affected when

‘‘success’ is defined in terms of completion of

treatment rather than in terms of short-term or longer

term behavioral outcomes.

“Client-treatment matching” is described in the

literature as an important reason for advancing

research. However, it is questionable that more than

one basic treatment exists with which individual

client needs can be matched, because most treatment

is based on the addiction model. Treatment for

substance abuse seems quite uniform, with rather

rigidly scheduled activities and little individualization. Furthermore, services are not currently differentiated as a function of the presenting problem, or

the characteristics of the adolescent, the family, and

the larger environment. Even when comprehensive

assessments are undertaken, it is unclear how these

data are used in program development.

Insufficient attention has been paid to whether

adolescents should be considered a special treatment

population in need of adolescent-specific treatment

services, rather than continue incorporating adolescents into substance abuse treatment programs

primarily intended for adults.

Similarly, insufficient attention has been paid to

the special needs of minorities in both the delivery

of services and the design of research efforts. Too

often, data are not collected or analyzed on an

ethnic-sensitive basis, so that little is known about

what types of substance abuse treatment work best

for which adolescent subpopulations.

Little attention has been paid to the differences

among adolescents at different ages and stages of

development. Adolescent programs, where they

exist, tend to treat adolescents without much distinction between early, middle, or late adolescence. And

adolescents with combined substance abuse and

other problems such as mental retardation, mental

illness, and delinquency may find themselves excluded from single-focus treatment programs because of their multiple diagnoses. Further exploration of the developmental stages of adolescence, the

maturational process, and the unique needs of

adolescents with dual-diagnoses is necessary so that

treatment programs can be structured in ways that

are responsive to the therapeutic needs of adolescents.

The need for increased funding for adolescentspecific substance abuse treatment services is accompanied by a comparable need in treatment and

services system research. In too many treatment

areas, research has yet to determine what works

effectively and what does not. Research models

which are specific to the characteristics of adolescents, different cultures, and substances need to be

developed and rigorously tested with a variety of

settings, providers, and clients if this deficit is to be

addressed. Support by Federal agencies—particularly NIDA--for future research on adolescent

%L~tation~ on h~th fimce Coverwe for subs~ce abu~ ~ea~ent we dis~ssed in ch. 16, ‘ ‘Financial Access to Hdth Semices,’ ~ VO1. rrr.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-559

substance abuse treatment, however, should require

a strong commitment to methodological integrity

and scientific evaluation.

Major Federal Policies and Programs

Related to the Use and Abuse of

Psychoactive Substances by Adolescents

Overview

The Federal role in the prevention and treatment

of psychoactive substance abuse changed throughout the 1980s. Prior to 1980, the Federal Government had taken some direct role in funding prevention and treatment activities. In 1981, with the

introduction of the Alcohol, Drug Abuse, and

Mental Health (ADM) Block Grant Program of the

Public Health Service Act, the bulk of Federal funds

for prevention and treatment were given directly to

the States in the fen-n of block grants, and States

were given primary responsibility for establishing

program requirements and monitoring program activities (Public Law 97-35).97 At the same time, the

National Institute on Drug Abuse (NIDA) and the

National Institute on Alcoholism and Alcohol Abuse

(NIAAA) in DHHS continued to take the lead role

in intramural and extramural research on alcohol

and illicit drug abuse.

In 1986, in response to increased public and

governmental concern about the spread of illicit

drugs and drug-related crime, Congress and the

executive branch joined together in strengthening

the Federal role related to drug abuse, by passing the

Anti-Drug Abuse Act of 1986 (Public Law 99-570).

This law had provisions affecting the actions of

numerous executive branch agencies, including the

White House, the U.S. Department of Justice, the

Federal Communications Commission, the U.S.

Department of Defense, the U.S. Department of

Education, the U.S. Department of Health and

Human Services, the National Park Service in the

U.S. Department of the Interior, and others. In 1988,

Congress passed, and the President signed, another

Anti-Drug Abuse Act (Public Law 100-690), further

strengthening the Federal role in antidrug activities,

and creating an executive branch office to coordinate

national drug control policy. This executive branch

office became known as the Office of National Drug

Control Policy (ONDCP).

In both Anti-Drug Abuse Acts, substantial funds

were authorized to be newly allocated to or reallocated within executive branch agencies for purposes

of: strengthening Federal efforts to encourage foreign cooperation in eradicating illicit drug crops and

in halting international drug traffic; improving

enforcement of Federal drug laws and enhancing

interdiction of illicit drug shipments; providing

strong Federal leadership in establishing effective

drug abuse prevention and education programs;

expanding Federal support for drug abuse treatment

and rehabilitation efforts; and for ‘‘other purposes’

as delineated in the acts (Public Law 99-570, Public

Law 100-690). ONDCP estimated the budget authority of the drug control agencies to have been

$9.378 billion in fiscal year 1990 (327,327a).

Forty-eight executive branch agencies, in 18 cabinet

departments or independent agencies, were counted

by ONCDP as being ‘‘national drug control program

agencies” in February 1991 (327).98

With respect to adolescents, several features of

the Anti-Drug Abuse Acts of 1986 and 1988 and

subsequent executive branch activities are worth

noting. As discussed above, alcohol and tobacco are

the substances most likely to be used and abused by

adolescents. 99 In contrast, both the 1986 and 1988

~For f~er discussion of the Alcohol, Drug Abuse, and Mental Health Bl~k Grmt progr~, see ch. 11, ‘‘Mental Health Problems: Prevention and

Services, ‘‘ in this volume.

98&-c~rd@ t. oNDcp, 12 c~b~et dcp~~nt~ ~ve agencies @t ~e MtioM] ~g control progr~ agencies: U.S. Dep~ent of Justice, U.S.

Department of the Treasury, U.S. Department of Transportation the U.S. Department of Agriculture, the U.S. Department of the Interior, the U.S.

Department of Health and Human Services, the U.S. Department of Education, the U.S. Department of State, the U.S. Department of Defense, the U.S.

Depwtrnent of Housing and Urban Development, the U.S. Department of Labor, and the U.S. Department of Veterans Affairs (327). Six independent

agencies are national drug control program agencies: ONDCP, the U.S. Judiciary, ACITON, the Agency for International Development the U.S.

Information Agency, and the Central Intelligence Agency (327). In additio% according to ONDCP, the following budget accounts are part of the mtiomd

drug control program budget: the Special Forfeiture Fund (ONDCP), the Asset Forfeiture Fund (U.S. Department of Justice), Support for Prisoners (U.S.

Department of Justice), and Emergencies in the Diplomatic and Consular Service (U.S. Department of State) (327). As dictated by the law mandating

the creation of ONDCP, national drug control program agencies were to be designated ‘ ‘jointly by the Director IONCDP] and the head of the department

or agency; or. . .by the president” (Public Law 100690, Title I, Subtitle A, Sec. 1010). As explained further in the drug control budget submitted by

ONDCP, not all activities of all the mtional drug control program agencies arc earmarked for drug control activities.

?9As discussed ~low, however, Prevention activities tided by me Office for Subs@ce Abuse prevention (oSAP) fi DHHS do include efforts tO

prevent or delay the use of alcohol and tobacco by adolescents and younger childrcm either because these are regarded as “gateway drugs” (see above)

or because the use of these substances is illegal for most adolescents.
11-560. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Anti-Drug Abuse Acts emphasized activities related

to controlled substances (illicit drugs). Each act has

some mention of activities related to alcohol abuse

(e.g., drunk driving prevention programs under Title

IX, Subtitle A, of Public Law 100-690), but such

activities are not a leading focus of the laws. As

perhaps the leading example of this focus on illicit

drugs, the activities of ONCDP were legislated to

include only those drugs included in section 102(6)

of the Controlled Substances Act (21 U.S.C. 802(6))

(Public Law 100-690, Title I, Subtitle A, Sec. 1010);

thus NIAAA is not considered a national drug

control program agency. Neither act authorizes

activities pertaining to tobacco use or dependence.

l00

Second, since the passage of the Anti-Drug Abuse

Act of 1986, there has been continuing tension

concerning the roles of the Federal Government

relative to drug supply reduction and demand

reduction. Supply reduction activities under the acts

are more relevant to illicit drugs than to alcohol or

tobacco, the substances most likely to be used by

adolescents, so one would expect such activities to

have a smaller immediate impact on adolescents in

general than effective demand reduction activities.

On the other hand, as noted above, one could argue

that supply reduction activities are of primary

importance in protecting adolescents from increasing quantities of—and growing illegal markets

for—illicit drugs, and from the violence and other

crime that is associated with the illicit drug market.

In any event, approximately 70 percent or more of

the budgets of the National Drug Control Agencies

have been allocated to supply reduction activities,

and this seems unlikely to change. Although, as

described below, Federal investment in substance

abuse prevention and treatment activities has grown

throughout the 1980s, as a general matter, ONCDP

continues to believe that the Federal Government

should have a more limited role in activities related

to reducing the demand for illicit drugs (defined in

public Law 100-690 as drug abuse education,

prevention, treatment, research, and rehabilitation)

than in activities related to reducing the supply of

illicit drugs (defined in Public Law 100-690 as

international drug control, foreign and domestic

drug enforcement intelligence, interdiction, and

domestic drug law enforcement, including law

enforcement directed at drug users). ONCDP argues

that “many supply reduction activities are intrinsically [Federal] Government operations. . whereas

most demand reduction efforts can and should be

shared by our schools, churches, and communities’

(327). Perhaps for this reason, the ONCDP national

drug control strategy for fiscal year 1992 suggested

some Federal pulling back from selected drug use

prevention activities.

As noted above, it would be difficult to assess the

impact of current illicit drug supply reduction

activities on adolescents, and no such attempt is

made here. lO1 102 This section provides a brief

overview of the current leading executive branch

activities in demand reduction activities (substance

abuse research, prevention, and treatment) specific

to adolescents. The two agencies with the largest

role in reducing the demand for drugs among

adolescents are the DHHS and the U.S. Department

of Education. Other Federal agencies with smaller

roles include ACTION, the U.S. Department of

Housing and Urban Development, and the U.S.

Department of Labor.103

Specific Federal Agencies and Their Roles

in Substance Abuse Prevention and

Treatment for Adolescents

U.S. Department of Health and Human Services

DHHS has by far the largest role in adolescentrelated demand reduction. The DHHS agency with

the largest role is the Alcohol, Drug Abuse, and

Mental Health Administration (ADAMHA), but

other agencies such as the Centers for Disease

l~ch of tie acts did have a p~iculm focus on the susceptibility of children and adolescents to tie use of drugs.

IOlON@p i~e~ a~~ ~,c~~ ~ ev~u~ tie effectiveness of its supply reduction activities. Accor@g to C)NCDP, &ti on drug availability,

including domestic marijuana production are “not yet available’ (327).

10’2~ ~ch 1987, OTA publish~ ~ ~~ysis of Feder~ effo~ in @g interdiction (stOpp@ or reducing the mowt of dlUgS CO@ WXOSS U.S.

borders) (285a). The U.S. General Accounting Offke has also analyzed Federal policies related to supply reduction/drug interdiction and has numerous

publications on the issue (281).

103~e us, Dep~~t of Tr~spoflation’s effo~ related to he reduction of driv@ ~der the influence of psychoactive ~bs~es are described

inch. 5, “Accidental Lnjuries: Prevention and Services, “ in this volume. The U.S. Department of Justice’s activities related to substance use and sales

by adolescent delinquents aredescribedinch. 13, “Delinquency: Prevention and Services,‘‘ in this volume. Within DHHS, the National Cancer Institute

provides most support for smoking prevention as part of its cancer prevention activities. These activities are discussed in ch. 6, “Chronic Physical

Illnesses: Prevention and Services, ” in this volume, and in ch. 19, “The Role of Federal Agencies in Adolescent Health, ’ in Vol. III.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services .11-561

Control (CDC), the Indian Health Service, the Office

of Human Development Services, Health Resources

and Services Administration, and the Office of

Disease Prevention and Health Promotion, also play

some role.

Alcohol, Drug Abuse, and Mental Health Administration Agencies---Four of ADAMHA’s five

agencies deal with substance use and abuse:

●

●

●

●

the Office for Substance Abuse Prevention

(OSAP),

the Office for Treatment Improvement (OTI),

the National Institute on Alcoholism and Alcohol Abuse (NIAAA), and

the National Institute on Drug Abuse (NIDA).

OSAP and OTI are two relatively new ADAMHA

agencies which fund program demonstration projects and other nonresearch activities. NIAAA and

NIDA are research agencies.l04

Office of Substance Abuse Prevention—OSAP

was created by the Anti-Drug Abuse Act of 1986

(Public Law 99-570) as “the cornerstone of the

Federal demand reduction strategy” and is “the

major prevention unit ofADAMHA’(310), OSAP’s

programs are important to a consideration of substance use by adolescents, because, as dictated by

the legislation that authorized the agency, a prime

target group for OSAP programs is ‘‘high-risk

youth. ‘ ‘

Most of OSAP’s prevention activities can be

categorized as primary or secondary prevention, but

some treatment demonstration projects are funded.

Under its High-Risk Youth Demonstration Grants

program, OSAP has funded the developing, testing,

and evaluation of promising approaches for working

with high-risk youth. OSAP’s fiscal year 1990

budget was $193.4 million overall, approximately

30 percent of which was estimated to be spent on

high-risk youth demonstration projects ($39.0 million) and community youth activities ($19.8 million)

(327).

In its summary of national drug control program

agency budget proposals for fiscal year 1992,

ONDCP recommended increasing the budget for

high-risk youth demonstration projects by about 8

percent over its fiscal year 1991 level (from $50.7

million to $54.8 million) and completely discontinuing the community youth activities program (327a,

327b).105

Office for Treatment Improvement---OTI was

created in fiscal year 1990, and its long-term goal is

to develop national prototypes for effective drug

treatment policy. OTI’s major responsibility, however, is to administer the ADM block grant, the drug

and alcohol portion of which was $895.6 million in

fiscal year 1990 (155a). Block grant funds are

provided to States, and there is little requirement for

State reporting. Thus, it is unclear what portion of

ADM block grant funds are used for adolescents, A

major OTI initiative directly relevant to adolescents

has been a competitive grant program to assist States

and communities in enhancing existing drug abuse

treatment programs for critical population groups,

including adolescents (defined as individuals up to

age 22), racial and ethnic minorities, and residents of

public housing projects. This grant project is not

directed toward the development of new treatment

approaches so much as the application of apparently

promising modes of service delivery (for example,

the use of aftercare services). For fiscal year 1991,

$38.1 million was appropriated for the program on

critical population groups, and a grants announcement was to be published in summer 1991 (327 b).

National Institute on Alcoholism and Alcohol

Abuse—-NIAAA is not considered one of the

national drug control program agencies (327,327a),

but it funds and conducts research on the prevention

and treatment of alcohol-related problems. NIAAA

has three priority areas specific to adolescents: 1)

defining sociocultural factors that promote adolescents’ drinking, 2) developing and testing preventive

interventions, and 3) assessing the impact of changes

in the drinking age on alcohol consumption

(270a,289a,289b). In fiscal year 1989, NIAAA spent

l@$NIAAA and NIDA do conduct research on the effectiveness of particular substance abuse prevention and treatment progmrns, but more of the~ focus

is on research on the epidemiology, risk factors, and effects of drugs and alcohol. When plojects involving intervention are funded by NIAAA and NIDA,

they are required to have a more rigorous research design than that required for OSAP and OTI projects (304a). Depending on the results of the OSAP

and OTI project evaluation, some projects can be expected to be subjected eventually to the rigors of controlled trials (31 la).

los~le Comufity yOUth activities Progrml is a combined block grant ($4.Y million in fiscal year l$Vl), State demonstration-t ($14.2 million in

fiscal year 1991), and Projects of National Significance ($1.1 million in fiscal year 1991) program to provide funds for after-school, vacation, and

weekend activities for dropouts and in-school youth (Public Law 100-690). As this Report was being prepared for publication it was not clear whether

Congress would grant to ONDCP’S request to discontinue funding for the community youth activities program.
II-562 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

over $6 million (under 5 percent) of its overall

budget on activities aimed at adolescents. In fiscal

year 1991, NIAAA funded an Adolescent Alcohol

Research Center.

National Institute on Drug Abuse—NIDA supports research on use and abuse of illicit drugs (e.g.,

marijuana, cocaine, PCP), although it also supports

some research on tobacco use and on the combined

use of alcohol and other drugs. In the late 1980s and

early 1990s, NIDA received considerable increases

in its overall budget; NIDA’s overall budget for

fiscal year 1990 was $379 million; its estimated

budget authority in fiscal year 1991 was $428.3

million (327).

Many of NIDA’s current projects are related to the

prevention or treatment of substance use by adolescents, but NIDA could not estimate for OTA what

proportion of its overall budget would be spent on

projects involving adolescents ages 10 to 18 (304a).

OTA’s review of material submitted by NIDA in

1989 suggested that most of NIDA’s adolescentrelated projects focus on prevention, and that very

few current projects were investigating new treatment approaches for adolescent substance users

(304a). In 1991, ONDCP said that the administration

was placing a high priority on research on drug abuse

treatment for adolescents, which it characterized as

“perhaps the least researched aspect of the field”

(327), and NIDA has initiated a large-scale study of

the effectiveness of drug treatment for adolescents,

with long-term followup of clients (327). NIDA has

also begun to devote more grant funds to the

investigation of risk factors for drug abuse among

inner-city minority adolescents.

Other DHHS Agencies-Within CDC, the Center for Chronic Disease Prevention and Health

Promotion’s Office on Smoking and Health is the

lead Federal agency on tobacco and health (320a).

CDC’s new Division of Adolescent and School

Health has the prevention of HIV and AIDS as its

major emphasis, but it has also focused on other

health-compromising behaviors by adolescents, including psychoactive substance use. The major

activity in this respect is the development of a Youth

Risk Behavior Surveillance System (YRBSS), which

—

will periodically question adolescents about their

engagement in a range of health-compromising

behaviors, including substance use.

American Indian and Alaska Native adolescents

are more likely than many other adolescents to use

alcohol and illicit drugs (286). In addition, they are

very likely to live in communities in which alcohol

abuse is almost epidemic (284). Yet a focus on

Indian adolescent substance use was long in coming

in the Indian Health Servicei the major health

service agency for Indians (286). The 1986 AntiDrug Abuse Act provided funds to be used for

substance abuse prevention and outpatient and

residential treatment of Indian adolescents, and in

1988, the Indian Health Service reported a commitment to providing services to all Indian adolescents

diagnosed with a substance abuse problem (286,327a).l06

According to ONDCP, eight Adolescent Regional

Treatment Centers were to be established by the end

of fiscal year 1991, an increase of one over fiscal

year 1990 (327a).

The Office of Human Development Services’

Administration for Children, Youth, and Families

funds two grant programs related to adolescent drug

use (327a,327b). One is the Drug Abuse Prevention

Program for Runaway and Homeless Youth, which

awards grants to public and private nonprofit agencies, organizations, and institutions to carry out

research, demonstration, counseling and services to

runaway youth and their families, and for other

activities (327b). The other is the Youth Gang Drug

Prevention program, which provides grants to projects designed to prevent the participation of adolescents in gangs that engage in illicit drug-related

activities, and for other purposes (327b). Each of

these programs had $14.8 million to carry out

existing grants in each of fiscal years 1990 and 1991,

and level funding was requested for fiscal year 1992

(327b).

Except for its role in administering the maternal

and child health services block grant,107 the Bureau

of Maternal and Child Health in the Health Resources and Services Administration has no direct

role in substance abuse prevention and treatment for

adolescents. The Bureau does participate in a

106~e BWeauof In&m Aff& @~) intheu+s. Dep~entof tie Interior ~sohas aro]C iII adol~mnt substance use preventio~and treatment through

drug education in BIA-supported schools and detention and diversion of Indian adolescents who become involved with Indian juvenile justice programs

because of alcohol and other drug use (286,327a,327b).

107c+C ~h, 19 ~ f~e Role of F~er~ Agencies in Adolescent He~~’ iII vol. Iu for ad~tional information on the maternal and child health SelViC~

block grant. ‘
Chapter 12—Alcoholf Tobacco, and Drug Abuse: Prevention and Services ● II-563

number of formal and ad hoc interagency coordinating activities, however (319a).

The Office of Disease Prevention and Health

Promotion (ODPHP) in the Office of the Assistant

Secretary of Health has a general focus on “highrisk youth and reducing high-risk behavior’ and has

supported a number of efforts to help improve

adolescent health (320a). These include initiating

the interagency Ad Hoc School Health Committee,

funding a marketing study of adolescent high risk

behaviors, and developing publications related to

school health programs (320a). ODPHP also oversees the development of the health objectives for the

nation (e.g., Year 2000 National Health Objectives).

Objectives related to reducing adolescents’ use of

tobacco, alcohol, and other drugs are included in the

objectives (320b).

U.S. Department of Education

The U.S. Department of Education was required

to get involved in drug abuse prevention with the

passage of the Anti-Drug Abuse Act in 1986 (Public

Law 99-570). By 1989, the Department had developed a three-pronged approach to the drug problem,

involving 1 ) the provision of leadership, 2) the

dissemination of information, and 3) the provision of

technical and financial assistance to States (57a).

The most prominent U.S. Department of Education activity related to adolescent substance use has

been the promotion of drug-free schools and communities, pursuant to the mandate of the Drug-Free

Schools and Communities Act (Public Law 99-570).

This legislation, which was enacted as part of the

1986 Anti-Drug Abuse Act and reenacted in 1988

with the Augustus F. Hawkins-Robert T. Stafford

Elementary and Secondary School Improvement

Amendments of 1988 (Public Law 100-297), supports State and local programs of drug abuse

prevention and education. It was subsequently

amended at the end of the first session of the 10lst

Congress to require schools to adopt firm drug

policies as a condition of eligibility for Federal funds

(Drug-Free Schools and Communities Act Amendments of 1989 [Public Law 101-226]). Other adolescent-related grant programs in the U.S. Department

of Education include demonstration grants to institutes of higher education, an emergency grants

program to local educational agencies that demonstrate a significant need for additional assistance in

combating drug and alcohol use, a school personnel

training program, a counselor training grant program, a Federal activities grants program, and

regional centers for drug-free schools and communities (327b).

In fiscal year 1990, approximately $435.9 million

in formula grants (based on the number of elementary and secondary school students (in the State)

was distributed to States under the Drug-Free

Schools and Communities Act local grants program;

in fiscal year 1991, the amount was $497.7 million

(327b). No increase was requested for fiscal year

1992 (327b), Neither were increases requested for

any of the other Department of Education programs

except for the emergency grants program (from

$24.3 million to $49.5 million) (327b).108

Other Federal Agencies

ACTION, the Federal agency that coordinates

volunteer activities, has taken an increasing role in

the drug war (327a). The ACTION program most

directly related to efforts to reduce adolescent drug

use is the Drug Alliance grant program (54 FR 173,

1989), In fiscal year 1991, this program was to

provide grants of up to $40,000 (with a requirement

for a 50-percent non-Federal match) for projects that

use nonstipended volunteers to provide positive peer

activities for youth serve as mentors for high-risk

youth, and other services (327b). In the program

announcement, ACTION cited increasing acceptance of the notion of “ ‘immunization ’-that voluntary service may in fact reduce the risk of drug

involvement among participating youth by reinforcing good work habits, helping enhance self-esteem,

establishing a sense of belonging within the community, and providing positive role models’ (54 FR

173, 1989). Applicants, who must be private nonprofit incorporated organizations or public agencies,

must adhere to ‘‘a strict policy of the nonuse of illicit

drugs’ ‘ and not endorse a philosophy or any

activities that would advocate ‘‘the tolerance of the

initial or responsible use of any illicit drug, or the

illicit use of any legal drug’ (54 FR 173, 1989).

108~e ~mcrgency ~mts Prowm provides assistmce tO local educational agencies that demonstrate a significant need for additional assistance in

combating drug and alcohol USC. Districts compete for funding to support a comprchcnsivc range of services, including cducatioml programs, counseling

programs, enhancement of school security, afterschool prograrm, programs for parents and other community outreach efforts, and alternative programs

for students with a history of drug abuse or others who arc difficult to reach in the rcgul,ar school setting (327b). ONDCP estimated that 50 awards would

be made under this program, ranging from $100,000 to $1 million (327b).
II-564 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Budget authority for the Drug Alliance grants was

$1.3 million in fiscal year 1990, and $2.2 million in

fiscal year 1991 (327a). The administration requested a reduction in funding to $1.5 million for

fiscal year 1992.

In fiscal year 1991, the U.S. Department of

Housing and Urban Development was to provide

$7.5 million in financial assistance for the creation

and implementation of Youth Sports programs in

public and Indian housing (327b). Individual grants

were to be for a maximum of $125,000 and would

require a 50 percent match by the applicant (327b).

No funds were requested by the Administration for

this program for fiscal year 1992 (327a,327b).

Adolescent drug use is addressed to some extent

by U.S. Department of Labor-funded programs such

as:

●

●

Job Corps-drug tests for applicants, drug

education, and treatment for enrollees;

Youth Opportunity Unlimited (YOU) program—

drug eradication control is one part of the

provision of coordinated, comprehensive services for all youth in six funded communities.

ONDCP estimates that $9.5 million was spent on

drug control activities in the Job Corps in fiscal year

1991, and $6.0 million for the YOU program in

fiscal year 1991. A substantial increase (to $25

million) was requested for YOU for fiscal year 1992

(327b).

Issues in Federal Programs and

Policies Related to the Use and Abuse of

Psychoactive Substances

Clearly, numerous resources are being applied to

the drug problem among adolescents. It is unclear,

however, whether the infusion of resources is being

targeted appropriately. Much of the Federal money

on prevention being given to States is provided with

little requirement for evaluation (280). In turn,

because few evaluation data are available, States

often have little idea of how best to use available

funding (281). Audiovisual materials, for example,

are often not evaluated before being sent out for use

by local school districts, and it is unclear whether the

materials are being used (265a). OSAP is attempting

to evaluate materials, but it does not have rigorous

research requirements.

Available curricula for substance abuse education

may be inappropriate. So-called ‘‘model curricula’

developed by the U.S. Department of Education

have been criticized as being inappropriate to the

needs of urban schools in multicultural settings

(180). On the other hand, States that believe they

have an effective approach to prevention have

pointed out that the amount available from the

Federal Government is insufficient. The cost of

putting one substance abuse counselor in every

middle school in the country, for example, was

estimated at $400 million in 1989, more than the

entire Drug-Free Schools and Communities Act

authorization in fiscal year 1988 (265a). Almost

$500 million was appropriated for Drug-Free

Schools and Communities Act programs in fiscal

year 1991, but it was to be used for drug abuse

education as well as early intervention (327b).

About $3.4 million was authorized for counselor

training grants, and $20 million for school personnel

training grants, in fiscal year 1991, but no funds were

allocated to actually placing counseling services in

schools (327b).

Some charge that funding has not been targeted to

high-risk areas (180). The U.S. Conference of

Mayors has criticized the channeling of Federal

money through block grants to States. The mayors

argue that it is their neighborhoods, police officers,

and children who are most under siege (246). The

Nation’s governors, on the other hand, support the

use of State block grants, arguing that direct money

to cities “would present an uncoordinated method

that could only serve to displace drug trafficking

rather than dismantle entire operations” (246).

It is further unclear whether national drug control

efforts are targeted toward the substances that are

most often used, and perhaps abused, by adolescents. The national drug control strategy has been

criticized for its relative lack of attention to problems of alcohol abuse among adolescents (180).

Tobacco is the substance used most often by

adolescents, but justification for studying tobaccorelated risk factors or attempting to reduce its use

among adolescents must often be justified by the

notion that tobacco is a “gateway drug. ”

Although very little adolescent-specific information is known about the effects of drugs such as

marijuana and cocaine, NIDA and NIAAA are

devoting only minimal funding to encourage research on the consequences of psychoactive substance use by adolescents. Support for research on

treatment for adolescents who abuse substances is
Chapter 12—Alcohol, Tobaccoj and Drug Abuse: Prevention and Services . //-565

beginning to increase. It appears that after several

years of increases in funding, support for some types

of drug prevention activities may be leveling off or

declining (327a,327b).

Conclusions and Policy Implications

Adolescents’ use, and possibly problem use, of

psychoactive substances has been of great public

concern. This chapter suggests that adolescents’ use

of substances that are legally available to adults—

i.e., alcohol and nicotine-is more prevalent than

their use of illicit drugs. One-third of high school

seniors report having had five or more alcoholic

drinks in a row during a 2-week period. Almost 19

percent of high school seniors report smoking at

least some portion of a cigarette daily. Using daily

use of illicit drugs as an indicator of problem use,

between 0.3 and 3 percent of adolescents nationwide

would appear to have a serious drug problem.109

Some local surveys and studies of homeless and

incarcerated adolescents, however, have found evidence of more extensive illicit drug use. Further,

daily use is not the only indicator of problem use;

CDC has found that 5 percent of students in grades

9 through 12 in Washington, DC, reported using

needles to inject illicit drugs at least once, possibly

putting themselves at risk of overdoses, addiction,

and HIV and other infections.

Extensive financial and human resources are

being applied to preventing psychoactive substance

use among adolescents, but it is unclear whether the

infusion of resources is being designed or targeted

appropriately. For example, more information is

needed about how many adolescents use substances

in ways that cause problems and interfere with

optimal development. Fortunately, additional Federal resources are being put into understanding the

extent of, and risk and protective factors for,

substance use among adolescents now believed to be

at particularly high risk (e.g., inner-city, low-income

adolescents). However, recent evidence that suggests that excessive substance use (as opposed to

occasional use or nonproblem use of drugs) may be

the result, rather than the cause, of other psychological problems suggests that considerable attention

should be given to assessing mental health status as

a risk factor, and attempting to prevent excessive

drug use through early treatment of poor psychological adjustment.

/s Prevention Effective?

Assessments of the effectiveness of psychoactive

substance use prevention efforts have been limited

by methodological shortcomings in most of the

evaluations. This situation is unlikely to change

soon because Federal agencies that support preventive interventions (e.g., OSAP, U.S. Department of

Education, Indian Health Service) often do not

require scientifically rigorous evaluations.

The substance use prevention programs that have

been evaluated relatively rigorously show relatively

little change in adolescents’ use of substances, even

using self-report measures. The generally unremarkable results of primary prevention programs do not

necessarily imply, however, that such programs

should be discontinued. Both the rigorously evaluated and not so rigorously evaluated programs may

achieve other goals for adolescents, for example:

1)

2)

3)

The

improvements in their social competence,

including their ability to make decisions,

refuse unwanted peer pressure, and otherwise

have rational discussions with their peers and

others;

improvements in their self-understanding; and

improvements in their knowledge about a

range of psychoactive substances and possible

physiological and developmental effects.

extent to which substance use prevention

programs achieve some or all of these goals is

largely unknown, because outcomes other than

reductions in use have not usually been measured.

The danger is that programs taking more broadbased approaches may be discontinued eventually if

they do not show marked reductions in use.

What About Treatment?

Some adolescents are problem users of alcohol

and/or other psychoactive substances and require

some form of treatment. However, numerous questions remain about treatment for substance-using

adolescents. For example, although instruments are

]09A tow of 0.3 ~rmnt of high ~~h~~l ~efior~ ~epoficd “sing co@e (~1 forms) 20 or more times in tie monti preuding the 1$)89 High School

Seniors/Monitoring the Future Survey; 2.9 percent of high school seniors reporting using marijuana or hashish 20 or more times in the month preceding

the 1989 sumey. No other survey found higher “daily” use of marijuana, but other sumeys found that daily use of cocaine was higher (e.g., the National

PRIDE survey found that an average of 0.6 percent of senior high school students reported daily use of cocaine).
II-566 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

under development, there is currently no valid way

to assess which adolescents need treatment specifically related to their substance use. There is very

little research on new treatments for adolescents or

regular data collection on the effectiveness of what

is being provided.

Evidence suggesting that some placements are

inappropriate includes data derived from NDATUS

that private treatment centers appear to be underutilized, while public facilities are almost always at

capacity. In addition, twice as many adolescents

(49,000 on the day the most recent NDATUS was

taken) were estimated to be in treatment for the use

of drugs other than alcohol, despite the fact that

alcohol is much more widely used among adolescents. Adolescent clients being treated for use of

drugs other than alcohol are served primarily in

private for-profit and not-for-profit settings. These

data suggest that financial considerations may be

driving placement decisions, but additional investigation on this point is needed. This issue is difficult

to investigate rigorously precisely because of the

lack of definitions of problem use among adolescents.

Less restrictive treatments, which might be sought

out by adolescents themselves, are often unavailable. All but five States and the District of Columbia

have statutes specifically authorizing at least some

adolescents

110 to receive drug- and/or alcoholrelated health services without parental permissionlll, but gaining access to such services may be

a problem. Only 17 percent of employees in medium

and large firms who were covered by private

insurance had coverage for outpatient substance

abuse treatment that was the same as that for

treatment of other illnesses.112 Medicaid payment

for substance abuse treatment is not required by

Federal law, Few school-linked health centers are in

existence; in any event, these tend not to deliver

many services or make many referrals for substance

use problems.l13 There is considerable enthusiasm

for the early intervention programs known as

Student Assistance Programs (based on the workplacebased Employee Assistance Program model), but

there is as yet no evidence as to their availability or

effectiveness. In 1987, 272,000 adolescents ages 10

to 18 were estimated to have had any treatment for

substance use problems.

Some barriers to treatment are due in part to the

fact that there is very little evidence on the effectiveness of contemporary approaches to substance abuse

treatment for adolescents, and considerable concern

about a number of features of the contemporary

treatment system. Of greatest concern is that the

centerpiece of the treatment approach for adolescents is the same as that for adults: the addiction

model, which requires thinking of oneself as a

lifetime addict who will never be able to control the

use of any psychoactive substances. This approach

may or may not be appropriate for adolescents, who

are still developing a sense of themselves. Evidence

concerning risk factors for problem use of substances, and the prevalence of psychiatric comorbidities in adolescent patients, suggests that greater

emphasis on adolescents’ mental health needs than

on the addiction model may be beneficial.

There is concern as well about the training and

credentials of substance abuse treatment personnel.

Treatment in substance abuse treatment facilities

tends to be delivered by recovering drug abusers,

who may not be the most effective models for

adolescents. However, the ability of mental health

professionals and primary care physicians to both

recognize and treat substance abuse problems has

not been demonstrated, and the little research that

has investigated the issue suggests the ‘recovering’

personnel are as effective as health care professionals.

Certain features of substance abuse treatment

modalities have been found to increase success rates,

although definitive conclusions are limited because

of a scarcity of methodological rigor.l14 Apparently

successful features include parental involvement

and adolescents’ perceptions of choice in treatment

decisions, including the decision to seek treatment.

Also, despite the emphasis in most programs on the

1 losome Smtes ~ve placed age I-cstrictions for allowing minors who are age 12 and over, or age 16 and over, to consent to such services.

11 Isee ch. 17, ‘ ‘Cement and Confidentiality in Adolescent Health Care Decisionmaking, ’ iU VO1. ~.

1 Izsee ch. 16, ‘‘F@&l Access to Health Services, ’ ~ VO1 ~.

1 IsSee ch$ 15, ‘ ‘Major Issues ~ me Delivq of Primary and Comprehensive Services to Adolescents, ’ iII VOL III.

114For exmple, pm~m success may& defined w mem completion of a scheduled tr~~ent pro-. when other outcomes w u~d, clients who

leave before their scheduled treatment is complete are often not counted as part of the evaluation. Outcome measures are often not comparable across

studies and no-treatment comparison groups are rarely used.
Chapter 12—Alcohol, Tobacco, and Drug Abuse: Prevention and Services . II-567

addiction model, the services most clearly associated with positive treatment outcomes are those

often considered ‘‘adjunctive’ to substance abuse

treatment: educational and recreational services and

social skills and assertiveness training. There is no

definitive research on whether outpatient or inpatient treatment is more effective.

The overall lack of effectiveness data and the

preliminary evidence concerning the relative effectiveness of voluntary treatment are especially troubling in light of the fact that in 32 States adolescents

can be admitted under ‘ ‘voluntary’ ‘ commitment

status by their parents, with no legal recourse to

contest this status.

Research

Much additional research is needed on psychoactive substance use and abuse among adolescents.

Given current data, it is impossible to determine the

number of adolescents using such substances or the

number for whom substance use is a problem.

Conclusions about the effectiveness of prevention

efforts can be only preliminary at this point, and it is

therefore impossible to say whether resources are

being wasted. An in-depth look at the effectiveness

of drug abuse prevention interventions currently

being funded seems warranted. The bulk of prevention efforts have focused on prevention of any and all

substance use by adolescents, and disturbed adolescents who may be in greatest need of intervention

may be getting neglected. The number of adolescents in need of treatment, the numbers in treatment,

and whether such treatment is appropriate and

effective are not known. There has been until

recently very little Federal support for research on

treatment effectiveness.

As noted here and in other chapters in this report,

there are considerable barriers to access to health

services for those adolescents who feel themselves

to be in need of them. Specific policy options related

to alcohol, tobacco, and illicit drug abuse by

adolescents are listed in Volume I.

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PREVENTION AND SERVICES

RELATED TO DELINQUENCY

AND HOPELESSNESS
Chapter 13

DELINQUENCY:

PREVENTION AND SERVICES

Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583

Background on Adolescent Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583

Definitional Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583

Sources and Limitations of Dataon Adolescent Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 587

Incidence and Prevalence of Adolescent Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 590

How Many Delinquent Acts Are Committed by Adolescents? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 590

How Many Adolescents Commit Delinquent Acts? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593

What Is the Pattern of Committing Serious Delinquent Acts Among Adolescents? . . . . . . . . . . . . . . . . . 594

Factors Associated With Adolescent Delinquency . . . . . . . . ...,.., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5%

Demographic Factors Associated With Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596

Other Factors Associated With Delinquency ,..,... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601

The Importance of Interactions Between Age and Factors Related to Delinquency,. . . . . . . . . . . . . . . . 614

Interactions bong Factors Associated With Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614

Factors Associated With Continued Official Delinquent Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614

summary: Factors Associated With Delinquency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615

Consequences of Adolescent Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616

Adolescents as Victims of Crime and Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618

Prevention of Adolescent Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .620

Primary Prevention of Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620

Family-Based Primary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620

School-Based Primary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621

Community-Based Primary Prevention . . . . . . . . . . . . . . ,.,.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623

Secondary Prevention of Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623

Vocational and Alternative Education Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624

Family Therapy and Family Communication Skills Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .624

Summary: The Effectiveness of Adolescent Delinquency Prevention Efforts. . . . . . . . . . . . . . . . . . . . . . . . . 624

Services and Interventions for Adolescents in the Juvenile Justice System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625

What Is the Juvenile Justice System? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .626

Who Are the Adolescents in the Juvenile Justice System? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 628

Adolescents Referred to the Juvenile Courts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 628

Adolescents in Juvenile Detention and Correctional Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629

The Effectiveness of the Juvenile Justice System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 632

Effects on Adolescents While They Are in the Juvenile Justice System . . . . . . . . . . . . . . . . . . . . . . . . . . 632

Effects on the Public While Adolescent Offenders Are in Custody . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633

Effects on the public and Adolescent Offenders After Offenders have the Juvenile Justice System . . . 634

The Effectiveness of Specific Treatment Interventions for Delinquent Adolescents . . . . . . . . . . . . . . . . . . . 635

Institutionally Based Treatment Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635

Community-Based Treatment Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636

Comparison of Community-Based and Institutionally Based Treatment for Delinquent Adolescents. . 638

Health Care in Juvenile Justice Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639

Health Problems of Adolescents Entering Juvenile Justice Facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639
Health problems Experienced by Adolescents During Incarceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640

Quality of Health Care in Juvenile Justice Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640

Summary: Services and Interventions for Adolescents in the Juvenile Justice System . . . . . . . . . . . . . . . . . 642

Major Federal Policies and Programs Pertaining to Adolescent Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . .

Legislative and Executive Branch Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .644

Judicial Branch Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 645

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 645

Chapter 13 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 648

Boxes

Box Page

13-A. Definitions That Pertain to Adolescent Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584

13-B. Factors That Protect Adolescents Exposed to Risk Factors for Delinquency . . . . . . . . . . . . . . . . . . . . . . 616

Figures

Figure Page

13-1. Arrest Rates for Serious Violent Offenses by Persons Under Age 18 and Age 18 and Over,

1%5-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .592

13-2. Arrest Rates for Serious Property Offenses by Persons Under Age 18 and Age 18 and Over,

1%5-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .592

13-3. Victimization Rates for Rape, Robbery, and Assault Committed by Persons Under Age 18,

1980-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .593

13-4. Arrest Rates for Murder and Nonnegligent Manslaughter by Persons Age 18 and Under, 1%5-88 .. 593

13-5. Arrest Rates for Aggravated Assault by Persons Age 18 and Under, 1%5-88 . . . . . . . . . . . . . . . . . . . . 594

13-6. Victimization Rates for Rape, Robbery, and Assault by Age and Sex, 1988 . . . . . . . . . . . . . . . . . . . . . 618

13-7 Victimization Rates for Theft by Age and Sex, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .618

13-8. Percent Mortality Due to Seven Leading Causes of Death for Black Adolescents Ages 10 to 14

and 15 to 19, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619

13-9. Percent Mortality Due to Seven Leading Causes of Death for White Adolescents Ages 10 to 14

and 15 to 19, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619

13-10. Victimization Rates for Rape, Robbery, and Assault by Age and Race, 1988 . . . . . . . . . . . . . . . . . . . . 619

13-11. Victimizati.on Rates for Theft by Age and Race, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .619

13-12. Juvenile Court Processing of Delinquency Cases, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627

13-13. Distribution of Juveniles in Public Juvenile Justice Facilities on Census Day in 1987, by Racial

and Ethnic Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 631

13-14. Distribution of Juveniles in Private Juvenile Justice Facilities on Census Day in 1987, by Racial

and Ethnic Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 632

Tables

Table Page

13-1. Comparison of Sources of National Data on Adolescent Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . 588

13-2. Comparison of Rates of Serious Offenses Reported by Different Sources of National Data

on Adolescent Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591

13-3. Serious Offenses by 17-Year-Olds: Trends in Incidence Rates Reported by Different Sources

of National Data on Adolescent Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .595

13-4 Rates of Involvement in Serious Offenses: Male-to-Female Ratios Reported by Diffenent Sources

of National Data on Adolescent Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .597

13-5. Arrest Rates for Serious Offenses Among Persons Under Age 18, by Race, 1987 . . . . . . . . . . . . . . . . 598

13-6. Rates of Involvement in Serious Offenses: Black-to-White Ratios Reported by Different Sources

of National Data on Adolescent Delinquency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .599

13-7. Selected Factors Associated With Serious Offending by Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . 602

13-8. Use of a Weapon by Institutionalized Offenders Under Age 18 Who Were Sentenced

for a Violent Offense, 1987. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612

13-9. Use of Guns and Other Weapons by Adolescent Murder Offenders, 1976 and 1988..............613

13-10. Use of Guns and Other Weapons To Kill Adolescent Murder Victims Ages 10 to 18, 1976 and 1988..613

13-11. Illustrative Primary and Secondary Preventive Interventions for Delinquency . . . . . . . . . . . . . . . . . . . . 621

13-12. Age at Which Criminal Courts in Different States Gain Jurisdiction of Young Offenders . . . . . . . . . . 626

13-13. Reasons for Referral of Delinquency Cases to Juvenile Courts, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . 626

13-14. Juveniles in Custody in Public and Private Juvenile Detention, correctional, and Shelter Facilities,

1977-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 630
Chapter 13

DELINQUENCY: PREVENTION AND SERVICES

Introduction

Delinquent behavior among U.S. adolescents has

recently received a great deal of public attention

(24,272,301,398a,399,463). Many of the popular

accounts of adolescent delinquency focus on serious

violent offenses against persons, including the kinds

of violent acts that prompted the U.S. Surgeon

General in 1985 to label violence a major public

health problem (406).

Violent behavior by adolescents sometimes results in injury or death, and children and adolescents

who observe violent behavior may experience emotional trauma (38),1 It is important to note, however,

that the primary victims of violence by other

adolescents and by other individuals are adolescents

(423). The U.S. Surgeon General’s report identified

violence as a major cause of injury and death among

young people. Furthermore, it called for increased

efforts on the part of health professionals to prevent

violence in order to reduce its attendant morbidity

and mortality (406).

But most delinquent acts by U.S. adolescents are

not violent ones, and some people believe that

delinquency can be considered an adolescent health

problem for reasons other than the injuries and

deaths associated with violence. Such reasons include the following:

●

●

Delinquent behavior by adolescents has been

associated with their engaging in healththreatening activities, such as alcohol, tobacco,

and drug abuse, risky driving behavior, and

precocious sexual experimentation.2

Delinquency and the psychiatric diagnosis of

conduct disorder3 are characterized by many of

the same behavioral features.4 A set of behaviors that might result in one adolescent’s being

diagnosed with ‘‘conduct disorder’ and directed to the mental health system for treatment

might lead to another adolescent’s being labeled ‘‘delinquent’ and referred to the juvenile

court for punishment and/or rehabilitation.

. Adolescents held in juvenile detention and

correctional facilities tend to have serious

unattended health problems—before, during,

and after their commitment to such facilities.s

This chapter examines the problem of adolescent

delinquency. The first section of the chapter is

devoted to background information on delinquency

among adolescents. Subsequent sections deal with

primary and secondary prevention efforts, services

for adolescent offenders within the juvenile justice

system, and major Federal policies and programs

pertaining to delinquency. The chapter ends with

conclusions and policy implications.

Background on Adolescent Delinquency

Despite intense societal interest in adolescent

delinquency, accurate knowledge about the incidence, prevalence, causes, and consequences of

adolescent delinquency is limited. This section

discusses what is known about these factors. Definitional issues and limitations in data that confound

analyses of delinquency are discussed below. Also

discussed below are demographic and other factors

associated with delinquency and information on the

consequences of delinquency.

Definitional Issues

The study of adolescent delinquency has been

plagued by semantic and definitional problems that

confound research design and the interpretation of

data. Definitions of some of the terms used in the

discussion in this chapter are provided in box 13-A.

IEwly ~e~etich ~dlcate~ hat ~xw~we t. violence hinders tie ~motio~ ad ktellec~~ development of children exposed to violence (38).

ZFor further dkCUSSiO~ ‘e 4

‘Covariation of Adolescent Health Problems, ’ prepared for OTA by D. Wayne Osgood and Janet K. Wilson (304).

3Co~uct dl~order is defined ~ ~e Dia8~o~ti~ and Stahstica/ Manual of Mental Disorders, 3rd cd., revis~ (DSM-111-R) as a “persistent pattern

of conduct in which the basic rights of others and major age-appropriate societal norms or rules are violated” (10).

dsome acts (e.g,, stwl~g) cm ~ characterized both as delinquent acts and as symptoms of conduct disorder. Conduct disorder is ch~acterimd bY

a pattern of behavior over time; an isolated act of delinquency, therefore, would not constitute a ‘‘pattern’ necessarily leading to a diagnosis of conduct

disorder. Conversely, not all behaviors included as symptoms of conduct disorder are delinquent behaviors; lying, for example, is a criterion for a

diagnosis of conduct disorder, but in most circumstances it is not a legal offense.

5A discussion of h~lth ~roblem wi~in the juvenile justice system is presented below.

-II-583-
II-584 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 13-A—Definitions That Pertain to Adolescent Delinquency

Adjudicated: Passed on judicially, settled, or decreed, or convicted and sentenced. An adjudicated case is one

in which the court has entered a judgment.

Adolescent delinquency: For purposes of this chapter, offenses committed by adolescents that would be

considered violations of criminal law if committed by adults (ranging from minor offenses such as simple assault

to serious offenses such as larceny-theft or aggravated assault) and offenses committed by adolescents that are

considered offenses only because they are committed by a minor (i.e., “status offenses’ such as running away from

home, truancy).

Aggravated assault: The unlawful intentional attempt to inflict or actual infliction of serious bodily injury

or death by means of a deadly or dangerous weapon.l

Antisocial behaviors by children: Also known as conduct problems in the criminology literature, these are

hostile or harmful behaviors that deviate from the social norm (e.g., aggression, stealing, lying, fighting).

Arrest rate: The number of arrests made in a given population per some population base during a given time

period (e.g., 5 arrests per 100,000 population). An arrest rate is a type of incidence rate.

Arson: Any willful or malicious burning or attempt to burn, with or without intent to defraud, a dwelling house,

public building, motor vehicle, aircraft, personal property of another, etc.l

Attention deficit hyperactivity disorder (ADHD): A mental disorder defined in the Diagnostic and

Statistical Manual of Mental Disorders, 3rd cd., revised (DSM-III-R) as a disturbance lasting at least 6 months that

is characterized by developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity. Onset

of the disorder, which is more common in males than females, is typically before the age of 4. Central nervous

system abnormalities are thought to be predisposing factors. Some impairment in schoolwork or cooperating in

group social activities is common.

Burglary/breaking or entering: The unlawful entry of a house or structure to commit a felony or a theft.

Attempted forcible entry (e.g., by breaking a window) is includedl

Career criminals: High rate or long duration offenders who contribute most to total crime rates.

Conduct disorder: A mental disorder defined in DSM-III-R as a disturbance lasting at least 6 months in which

a young person persistently violates basic rights of others and violates major age-appropriate societal norms. The

diagnosis is made when an individual displays at least 3 of 13 specified behaviors (e.g., stealing, running away,

frequent lying, deliberate fire-setting, frequent truancy, breaking into someone else’s property, deliberately

destroying property, being physically cruel to animals, using a weapon in more than one fight). Onset is usually

prepubertal. Predisposing factors are thought to include ADHD, parental rejection, absence of father, early

institutional living, and association with a delinquent subgroup. Complications include school suspension, legal

difficulties, and psychoactive substance use.

Cross-sectional studies: In criminology research, studies that compare individuals involved in offending

behavior with those who do not commit offenses at one point in time. Some studies may be broader and, for example,

compare families of very delinquent children with those of not-so-delinquent children.

Delinquent adolescents: Adolescent juvenile offenders.

Demographic factors: Age, gender, race, ethnicity, geographic location, and socioeconomic status are

typically defined as demographic factors.

Drug abuse violations: State and local offenses relating to the unlawful possession, sale, use, growing, and

manufacturing of a narcotic drug.l

Forcible rape: Gaining carnal knowledge of (having sexual intercourse with) a female forcibly and against

her will. Included are rape by force and attempts or assaults to rape.l

Incidence rate for an offense: In the criminal justice field, the number of offenses of a given type that occur

in a given population during a specified time period per some population base. Incidence rates are sometimes

measured in terms of arrest rates, victimization rates, or offending rates for an offense. Compare prevalence rate

for an offense.
Chapter 13-Delinquency: Prevention and Services .11-585

Juvenile: A young person who has not yet reached the age at which he or she should be treated as an adult

for purposes of criminal law. In some States, this age is 17. In law, the terms juvenile and minor are usually used

in different contexts (juvenile when referring to young legal offenders and minor when referring to legal majority

or capacity).

Juvenile courts: Courts having special jurisdiction, of a paternal nature, over delinquent, dependent, and

neglected children.

Juvenile justice facilities: Custodial facilities for juvenile offenders (and abused, neglected, or other minors

under the jurisdiction of the juvenile or family courts). These can be classified along several, often overlapping

dimensions that include purpose, term of stay, type of environment (institutional or open), and sponsorship (public

or private). Juvenile detention facilities (usually called juvenile detention centers or juvenile halls) typically hold

juveniles who have been arrested for short periods prior to adjudication; they may also be used for juveniles whose

cases have been adjudicated and who are awaiting transfer to long-term placements or who have been sentenced

to short periods of confinement. Juvenile correctional facilities are facilities for the commitment and supervision

and treatment of juvenile offenders whose cases have been adjudicated. Long-term residential facilities that serve

adolescent offenders range from training schools with strict controls to less-restrictive forestry camps or farms,

halfway houses, and group homes. Juvenile facilities with institutional environments typically impose restraints

on residents’ movements and limit access to the community. Juvenile facilities that have open environments allow

greater movement of residents and more access to the community. Public juvenile facilities are under the direct

administration and operational control of a State or local government and staffed by governmental employees.

Private juvenile facilities are either profitmaking or nonprofit and subject to governmental licensing but are under

the direct administration and operational control of private enterprise: such facilities may receive substantial public

funding in addition to their support from private sources.

Juvenile justice system: The system--actually 50 distinct statewide juvenile justice systems-that includes

law enforcement officers and others who refer delinquent and maltreated minors to the courts, juvenile courts which

apply sanctions for delinquent offenses and oversee the implementation of child protective services, juvenile

detention and correctional facilities, and agencies that provide protective services and care (e.g., foster care) for

minors who are victims of abuse and neglect.

Juvenile offender: A juvenile who has violated Federal, State, municipal, or local criminallaws or has

committed status offenses (e.g., running away from home, truancy).

Larceny-theft (except motor vehicle theft): The unlawful taking, carrying, leading, or riding away of

property from the possession or constructive possession of another. Examples are thefts of bicycles or automobile

accessories, shoplifting, pocket-picking, or the stealing of any property or article which is not taken by force and

violence or by fraud. Attempted larcenies are included. Embezzlement, “con” games, forgery, worthless checks,

etc., are excluded.l

Learning disabilities: A generic term that refers to a heterogeneous group of disorders manifested by

significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning, or mathematical

abilities or of social skills.

Longitudinal studies: Studies that examine the development of individuals or families or groups over a period

of time. In the field of criminology, the effects of experimental interventions at different times are investigated in

longitudinal-experimental studies. The aims of longitudinal-experimental studies or surveys are to establish the

course of development of criminal careers, and to establish the effects of specific events on the course of

development of criminal careers in order to test hypotheses about what causes criminal behavior and what can

prevent it before and reduce it after it occurs.

Meta-analysis: A statistical or quantitative analysis of a large collection of results from individual studies for

the purpose of integrating the findings.

Minor: A person who is under the age of legal majority, either age 18 or 19, depending on the State.

Minor offenses: See offenses (serious and minor).

Motor vehicle theft: The theft or attempted theft of a motor vehicle. A motor vehicle is self-propelled and runs

on the surface and not on rails. Specifically excluded from this category are motorboats, construction equipment,

airplanes, and farming equipment.

Continued on next page
II-586 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 13-A—Definitions That Pertain to Adolescent Delinquency-Continued

Murder and nonnegligent manslaughter: The willful (nonnegligent) killing of one human being by another.

Deaths caused by negligence, attempts to kill, assaults to kill, suicides, accidental deaths, and justifiable homicides

are excluded. Justifiable homicides are limited to: 1) the killing of a felon by a law enforcement officer in the line

of duty and 2) the killing of a felon by a private citizen.l

Offending rate: The number of offenses that occur in a given population during a specified time period per

some population base (e.g., 5 offenses per 100,000 population). The offending rate is usually based on offenses that

are self-reported by offenders. An offending rate is a type of incidence rate.

Offenses (serious and minor): Infractions of the law irrespective of the age of the offender. For purposes of

this chapter, serious offenses are Federal Bureau of Investigation Part I offenses (see below) even though individual

Part I offenses may not be considered serious by other definitions. Minor offenses are Federal Bureau of

Investigation Part II offenses (see below) even though individual Part II offenses may not be considered minor by

other definitions.

Part I offenses (index offenses): Under the Federal Bureau of Investigation’s reporting system, these are

specified violent offenses against a person (i.e., murder and nonnegligent manslaughter, forcible rape, robbery, and

aggravated assault) and specified property offenses (i.e., burglary, larceny-theft, motor vehicle theft, and arson).l

For purposes of this chapter, Part I offenses are considered serious offenses.

Part II offenses: Under the Federal Bureau of Investigation’s reporting system, any offenses not classified as

Part I offenses. Part II offenses include acts that are considered crimes if committed by adults-e. g., drug abuse

violations, liquor law violations, gambling, embezzlement, fraud, forgery, weapons violations, prostitution and

commercial vice, offenses against the family and children, assaults without weapons, involvement with stolen

property, vagrancy, disorderly conduct, driving under the influence, and drunkenness. Part II offenses also include

status offenses (e.g., violation of curfew, loitering, and runaway violations).l For purposes of this chapter, Part II

offenses are considered minor offenses.

Prevalence rate for an offense: In the criminal justice field, the ratio of the number of persons engaging in

an offense at a particular time period to the number of persons in that population. In studies of delinquency, the

prevalence rate is typically expressed as the percentage of persons in a population who engage in one or more

offenses of a given type within a specified time period If the time period is during all of adolescence or a lifetime,

the prevalence rate is known as a cumulative prevalence rate. Prevalence measures the number of people involved

rather than the number of offenses. Compare incidence rate for an offense.l

Prevention of adolescent delinquency: Primary prevention of adolescent delinquency means identifying

individuals at risk for delinquent behavior because of their general life situations (e.g., children in stressed families)

or identifying environments at risk for delinquent activity (e.g., school settings) before the delinquent behavior has

occurred, and intervening to reduce the amount of delinquent behavior in that group or setting. Secondary

prevention of adolescent delinquency means attempting to keep adolescents who have already shown indications

of troublesome behavior (e.g., school problems) from engaging in delinquent acts such as theft or assault.

Recidivism: A tendency to relapse into a previous condition or mode of behavior (especially relapse into

delinquent behavior).

Robbery: The taking or attempting to take anything of value from the care, custody, or control of a person

or persons by force or threat of force or violence and/or by putting the victim in fear.l

Self-report data: Data regarding a survey respondent’s attitudes, knowledge, or behavior that are reported by

the respondent himself or herself.

Serious property offenses: For purposes of this chapter, Part I offenses against property (i.e., burglary,

larceny-theft, motor vehicle theft, and arson).

Serious violent offenses: For purposes for this chapter, Part I violent offenses against a person (i.e., murder

and nonnegligent manslaughter, forcible rape, robbery, and aggravated assault).

Simple assault: The unlawful intentional attempt to inflict or actual infliction of less than serious bodily injury

without a deadly or dangerous weapon.l
Chapter 13-Delinquency: Prevention and Services . II-587

Status offenses: Acts committed by minors that would not be considered offenses if committed by an adult

(e.g., running away from home, purchasing of intoxicating liquor, truancy, curfew violations). Under the Federal

Bureau of Investigation’s reporting system, status offenses are considered Part 11 offenses.

Treatment of delinquent adolescents: A term often used synonymously with rehabilitative efforts and

sometimes contrasted with punishment. Institutionally based treatment interventions are interventions provided

in juvenile facilities with institutional environments (e.g., training schools or ranches). Community-based

treatment interventions are interventions provided in community environments or in juvenile facilities with open

environments (e.g., halfway houses, group homes).

Victimization rate: The number of offenses experienced by a given population per some population base

during a given time period. For example, the victimization rate of adolescents derived from National Crime Survey

data is the number of offenses experienced by individuals ages 12 years of age and over committed by individuals

under age 18 per 100,000 individuals under age 18 in the population for 1 year. A victimization rate is a type of

incidence rate.2

%&w we deftitions USed by the Bureau of Justice Statistics of the U.S. Department of Justice in the National crime Swey.

Delinquent acts are of two general types: tion and treatment programs because it determines

1. acts committed by minors that would be the measure of preintervention and postintervention

delinquency to be used. considered violations of criminal law6 if committed by an adult, and

2. status offenses—i.e., acts committed by mi- Sources and Limitations of Data on

nors that would not be considered offenses if Adolescent Delinquency

committed by an adult (e.g., running away

from home, truancy). Estimating the extent of adolescent involvement

in delinquency is difficult. Information about the

Adolescent delinquency can be conceptualized in four principal sources of national data on the

various ways--e. g., in legal terms such as arrest and incidence, prevalence, and demographic correlates

adjudication or in behavioral terms such as stealing,

assault, murder. The use of different definitions of

delinquency confounds analyses of all areas of

delinquent behavior—the incidence and prevalence

of delinquency, factors associated with delinquency,

and, perhaps most critically, assessments of the

effectiveness of delinquency prevention and treatment efforts. The definition chosen determines what

type of adolescents are studied; for example, if the

legal definition is used, only adolescents who are

officially recorded as delinquents are included in

determining the number of offenses committed by

adolescents. The definition of delinquency chosen is

also critical in measuring the ‘‘success’ of prevenof adolescent delinquency is shown in table 13-1:

1. the Uniform Crime Reports,

2. the National Crime Survey,

3. the National Youth Survey, and

4. the Monitoring the Future/High School Seniors Survey.

Each source has substantial limitations, and the

different sources have different sample populations,

have different methods, and cover different ages,

offenses, and years.7 Most researchers and policymakers agree that no single source provides an

adequate measure of delinquency among adolescents (58,99,100,101,123, 201 ,202,214,353 ).8

SFollow~g ~c te~olo= of the field, the terms ‘ ‘crime’ ad ‘cm “ are nor used to refer to acts committed by minors that would be considered

crimes if committed by adults. Instead, the terms ‘‘offense’ and $ ‘delinquent acts’ are used when referring to such acts. The terms ‘‘crime” and

“criminal’ are only used to refer to such acts committed by adults. (Offense, however, is a generic term that may be used to describe both delinquent

acts and crimes.)

7Exte~ive descriptions and Compmative alyses of these sources are in the litemtum. See, for ex~ple> J.H. ‘ub* “Assessment of National Juvenile

Justice Data Collection Efforts: Chitdren/Youth as Victims of Personal Crimes and Other Offenses by Peers/Others” (257); S. Menard, “Short-Term

Trends in Crime and Delinquency: A Comparison of UCR, NCS, and Self-Report Data” (282); J.G. Bachman and L.D, Johnsto% The Monifon”ng the

Future Project: Design and Procedures (22); J.G. Bachman, L.D. Johnston, and P.M. O’Malley, Monitoring the Future; Questionnaire Responses From

the Nation’s High School Seniors, 1976 (23).

8Nonethelcss, tie advmtages and llmltatiom of Official records and sclf_reports tie somew~t complementary. If both types of sources show Simikir

reSulLs, the results have greater validity.
II-588 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 13-l—Comparison of Sources of National Data on Adolescent Delinquency

Monitoring the Future/

Uniform Crime Reports National Crime Survey High School Seniors

(U.S. Department of (U.S. Department of National Youth Survey Survey

Justice) Justice) (Elliott et al.) (Bachman et al.)

Period measured . . . . . . . . . . . Annually since 1930 Annually since 1973 Annually from 1976- Annually since 1975

1980, and in 1983,1986,

1989

Data source . . . . . . . . . . . . . . . . Arrests reported by law Self-reports by victims Self-reports by survey Self-reports by survey

enforcement agencies respondents respondents

Data collection method . . . . . . Arrests are reported to National household in- National interview sur- National survey of a samthe FBl (or to centralized terview survey of a na- vey of a sample of 1,044 ple of about 16,000 to

State agencies that then tional sample of 49,000 households with am- 18,000 high school senreport to the FBI) by households with 101,000 hort of 1,725 youth ages iors, with an annual folover 12,000 law enforce- persons 11 to 17 in 1976 lowup survey of sample

ment districts subset

Serious offenses included . . . Murder and nonnegligent Rape Rapea Robbery b

manslaughter Robbery (personal) Robbery Assault (aggravated)

Forcible rape Assault (aggravated) Assault (aggravated) Larceny-theft

Robbery Household burglary Burglary Motor vehicle theft

Assault (aggravated) Motor vehicle theft Larceny/theft Arson

Burglary Household larceny Motor vehicle theft

Larceny-theft Personal larceny Arson (as of 1980)

Motor vehicle theft

Arson

Minor offenses included . . . . . Other (nonaggravated

assaults)

Forgery and counterfeiting

Fraud

Embezzlement

Stolen property offenses

Vandalism

Weapons offenses

Prostitution and commercialized vice

Sex offenses (except

forcible rape and

prostitution and commercialized vice)

Drug abuse violations

Gambling

Offenses against family

and children

Liquor law violations

Driving under the influence

Drunkenness

Disorderly conduct

Vagrancy

All other nontraffic offenses

Suspicion

Curfew and loitering offenses (Iimited to persons under age 18)

Runaways (limited to persons under age 18)

Simple assault Simple assault

Stolen property: buying,

receiving, possessing

Vandalism (except 1977)

Weapons: carrying,

possessing, etc.

Prostitution and commercialized vice (been

paid for sex)

Drug abuse violations (includes marijuana)

Liquor law violations

(alcohol use for those

under age--varies by

year and jurisdiction;

sale of alcohol to a

minor)

Drunkenness

Disorderly conduct

Sex offenses other than

prostitution and rape

(obscene phone calls;

sexual intercourse for

those under age)

Fraud (1979, 1980,1983,

1986, 1989)

Forgery and counterfeiting (passing bad

checks or phony

money) (1979, 1980,

1983, 1986, 1989)

Embezzlement (1983,

1986, 1989)

Driving under the influence (1983, 1986,

1989)

Runaways (1976, 1980)

Simple assault

Vandalism

Liquor law violation (alcohol use; whether

this is underage may

vary by jurisdiction

and by year

Drug abuse violations (includes marijuana)
Chapter 13—Delinquency: Prevention and Services . II-589

Table 13-l—Comparison of Sources of National Data on Delinquency—Continued

Monitoring the Future/

Uniform Crime Reports National Crime Survey High School Seniors

(U.S. Department of (U.S. Department of National Youth Survey Survey

Justice) Justice) (Elliott et al.) (Bachman et al.)

Adolescent agesc of

offenders measured . . . . . . 10-12, 13-14, 15, 16, Under 12, 12-14, 11-17 (1976) High school seniors

17, 18 15-17, 18-20 12-18 (1977) (17 and 18)

13-19 (1978)

14-20 (1979)

15-21 (1980)

18-24 (1983)

Ages of offenders,

reported . . . . . . . . . . . . . . . . . Under 10-65+ Under 12-30+ 11-30 17-28

~he specif ic terms in the National Youth Survey are not exactly as listed here, but the survey items were designed to allow for comparison with the Uniform

Crime Reports.

%he specific terms in the Monitoring the Future/High School Seniors Survey are not exactly as listed here, but most of them approximate those in the Uniform

Crime Reports. It should be noted, however, t hat motor vehicle theft in the Monitoring the Future database corresponds only weakly with motor vehicle theft

in the Uniform Crime Reports. In the Monitoring the Future survey, the term motor vehicle theft means taking a motor vehicle without permission, and there

is no implication that the vehicle has been stolen.

cAdolescents, for the purpose of this OTA report, are individuals age 10 through 18.

SOURCES: Uniform Crime Reports: U.S. Department of Justice, Federal Bureau of Investigation, Uniform Crime Repotis: Crime in tie United States

(Washington, DC: U.S. Government Printing Office, various dates). National Crime Survey: U.S. Department of Justice, Office of Justice

Programs, Bureau of Justice Statistics, Crimina/ Victimization in the United States, 1987, A National Crime Survey Report, NCJ-1 15524

(Washington, DC: June 1989). National Youth Survey: D.S, Elliott, S.S. Ageton, D. Huizinga, et al., 7he Prevalence andhmidence of De/inquerrt

Behavior: 1976-1980, National Youth Survey Report No. 26 (Bouider, CO: Behavioral Research Institute, March 1983); S. Menard, Research

Associate, Behavioral Research Institute, Boulder, CO, personal communication, November 1990. Monitoring the Future/High School Seniors

Survey: J.G. Bachman, L.D, Johnston, and P.M. O’Malley, Monitoring fhe Future: Questionnaire Responses From the Nation’s High School

Seniors (Ann Arbor, Ml: Institute for Sociai Research, University of Michigan, various dates); N. Zili, J.L. Peterson, K.A. Moore, et al., Nationa/

Statistics on Children, Youth, and lheir Families: A Guide to Federal Data Programs, 2nd ed. (Washington, DC: April 1988).

The Uniform Crime Reports program maintains

arrest data reported annually by local law enforcement agencies to the Federal Bureau of Investigation

in the U.S. Department of Justice (407,408,409,410).

Uniform Crime Reports data have been collected

since 1930 and cover more types of offenses than

data from other sources; they also cover offenses

committed by individuals of all ages, and they are

up-to-date and easy to interpret. One limitation of

Uniform Crime Reports data, however, is that they

may be affected by underreporting of arrests, particularly underreporting of arrests for minor offenses

(282). Another limitation is that they may be

affected by law enforcement agencies’ bias toward

the detection and arrest of offenders from certain

groups in society (e.g., black male adolescents)

(280). Furthermore, the use of arrest rate data to

detect trends over time is problematic. One reason is

that law enforcement agencies may focus on different types of offenses in different historical periods

(e.g., a drug crisis may limit resources available for

the detection of other types of crimes); another

reason is that changes may occur in the definitions

of offenses.

The National Crime Survey is a national household interview survey of Americans ages 12 and

over administered annually by the Bureau of Justice

Statistics of the U.S. Department of Justice

(416,419,423,447). The National Crime Survey

obtains information based on victims’ reports about

offenses that may not have been reported to or

detected by law enforcement officials and thus may

not be reflected in the Uniform Crime Reports. The

National Crime Survey has several important limitations with respect to adolescents. First, the designation of the ages of the victimizers relies on accurate

recall by the victim. Second, the survey has been less

successful in interviewing young black males than in

interviewing other groups. Third, victims often do

not identify victimizers whom they know (257).

Other limitations of the National Crime Survey are

that it does not collect data from people who do not

live in households, that it does not obtain data from

victims younger than age 12, that the data reports are

not timely, and that only six out of eight Federal

Bureau of Investigation Part I offenses (serious

offenses) and only one Federal Bureau of Investigation Part II offense (minor offense) are covered. The

usefulness of the National Crime Survey for trend

analysis is limited because the methods of the study

have changed over time (257).

The National Youth Survey is a confidential

interview survey begun by Elliott and colleagues at

the Behavioral Research Institute in Boulder, Colo-
11-590. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

rado (100,102,103,104). The survey began in 1976

with a national cohort of 1,725 11- to 17-year-olds

(100). Since 1976, the survey has continued to

follow the original cohort’s involvement in delinquency and crime, substance use, and mental health

problems. 9 The 1976 and 1977 portions of the

National Youth Survey, conducted when cohort

members were ages 11 to 17 and ages 12 to 18,

respectively, are useful in revealing the incidence

and prevalence of offenses committed by adolescents, including those not known to law enforcement

agencies or victims. It is important to note, however,

that these data for adolescents are now about 15

years old and may not reflect current adolescents’

involvement in offenses. Another limitation of the

National Youth Survey is that although it includes a

broad spectrum of serious and minor offenses, it

does not include all Part I offenses (serious offenses). Another point is that survey respondents

may underreport their involvement in delinquency

(257); on the other hand, Elliott and his colleagues

have had to adjust reported rates for serious offenses

downward when discussion with the respondents

revealed that the actions reported were not ones that

would have subjected the respondents to arrest (98).

The Monitoring the Future/High School Seniors

Survey is a national survey conducted annually since

1975 by Bachman and other researchers at the

University of Michigan’s Institute for Social Research (22,23,24,25). This survey, which uses a

self-report instrument, annually surveys 16,000 to

18,000 high school seniors (and conducts an annual

followup survey of a sample subset) (25). Although

it includes some items pertaining to involvement in

delinquency (and for the older respondents, crimes),

the Monitoring the Future/High School Seniors

Survey is limited in that it begins with those who are

already high school seniors, excludes school dropouts, and does not collect data that are completely

racially and ethnically representative of the country’s adolescents (257).

The nationally oriented Uniform Crime Reports,

National Crime Survey, National Youth Survey, and

Monitoring the Future/High School Seniors Survey

are complemented by community-level, special research studies that examine the ‘‘causes’ of delinquency. Most of these community-level studies are

cross-sectional rather than longitudinal, however,

and many have design problems that prevent them

from assigning causality (126). Some study designs,

for example, use measures of delinquency (e.g.,

arrests) for a period in the past while deriving

‘‘causal” variables from reports in the present. This

temporal sequence is more likely to measure the

effects of delinquency on the variables than the

reverse (240). Prospective longitudinal studies offer

the best opportunity for identifying “causal” factors, but they are expensive and rare. Further, even

some longitudinal studies are based on retrospective

self-reports that contain biases due to respondents’

poor memories; others may be applicable only to

specific geographic areas or social climates.

Incidence and Prevalence of

Adolescent Delinquency

In considering adolescent delinquency, it is important to note that the terms incidence rates and

prevalence rates mean something different in the

criminal justice field than they do in public health

epidemiology (see box 13-A).10 Incidence rates—

the number of offenses or arrests per 100,000

adolescents in the population in any given year—

will not reveal how many adolescents are involved

in delinquency, because incidence rates measure the

number of offenses and one adolescent could

commit any number of offenses in a given year.

Conversely, prevalence rates—the percentage of

adolescents committing delinquent acts in a given

year-will provide information on how many adolescents are committing delinquent acts in a given

time period but will not reveal how many delinquent

acts are committed.

How Many Delinquent Acts Are Committed

by Adolescents?

Information on incidence rates for offenses committed by adolescents can give a partial understanding of the extent of adolescent involvement in

delinquent behavior. Arrest, victimization, and selfreported offending rates are analogous to incidence

rates, and this section reviews data on arrest,

%esults of analyses by Elliott and his colleagues of covariation among these problems are reported in ‘Covariation of Adolescent Health Problems,”

a paper prepared for OTA by D. Wayne Osgood and Janet K. Wilson (304).

10A co~oW@ factor in determiningg the incidence and prevalence of delinquency is that most delinquent acts are committed by groups (e.g., gangs)

mther than individuals (121,468). Determining the incidence and prevalence of offending by adolescents in groups such as gangs is extremely diffkult

because the composition of adolescent gangs changes very often (123).
Chapter 13—Delinquency: Prevention and Services ● II-591

Table 13-2—Comparison of Rates of Serious Offenses Reported by Different Sources of

National Data on Adolescent Delinquency

National Youth Survey:

Uniform Crime Reports: National Crime Survey: Adjusted self-reported

Arrest rate 1988- Victimization rate 1987— offending rate 1979--

under age 18a age 17 and underb

ages 14-20C d

Serious violent offenses . . . . . . . . . . . . . . . . . . . . . . 143 573 34,570

Serious propertv offenses . . . . . . . . . . . . . . . . . . . 1,067 NA 137,135

NA - not available.

aAmesf rafes are the number of arrests made in a given population per some population base during a given time period. The arrest rate here is the number

of arrests for serious offenses (violent or property) of individuals underage 18 in 1988 per 100,000 individuals underage 18 in the population in 1988. Serious

violent offenses included were murder and nonnegligent manslaughter, forcible rape, robbery, and aggravated assault. Serious property offenses included

were burglary, larceny-theft, motor vehicle theft, and arson.

b Victimization rafesare the num~r of offenses experienced by a given population per some population base during a given time period. The vktimizatiotl rate

here is the number of serious offenses (violent or property) experienced by individuals 12 years of age and over committed by individuals under age 18 in

1987 per 100,000 individuals under age 18 in the population in 1987. Serious violent offenses included were rape, robbery, and aggravated assault.

c~endingrates are the number of offenses that occur in a given population per some population base during a 9iven time period. The offendif19 rate ‘ere

is the number of serious offenses (violent or property) self-reported by individuals 14 to 20 years of age per 100,000 individuals 14 to 20 years of age in 1979.

Serious violent offenses included were rape, robbery, and assault. Serious property offenses included were larceny-theft, motor vehicle theft, and burglary.

dAdjusted rates are rates corrected for trivial events that would not have evoked a Police response.

SOURCES: Uniform Crime Reports: U.S. Department of Justice, Federal Bureau of Investigation, Uniform Crime RepOtis: Crime in the UnitedStates, 1988

(Washington, DC: U.S. Government Printing Office, 1989). National Crime Survey: U.S. Department of Justice, Office of Justice Programs,

Bureau of Justice Statistics, calculations based on unpublished National Crime Survey data on criminal victimization, Washington, DC, 1990.

National Youth Survey, adjusted rates: D.S, Elliott and D. Huizanga, “SeJf-Reported Measures of Delinquency and Crime: Micro Issues and

Computer Findings,” Behavioral Research Institute, Boulder, CO, 1984.

victimization, and self-reported offending rates related to offenses committed by adolescents. Most of

the discussion focuses on serious offenses rather

than minor offenses.

In 1988, there were 1.6 million arrests of U.S.

adolescents ages 10 to 17 (410,412). Uniform Crime

Reports data for 1988 indicate that arrests for serious

property offenses by adolescents are much more

common than arrests for serious violent offenses

against persons (see table 13-2). Self-reported offending rate data from the National Youth Survey

(when adjusted to exclude trivial events) are consistent with arrest data in showing that serious property

offenses are committed relatively more frequently

by adolescents than are serious violent offenses (see

table 13-2).11 It is important to note, however, that

the self-report data from the National Youth Survey

are dated and may not apply to today.

Although current rates of arrests for serious

offenses by U.S. adolescents may seem high, there

is some evidence that the aggregate arrest rates for

serious violent offenses and for serious property

offenses committed by U.S. adolescents have declined since the mid-1970s. The aggregate arrest

rates among individuals under age 18 for serious

violent offenses (murder, forcible rape, robbery, and

aggravated assault) declined slightly (1.3 percent)

from 1974 to 198312 then leveled off at the 1973

level (see figure 13-1). The arrest rates among

individuals under age 18 for serious property offenses (burglary, larceny-theft, motor vehicle theft,

and arson) declined sharply from 1975 to 1983 and

have hovered around the 1983 level ever since (see

figure 13-2).

The recent decline in aggregate arrest rates for

serious offenses among individuals under age 18 is

paralleled by a decline in the aggregate victimization

rate for rape, robbery, and assault committed by

persons under age 18 (see figure 13-3). Also, the

victimization rate for serious offenses committed by

12- to 17-year-olds decreased 8 percent from 1973 to

1983 (256) and after that fluctuated around the 1982

level.

1 I As ~oted ~~ve, “Ictlm MC, re~onably, not asked to report on property offenses. As aconsequcnce, the relative rates of violent and Prope~ offe~es

cannot be compared using victimization data. Victimization rates for violent offenses are higher than arrest rates, but much lower than self-reported

offending rates, for such offenses.

12 Different data souces my use different age categories, ~ng inte~re~tion of mends more difficult. For example, some data a.fe available for

adolescents ages 10 to 18, whiIe other statistics are aggregated below age 18 and the 10- to 18-year-old offenders cannot be distinguished from those

younger than 10 years of age. However, the proportion of arrests for serious violent and property offenses committed by children underage 10 is extremely

small (see figures 13-4 and 13-5). The relative insignificance of arrest data for children under age 10 may reflect a law enforcement bias against such

arrests as well as the rarity of such offenses by young children.
II-592 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 13-1—Arrest Ratesn for Serious Violent

Offensesb by Persons Under Age 18 and

Age 18 and Over, 1965-88

Arrests/100,000 population

1,400

1’600~

1,200 1

1,000

/

600 i I

o ~—r————i

1965 1969 1973 1977 1981 1985 1988

Year

~ Under age 18 ~ Age 18 and over

aThe amest rate is the number of arrests made in a giVen population per

given population base. The arrest rate here is the number of arrests per

100,000 population of the same age group.

bserious tio/ent offenses are murder and nonnegligent manslaughter,

forcible rape, robbery, and aggravated assault.

SOURCE: U.S. Department of Justice, Federal Bureau of Investigation,

Age-Speci”fic Arrest Rates and Racw-Specit7c Arrest Rates for

Selected Offenses 19651988 (Washington, DC: April 1990).

Trends in arrest rates among U.S. adolescents

vary tremendously by type of offense, and considering aggregate figures alone, without looking at

trends for specific offenses, may lead one to miss

important policy implications (409). Potentially the

most troubling recent trends are increases in arrest

rates among U.S. adolescents ages 13 through 18 for

the serious violent offenses of murder and nonnegligent manslaughter (see figure 13-4) and for aggravated assault (see figure 13-5). There also have been

increases in arrest rates among U.S. adolescents for

the less serious offenses of simple assault and

weapon use (409). Fortunately, arrest rates among

U.S. adolescents for some serious property offenses

(robbery, burglary) and minor offenses (narcotic

drug law/drug abuse violations) have recently declined. Arrests for larceny-theft have been relatively

stable since 1974.

The interpretation of arrest rates is actually

somewhat difficult. The reason is that changes in

arrest rates over time may be biased by greater or

lesser law enforcement efforts directed toward

particular offenses over time, shifts in police capacFigure 13-2-Arrest Ratesa for Serious Property

Offensesb by Persons Under Age 18 and Age 18 and

Over, 1965-88

Arrests/100,000 population

“600~1

1,400 { I

200

i I

0-1 , 1 1 , I r 1 1 I , 1 , 1 r I r 1 I 1

1965 1969 1973 1977 1981 1985 1988

Year

~ Under age 18 ~ Age 18 and over

aThe a~est rate is the number of arrests made in a giVen population per

given population base. The arrest rate here is the number of arrests per

100,000 population of the same age group,

bse~usprope~ offenses are burgtary, larceny-theft, motor vehicle theft,

and arson.

SOURCE: U.S. Department of Justice, Federal Bureau of Investigation,

Age-Specific Arrest Rates and Raa+Specitic Arrest Rates for

Se/acted Offenses IsW$1988 (Washington, DC: April 1990).

Photo credit: Benjamin Smith, Washington, DC

Recent increases in arrest rates among U.S. adolescents

for the serious violent offenses of murder/nonnegligent

manslaughter and aggravated assault are disturbing.

ity to apprehend offenders, or other factors unrelated

to changes in adolescent behavior. It is interesting to

note that self-reported offending rate data from high

school seniors support somewhat the inference that

there has been an increasing adolescent commission
Chapter 13—Delinquency: Prevention and Services ● II-593

Figure 13-3-Victimization Rates for Rape, Robbery,

and Assaulta Committed by Persons Under Age 18,

1980-87

Number of offenses experienced by victims age 1 2

and over per 100,000 victimizers under age 1 8

2,00 0

1,800 - / P,

/ ’

\

1,600 -

‘\,

(

1,400 -

1,200 7

1,00 0 4

800 “

-—-- ‘~- ‘–-T-— ‘-- 

- ~--- ‘ --- ~—~–.—.–-4

1980 1981 1982 1983 1984 1985 1986 1987

Year

~he victimization rate is the number of offenses experienced by a given

population per some population base during a given time period. The

victimization rate here is the number of rapes, robberies, and assaults

experienced by victims age 12 and over committed by victimizers under

age 18 per 100,000 victimizers under age 18.

bAssauit inc[udes aggravated assault and simple assault.

SOURCE: K. Whitaker, Office of Justice Programs, Bureau of Justice

Statistics, U.S. Department of Justice, compilation of National

Crime Survey data from Crimina/ Victimization in the United

States 1980-87, Washington DC, 1989.

of some violent offenses; however, reports of crime

victims do not support that inference (see table

13-3).13

To the extent that arrest rates and adolescents’

self-reported offending rates reflect adolescent behavior, the increase in rates for simple assault,

aggravated assault, and murder and nonnegligent

manslaughter could be indicative of a trend among

adolescents to increased violent assaults against

persons. This increase in violent assaults points to an

increasing need for prevention.14

How Many Adolescents Commit Delinquent Acts?

For the purposes of understanding adolescent

involvement in delinquent behavior and formulating

policy to prevent and control delinquency, it may be

Figure 13-4--Arrest Ratesa for Murder and

Nonnegligent Manslaughter by Persons Age 18 and

Under, 1965-88

Arrests\ 100,000 population

3 5

T

3 0 +

7

/’

~

~–~+*~– .t- -

-1 0 “ -

 - - - “ -

 - - “ ‘~’ ‘~’ ‘~’ ‘- ‘+’ ““ ‘“ ‘“ -

‘1

1965 1968 197 1 1974 1977 1980 1983 1986498 8

Year

‘-- Age 12 + Age 13-14 + Age 1 5

and under

h Age 16 — Age 1 7 d Age 1 8

aThe arrest rate is the number of arrests made in a given population per

given population base. The arrest rate here is the number of arrests per

100,000 population of the same age group.

SOURCE: U.S. Department of Justice, Federal Bureau of Investigation,

Age-Spedfic Arrest Rates and Race-Speeific Arrest Rates for

Se/acted Offenses 1965-1988 (Washington, DC: April 1990).

important to know not just the number of offenses

but the number of adolescents who commit delinquent acts, the frequency with which such acts are

committed, and the types and seriousness of the

offenses. If most delinquent offenses are committed

by a small number of adolescents who commit many

offenses each, the implications are likely to be

different from the implications that would exist if

individual adolescent offenders commit only a few

offenses each.

Determining g how many adolescents commit delinquent acts nationwide is as difficult as determining how many offenses are committed by adolescents. Recent data on the number of U.S. adolescents

ls~~~ugh @=y were not ~k~d about o~er violent offenses (e.g., m~del-), ~gh school seniors were increasingly likely tO report kEIV~g COU3mifid

an aggravated assault in the period from 1975 to 1985 (303). On the other hand, victims reported no increase in being assaulted by 15- to 17-year-olds

in the period from 1980 to 1987 (see table 13-3).

14& discussed ~low, even if ~est rates for cefl~n violent offemes Wme not increming, very }itl]e effort has been devoted tO atlemptS tO preVcXIt

adolescents’ usc of violence. One could argue, therefore, that the need for preventive interventions exists regardless of changes in rates.
II-594 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 13-5-Arrest Rates” for Aggravated Assault by

Persons Age 18 and Under, 1965-88

Arrests/100,000population

‘oo~--------’------

300

200

100

.s+. “- 0 ~ , w+=+= —

65 68 71 74 77 80 83 86 88

Year

~ Age 1 2 + Age 13-14 + Age 15

and under

— Age 1 6 + Age 1 7 ~ Age 1 8

~he amestrate is the number of arrests made in a given population per

given population per some base. The arrest rate here is the number of

arrests per 100,000 population of the same age group.

SOURCE: U.S. Department of Justice, Federal Bureau of Investigation,

Age-Spea”fic Arrest Rates and Race-Spedfic Arrest Rates for

Se/ected Offenses 7%%-7988 (Washington, DC: April 1990).

engaging in delinquent acts are not available. Data

on adolescents in the National Youth Survey are

quite old, having been collected between 1976 and

1980. Data in the Uniform Crime Reports and the

National Crime Survey provide information on the

number of offenses and cannot be easily manipulated to obtain prevalence rates. Information about

prevalence can be obtained from longitudinal research projects, but such studies are typically

community based and may not be generalizable to

other communities.

Available data from the National Youth Survey

suggest that a large majority of U.S. adolescents

commit minor offenses at least once and that a

considerable minority of adolescents also commit

serious offenses at least once. A small percentage

repeatedly engage in both serious and nonserious

acts of delinquency (100). Elliott and his colleagues

conducting the National Youth Survey discovered

that most adolescents become involved in some

level of delinquent behavior during the course of

their adolescence--although their infractions are

usually relatively minor (e.g., a status offense,

vandalism, minor assaults) (100). In addition, they

found that 21 percent of the participants in the

survey had committed at least one serious offense in

1976 (100). If 21 percent of the 29.2 million

adolescents who were 11 to 17 years old in 1976

committed serious offenses, then approximately 6.1

million adolescents committed one or more serious

offenses that year.

The findings of many other studies parallel those

of the National Youth Survey. A review published in

1981 noted that a ‘‘substantial minority of the

adolescent male population has been or will be

arrested or convicted’ (128). The figures vary from

20 to 70 percent depending on demographic characteristics, seriousness of offense, or other factors

included in the studies reviewed (128). Another

review, published in 1986, noted that the best

available estimates indicate that between 25 to 35

percent of urban males will be arrested for a serious

crime in their lifetimes, and 15 percent will be

arrested by age 18 (48).

What Is the Pattern of Committing Serious

Delinquent Acts Among Adolescents?

An understanding of the duration and level of

involvement of adolescents in serious delinquent

behavior is important to an analysis of policy

implications. Available data suggest that not all

adolescents who commit a single serious offense are

destined to become “career criminals. ” For which

adolescents does involvement in serious delinquent

behavior suggest the beginning of a criminal career

and for which is such involvement limited?15

15AU impomt consideration in tracking the careers Of ~s is the possible effeets of involvement with the juvenile justice system. A basic

question is whether being apprehended leads to worse or better behavior. Does being arrested early in life lead to exposure to older adolescents and new

forms of delinquent behavior or expectations by police and others that the adolescent is “a delinquent”? Or do the adolescents who begin their careers

of multiple offenses early and continue unabated do so because they have eseaped apprehension? As discussed more fully below under effectiveness

of the juvenite justice system, available data are unable to answer this question deftitively.
Chapter 13—Delinquency: Prevention and Services ● /1-595

Table 13-3-Serious Offenses by 17-Year-Olds: Trends in the Incidence Rates Reported by Different Sources of

National Data on Adolescent Delinquencya

Data source

National Youth Monitoring the Future/High

Uniform Crime Reports National Crime Survey Survey (self-reported School Seniors Survey (selfType of offense Yearsb

(arrest ratesc) (victimization ratesd

) offending ratesa) reported offending ratese

)

Aggravated assault .. ........1976-80 Upward trend No obvious trend

1975-85 Upward trend Upward trend

1980-87 Upward trend No obvious trend

1978-88 Upward trend

1984-88 Upward trend

Robbery .. ....... .. ....... .1976-80 Upward trend No obvious trend

1975-85 No obvious trend No obvious trend

1980-87 Downward trend No obvious trend

1978-88 Downward trend

1984-88 Downward trend

Forcible rape . . . . . .. .. . . . . ..1976-80 Upward trend No obvious trend

1980-87 No obvious trend No obvious trend

1978-88 No obvious trend

1984-88 Downward trend

Murder and nonnegligent 1978-88 No obvious trend

manslaughter . . . . . . . . . . . . ..1984-88 Upward trend

Larceny-theft ... .... .. ... ...1976-80 No obvious trend No obvious trend

1975-85 No obvious trend Downward trend

1978-88 No obvious trend

1984-88 No obvious trend

Burglary .. .. ... .... .. ... ...1976-80 No obvious trend No obvious trend

1978-88 Downward trend

1984-88 Downward trend

Motor vehicle theft .. .. ... .. ,1976-80 No obvious trend No obvious trend

1975-85 No obvious trend, then No obvious trend

downward trend,

then upward trend

1978-88 No obvious trend, then

downward trend,

then upward trend

1984-88 Upward trend

Arson . . . . . . . . . . . . . . . . . . . . .1975 -85 Upward trend, then No obvious trend

downward trend, then

no obvious trend

1978-88 No obvious trend, then

downward trend, then

no obvious trend

1984-88 No obvious trend

asjnce 17 ~a~ the only age included in all four national data sources, the trends described for individual offenses are for 17-yeardds.

bhe arrest rate here refers to the number of arrests of 17-year-olds per 100,000 17-year-olds in the population. The years used as the beginning and the end

points for trends in the table reflect readily available data.

~his column shows trends in arrest rates for serious offenses (violent or property) among 17-year-olds in 1988.

*he victimization rate here is the number of serious offenses (violent or property) experienced by individuals 12 years of age and over committed by individuals

17 years of age in 1987 per 100,000 individuals 17 years of age in the population.

eThe self. rew~jng offe~ing rate here is the num~r of serious offenses (violent or property) self-reported by individuals 17 years of age per 100,000 individuals

17 years of age in the population.

SOURCES: Uniform Crime Reports: U.S. Department of Justice, Federal Bureau of Investigation, Uniform Crime Reporfs, Crime in the United States, 1988

(Washington DC: U.S. Government Printing Office, August 1989). National Crime Survey: U.S. Department of Justice, Office of Justice

Programs, Bureau of Justice Statistics, Criminal Victimization in the United States, 1987, A National Crime Survey Report, NCJ-1 15524

(Washington, DC: June 1989). National Youth Survey: D.S. Elliott, S.S. Ageton, D. Huizinga, et al., The Prevalence andhcidence of fkdinquenf

Behavior: 1976-1980, National Youth Survey Report No. 26 (Boulder, CO: Behavioral Research Institute, March 1983). Monitoring the

Future/High School Seniors Survey: D.W. Osgood, P.M. O’Malley, J.G. Bachman, et al., “Time Trends and Age Trends in Arrests and

Self-Reported Behavior,” Criminology 27(3):389-41 7, 1989; J.G. Bachman, L.D. Johnston, and P.M. O’Mailey, A.fonitori”ng the Future:

Questionnaire Responses From the Nation’s High Schoo/ Seniors, 7986 (Ann Arbor, Ml: Institute for Social Research, University of Michigan,

1987).
//-596 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Elliott and his colleagues conducting the National

Youth Survey found that, over a 5-year period (1976

to 1980), the majority of adolescents who committed

any serious violent offense had a “career length’ of

1 year (108). Their finding is consistent with studies

of arrest histories that found that a majority of

adolescent violent offenders have a single arrest for

a serious violent offense and few continue violent

offending into adulthood (180).

But the National Youth Survey and other studies

have found that there is a small subset of adolescent

offenders who commit multiple, serious offenses

(48,108,119,129,180,369,458,459). The estimates

vary from study to study, in part because the studies

use different data sources and were done at different

times. Adolescent offenders who commit multiple,

serious offenses have received considerable attention in the research literature because they are the

adolescents most likely to go on to commit multiple

crimes as adults and are responsible for most of all

arrests (48, 180). Chronic offenders also appear to be

different from nonchronic offenders because they

are likely to have begun delinquent behaviors at an

earlier age and to have continued them later

(48,1 19,129,366,458).

Researchers differ as to whether adolescents who

commit multiple offenses move toward increasingly

serious offenses over time. Some researchers interpret the evidence to indicate that delinquent careers

escalate from the nonviolent to the violent (48,458);

other researchers conclude that there is no consistent

sequence in the appearance of violence in the course

of an adolescent’s offending (180,182).

It is likely that adolescents who commit more than

one offense commit a variety of offenses, both

serious and minor, rather than specializing in a

single type of offense (108,126,129,180,182). According to one study, chronic offenders typically

alternate between property offenses and a smaller

number of violent offenses (182). The National

Youth Survey found that even adolescents involved

in serious violent offenses commit other types of

crimes (108). Indeed, it found that adolescents

involved in serious offenses usually commit relatively few serious offenses and many minor offenses

and are therefore more likely to be arrested for a less

serious offense (101). The relatively small number

of adolescent males who commit sex crimes do not

commit other types of crimes (329).

Factors Associated With

Adolescent Delinquency

The importance of understanding factors that are

correlated with or predict delinquent behavior (risk

factors) lies in the possible use of such understanding as the basis for targeting resources and for

developing and evaluating interventions. It is important to note that conclusive information about many

of the factors that have been investigated as possible

correlates of adolescent delinquency is not available.

Many adolescents (an average of 40 percent across

studies) who have been exposed to risk factors do

not become offenders, as measured by arrest before

age 18 (432). Furthermore, a small number of

adolescents become delinquent without any identifiable risk factors in their background (353).16 This

group remains an “enigma,” testifying to lack of

adequate understanding of delinquency (353).

Demographic Factors Associated With Delinquency

National data on U.S. adolescents’ involvement in

delinquency are often reported in terms of demographic factors—age, gender, race, ethnicity, and

urban/rural location. Current national data sources

on delinquency do not report information on socioeconomic status. Communitywide analyses are the

source of much data on this factor.

Age-Involvement in delinquency changes with

age during adolescence. Incidence rates, as measured by arrest rates, victimization rates, and offending rates, indicate that, in general, the level of

adolescent involvement in delinquent acts-whether

violent or nonviolent, serious or minor-generally

peaks some time between 15 and 17 years of age and

declines thereafter (102,107,122,284,285, 412).17

lc~omtion a~u[ factors that protwt adolescents exposed to risk factors for delinquency is presented later in thk Chapter. See box 13-B.

17A~.ate ~es[ ratm for serious violent Offemes ad ~st rates for aggravated m~~t follow a slighdy different pattern. Aggregate arrest rates

for serious violent offenses typically peak at 18 years of age and the arrest rate for aggravated assault usually peaks at age 21 (412). ‘Ile peak age for

aggravated assault in arrest rate data is much higher than the peak ages of 14 to 16 reported for felony assault in the National Youth Survey (100) and

the peak age of 17 reported in the Monitoring the Futurt#High School Seniors Survey for aggravated assault (303). Perhaps arrest data show a higher

peak age than adolescents’ self-reports because older adolescents and young adults are more likely than younger adolescents to be in locations where

police are readily available (e.g., bars). Assaults by younger adolescents may take place in schools and playgrounds where they have been less likely

to be reported to or observed by police. Arrest rates for arson are unusual in tbat they have peaked at 13 to 15 years of age for more than 21 years (412).
Chapter 13—Delinquency: Prevention and Services ● II-597

Table 13-4-Rates of Involvement in Serious Offenses: Male-to-Female Ratios Reported by Different Sources of

National Data on Adolescent Delinquency

Male-to-female ratios

Uniform Crime Reports:

Arrest rate,

1987—under age 18a

Serious offenses . . . . . . . . . . . . . . . . . 7.5:1

Serious violent offenses . . . . . . . . . .

Murder . . . . . . . . . . . . . . . . . . . . . . .

Forcible rape . . . . . . . . . . . . . . . . . .

Aggravated assault . . . . . . . . . . . .

Robbery . . . . . . . . . . . . . . . . . . . . . . .

Felony assaultg . . . . . . . . . . . . . . . .

Serious property offenses . . . . . . . .

Burglary . . . . . . . . . . . . . . . . . . . . . .

Larceny/theft . . . . . . . . . . . . . . . . . .

Motor vehicle theft . . . . . . . . . . . . .

Arson . . . . . . . . . . . . . . . . . . . . . . . . .

Felony thefth . . . . . . . . . . . . . . . . . . .

7.5:1

10.8:1

44.3:1

5.2:1

12.9:1

3.6:1

11.9:1

2.5:1

8.0:1

8.5:1

National Crime Survey: National Youth Survey: National Youth Survey:

Victimization rate, Self-reported offending rate, Prevalence rate,

1987-under age 18b 1976-ages 1 1-17C 1976-ages 11 -17d

0.5:1 (excluding murder 3:1 (excluding murder

and arson)e

and arson)

307:1f

0.5:1 (excluding murder)e3:1

NA NA NA

16.6:1 NA NA

5.3:1 NA NA

1 2.1:1 0.5:1 e3:1

0.5:1” 3:1

NA NA

NA NA

NA NA

NA NA

NA NA

2:1 2:1

NA - not available.

aArre~~rate~are the num~r of arre~t~ made in a given population per some population base in a given time period. The maleto-female ratiOS fOr arrOSt ~tOS

here were calculated from arrest rates in the U.S. Department of Justice, Federal Bureau of Investigation, Age-SpecificArresf Rates and Race-Specit7cArrest

Rates for Selected Offenses, 19651988 (412).

bvicfjmizafjon ~afe.s are the num~r of ~ffenses experienc~ by a given population committ~ by individuals per some population base over a specified time

periccf. The male-to-female ratios for victimization rates here were derived from unpublished data from the U.S. Department of Justice, Bureau of Justice

Statistics, National Crime Survey (421 ).

Coffen~ing ~a~e~ are the number of self-reported offenses that ~cur in a given population per some population base during a specified timf3 period. ThO

male-to-female ratios for offending rates here are from D,S. Elliott, S.S. Ageton, D. Huizinga, et al., me Prevalence and /na”dence of Delinquent Behaw”or,

1976-1980 (1 00).

dpreva/en@ ~ate5 here are the proportion of individuals in the same population involv~ in a self -report~ offense within a designated time period. The

male-to-female ratios for prevalence rates here are from D.S. Elliott, S.S. Ageton, D. Huizinga, et al., The Prevalence and Incidence of Delinquent Behavior,

1976-1980 (1 00).

OMale-to-female ratio5 for serious of fense5, seriou5 violent offenses, and sp~ific violent offenses ranged from 2:1 to 26:1, but the majority were 5:1 or greater

f~~~~~~ violent offenses included in the National Crime Survey were rape, rob~y, aggravated assault, and Sinlp10 aSSaUlt.

9Felony assault includes aggravated assault, sexual assault, and gang fights.

hFelony theff includes larceny_thefi, motor vehicle thefi, burglay, and possession of stolen goods.

SOURCES: Uniform Crime Reports: U.S. Department of Justice, Federal Bureau of Investigation, Uniform Crime Reports.’ Crime in the United States, 1987

(Washington, DC: U.S. Government Printing Office, 1988). National Crime Survey: U.S. Department of Justice, Office of Justice Programs,

Bureau of Justice Statistics, Crimina/ Vktirnization in the LkritedStafes, 198Z A National Crime Survey Report, NCJ-1 15524 (Washington, DC:

August 1988). Nationai Youth Survey: D.S Elliott, S.S. Ageton, D. Huizinga, et al., The Prevalence and Ina’denc-e of Delinquent Behavior:

1976-1980, National Youth Survey Report No. 26 (Boulder, CO: Behavioral Research Institute, March 1983).

These incidence data are supported by prevalence

data from the National Youth Survey. Elliott and

colleagues found that approximately 5 percent of

respondents at each age between ages 12 and 17 had

committed three or more serious violent offenses;

the annual prevalence rate for such offenses dropped

sharply after age 17, however, and was lower at age

21 than at age 12 (108).18 Prevalence rates for

serious property offenses also begin to decline at age

17. The National Youth Survey prevalence data, as

well as data from other longitudinal studies, suggest

that many adolescents may abandon delinquent

behavior as they mature (100).

Gender—Male adolescents are more involved in

most types of delinquent behavior than female

adolescents (48,69,87,100,1 10,162,165,209,302,386,

452).19 For serious offenses, male adolescents dominate the statistics (see table 13-4), although it is

important to note that male-to-female arrest rate and

victimization rate ratios cover a broad range.

The gender gap in adolescent arrest rates appears to be narrowing (412). Between 1965 and

18~e Mofit~fig the Fu~e~@ SCh~~l se~o~ Suey, w~ch does not us@ly ~chlde adolescents Uder age 17, found that the prOpOfiOn Of

individuals committing at least one robbery or one aggravated assault started to decline at age 17 (303).

19some re5emhers~lieve ~[the extent t. w~ch~e de~quency exceeds female deliquenr,y is exaggerated (202,294). Whether @at exaggeration

is minor (as suggested by Hindelang et al. (202) or serious (as suggested by Morns (294)) is uncertain.

In contrast, the gender differential in offending rates and prevalence rates for felony assault (which includes aggravated assault, sexual assault, and

gang fights), robbery, and felony theft are similar (102).
II-598 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

1987, the arrest rates for both sexes increased for

serious violent offenses and for serious property

offenses (412). The arrest rates for female adolescents changed at a greater rate than arrest rates for

males. Among individuals under age 18 the ratio of

male-to-female arrest rates for serious violent offenses decreased from 11.4 to 1 in 1965 to 7.5 to 1

in 1987. Similarly, the ratio of male-to-female arrest

rates for serious property offenses decreased from

6.7 to 1 to 3.6 to 1 over the same period. The

significance of these changes-whether they reflect

an increase in serious offenses among female

adolescents, manifest changing social views that

permit or encourage police to arrest more female

adolescent offenders, or result from some other

factor—is not known.

Racial and Ethnic Background—Arrest rates

for serious offenses, particularly serious violent

offenses, are much higher for black adolescents than

for white adolescents and are higher for white

adolescents than for other adolescents (American

Indians, Alaska Natives, Asians, and Pacific Islanders) (see table 13-5). In 1987, the arrest rate for

serious violent offenses was about six times higher

for black adolescents under age 18 than for white

adolescents under age 18 (see table 13-6).20

Why arrest rates for black adolescents are higher

than those for white adolescents is not entirely clear.

Black adolescents are more likely than white adolescents to live in families with low incomes and in

urban areas. The arrest rates of adolescents in

families with low income are higher than the arrest

rates of adolescents of higher incomes; and arrest

rates of adolescents in urban areas are higher than the

arrest rates of adolescents who live in suburban or

rural areas. Even after adjustments are made for

income and urban location, however, there is a much

greater likelihood that black adolescents who engage in delinquent behavior will be arrested for

serious offenses (especially for serious violent

offenses) than white adolescent offenders. The

greater likelihood that black adolescents will be

arrested may reflect greater law enforcement efforts

Table 13-5-Arrest Ratesa for Serious Offenses Among

Persons Under Age 18, by Race, 1987

Arrests/1OO,OOO population

Type of offense Black White Otherb

Serious violent offenses . . . . . . . . . 489.8

Murder . . . . . . . . . . . . . . . . . . . . . . 10.9

Forcible rape . . . . . . . . . . . . . . . . 34.3

Robbery . . . . . . . . . . . . . . . . . . . . . 231,9

Aggravated assault , . . . . . . . . . 212.7

Serious property offenses .......1,933.4

Burglary . . . . . . . . . . . . . . . . . . . . . 390.5

Larceny/theft .................1,268.9

Motor vehicle theft . . . . . . . . . . . . 274.0

Arson . . . . . . . . . . . . . . . . . . . . . . . 11.8

75.0

1.6

4.9

20.0

48.5

959.8

229.9

648.0

81.9

11.9

50.8

1.9

2.2

18.5

28.1

684.4

122.6

490.4

72.4

6.1

~he arrest rate is the number of arrests made in a given population per

some population base. The arrest rate here is the number of arrests per

100,000 population of the same age group.

hhis category includes American Indians, Alaska Natives, Asians, and

Pacific Islanders.

SOURCE: U.S. Department of Justice, Federal Bureau of Investigation,

Age-Spedic Arrest Rates and Race-Specific Arrest Rates for

Se/ected Offenses, 19651988 (Washington, DC: April 1990).

in black neighborhoods, greater delinquent activity

by individual black offenders, or discriminatory

police practices. Huizinga and Elliott attribute the

high arrest rates of black adolescents (as compared

with white adolescents) to black adolescents’ having

a greater risk of being arrested regardless of their

actual involvement in crime (215).

Data on victimization rates from the National

Crime Survey and data on self-reported offending

rates from the National Youth Survey suggest that

racial differences in adolescent offending are less

pronounced than is indicated by data on arrest

rates. In the 1987 National Youth Survey for

example, the black-to-white ratio in victimization

rates for serious violent offenses was 2 to 1, very

similar to the ratio of 1.9 to 1 for offending rates in

a similar category (see table 13-6).21

In the case of minor offenses among individuals

under age 18, the black-to-white ratio in 1987 arrest

rates for minor offenses other than status offenses

was 1.8 to 1 (412). For minor offenses including

status offenses, the black-to-white ratio in arrest

rates was only 1.5 to 1. Self-reported offending rate

data from the National Youth Survey indicate that

~~ 1987, black adolescents wem 15 ~rcent of the population under age 18 (402) but accounted for 54.6 percent of the arrests for Serious viOlent

offenses, 55 percent of arrests for murder, 56.7 percent of arrests for forcible rape, 67.9 percent of arrests for aggravated assault, and 44.8 percent of arrests

for robbery by individuals under age 18 (409,415).

21~ere is some evidence tittie low raci~ differenti~ in the National Youth Survey self-report dab is ptirdly atibutable to differen~~ v~i~ty

between races in reporting offenses to the sumey. When self-report data were checked with ofilcial records, the National Youth Survey. as other

self-report studies, found a grater degree of underreporting by black adolescents than by white adolescents, particularly for the more serious offenses

(214). On the other hand, the exact magnitude of the differential in underreporting is not known (214). Many methodological problems, including small

sample size and errors in officiat records, leaves the issue unresolved (98).
Chapter 13—Delinquency: Prevention and Services ● II-599

Table 13-6-Rates of Involvement in Serious Offenses: Black-to-White Ratios Reported by Different Sources of

National Data on Adolescent Delinquency

Black-to-white ratios

Uniform Crime Reports: National Crime Survey: National Youth Survey: National Youth Survey:

Arrest rate, Victimization rate, Self-reported offending rate, Prevalence rate,

1987—under age 18a 1987-under age 18b 197&ages 11-17C

1976-ages 11 -17d

Serious offenses . . . . . . . . . . . . . . . . .

Serious violent offenses . . . . . . . . . .

Murder . . . . . . . . . . . . . . . . . . . . . . .

Forcible rape . . . . . . . . . . . . . . . . . .

Aggravated assault . . . . . . . . . . . .

Robbery . . . . . . . . . . . . . . . . . . . . . . .

Felony assaultf. . . . . . . . . . . . . . . . .

Serious property offenses . . . . . . . .

Burglary . . . . . . . . . . . . . . . . . . . . . .

Larceny/theft . . . . . . . . . . . . . . . . . .

Motor vehicle theft . . . . . . . . . . . . .

Arson . . . . . . . . . . . . . . . . . . . . . . . . .

Felony theftg 

. . . . . . . . . . . . . . . . . . .

3:1

6.5:1

6.8:1

7:1

11.5:1

4.4:1

NA

2:1

1.7:1

2:1

3.3:1

NSD

NA

NA

2:1e

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NSD

1 .9:1

Not collected

NA

NA

NSD

5:2

Not collected

NA

NA

Not collected

NSD

1.5:1

Not collected

Not collected

NA

NA

2:1

3:2

Not collected

NA

NA

Not collected

NSD

NA - not available; NSD = no significant difference.

aA~esfrates are the numbr of arrests made in a given population per some population base in a given time period. The black-t~white ratios for arrest Htes

here were calculated from arrest rates in the U.S. Department of Justice, Federal Bureau of Investigation, Age-SpecificArrest Rates and Race-SpacificArrest

Rates for Se/ected Offenses, 1965-1988 (41 2).

bvi~imization rates are the num~r of offenses experiem~ by a given population ~mmitted by indiv~uals per some population base over a specified time

period. The black-to-white ratios for victimization rates here were derived from unpublished data from the U.S. Department of Justice, Bureau of Justice

Statistics, National Crime Survey (421 ).

coffending rates are the number of self-reported offenses that occur in a given population per some population base during a spedfi~ time Pefi~. The

black-to-white ratios for offending rates here are from D.S. Elliott, S.S. Ageton, D. Huizinga, et al., The Prevalence and Incidence of Delinquent Behavior,

1976-1980 (1 00).

dpreva/enm rates here are the propo~ion of individuals in the same ppulation involved in a self-report~ offense within a designated time period. The

black-to-white ratios for prevalence rates here are from D.S. Elliot, S.S. Ageton, D, Huizinga, et al., The Prevalence andkidence of Delinquent Behaw”or,

1976-1980 (1 00).

eSerious violent offenses included in the National Crime Survey were rape, robbery, aggravated assault, and simple as~ult.

fFelony assault includes aggravated assault, sexual assault, and gang fights.

9Felony theft includes larceny-theft, motor vehicle theft, burglary, and possession of stolen goods.

SOURCES: Uniform Crime Reports: U.S. Department of Justice, Federal Bureau of investigation, Uniform Crime Reports: Crime in the United States, 1987

(Washington, DC: U.S. Government Printing Office, 1988). National Crime Suwey: U.S. Department of Justice, Office of Justice Programs,

Bureau of Justice Statistics, Crimina/ Victimization in the United States, 1987, A National Crime Survey Report, NCJ-1 15524 (Washington, DC:

June 1989). National Youth Survey: D.S Eiiiott, S.S. Ageton, D. Huizinga, et al., The Prevalence and Incidence of Delinquent Behavior:

1976-1980, Nationai Youth Survey Report No. 26 (Bouider, CO: Behavioral Research institute, March 1983).

the black-to-white ratio in offending rates for minor cant higher rates for some offenses (alcohol use,

offenses is 1.2 to 1, and in the only two offenses for drunkenness, disorderly conduct, and drug use), and

which black-white differences are statistically sig- black adolescents had statistically significant higher

nificant (liquor law violations and drug use), whites rates for others (carrying a hidden weapon and

have higher offending rates than blacks (102).22 prostitution) (100).

Available prevalence data from the National

Youth Survey, measuring the number of 11- to

17-year-olds involved in delinquent acts in 1976,

also differ by race (see table 13-6). That survey

found that the black-to-white ratio in prevalence

rates for all serious offenses in 1976 was 1.5 to 1.

The National Youth Survey also found racial differences in prevalence rates for some specific minor

offenses: white adolescents had statistically signifiThere is little information on differences in the

ethnic origin of adolescent offenders. Hispanics are

the only group to be differentiated in national arrest

data, and the data are very inexact and cover only a

short period of time.23 In 1986, Hispanic youth under

18 years of age, who represented 9.5 percent of all

youths under age 18, accounted for 11.8 percent of

juvenile arrests for property crimes and 14.5 percent

of arrests for violent crimes (408).

ZZ~e~e findings differ from hose of seve~ Caly self-report Stu(fies which found no difference between blacks ~d whites (63,1 IO*1 15! 171); one

found no difference when social class was controlled (162). Other self-report studies found slight racial differences (203,386), or differences only in

prevalence (452).

zsH1s~~~s were included in WC Fede~l B~@u of Investigation’s Ufiorm crime RepOfl prog~ as Of 1980. me Federal Bureau of hlVeStigatiOtl

stopped collecting data by Hispanic/non-Hispanic categories at the end of the 1986 reporting year because of concerns about the accuracy of the data.
11-600. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Hawaii has examined its adolescent population in

relation to delinquent acts and found a disproportionate incidence of arrests among Native Hawaiians. Twenty-four percent of the Hawaiian population under age 18 are Native Hawaiians, yet State

data indicate that Native Hawaiians account for 35

percent of all arrests among this age group (287).24

Socioeconomic Status-The most common measure of social class of adolescents is parental socioeconomic status (240).25 Reviews of this factor have

concluded that some—albeit limited--evidence suggests that delinquent behavior is somewhat more

likely and more frequent in adolescents from low

socioeconomic backgrounds than in adolescents

from higher socioeconomic backgrounds, but that

the association is restricted to the more serious

offenses (48,268,353,389).26 Further, studies have

found that delinquency occurs in all social groups

(268,353).

Findings concerning the relationship between

socioeconomic status and adolescent delinquency

differ depending on the source of information used

by researchers. Studies based on official arrest or

court records have been more likely than studies

based on self-reports to find an association between

socioeconomic status and delinquency (268,353).

Studies based on self-reports of nonserious delinquent behaviors generally have found little or no

relationship between parental socioeconomic status

and adolescent delinquency or a weaker association

than studies based on official reports have found

(353). A recent major study based on self-reports of

serious offenses, however, did find a relationship

between socioeconomic status and delinquency,

mainly serious assaultive offenses (99). Not only did

adolescents from families of lower socioeconomic

status report committing more serious offenses than

adolescents from middle-class and working-class

families, but a disproportionately high number of

adolescents from families of lower socioeconomic

status reported involvement in serious offending

(100). This study did not find any difference

between middle-class and lower class adolescents

with respect to measures of minor delinquent

activities, however (100).

Whatever relationship between socioeconomic

status and adolescent delinquency there is seems to

be relatively weak. Loeber and Dishion’s metaanalysis of self-report and official measures of a

number of early predictors of adolescent delinquency (e.g., child problem behavior) concluded

that socioeconomic status is the lowest ranking

predictor for delinquency and recidivism (268).27

The fact that the relationship between parental

socioeconomic status and adolescent delinquency is

a weak one suggests that the association is indirect.

A recent study based on self-reports found that

economic hardship does not have a direct effect on

delinquent and drug-using behaviors of males and

females in the 9th through 12th grade but that it does

have an indirect effect (259). That study measured

the effects of the current decline in parental economic status in the Midwest Farm Belt on adolescents behavior.28 Most of the adolescents were

members of working-class and lower middle-class

families, Economic hardship resulted in an increase

in inconsistent parental discipline, and this in turn

increased delinquent and drug-using behavior, particularly in males. This finding is consistent with

that of other studies which find that delinquency is

not associated with social class per se but is probably

mNative Hawaii~ tend to have lower incomes than non-Native Hawaiians and are overrepresented by 43.1 percent in the poveIIy pOptiatiOn (287).

Since arrests for delinquent behavior are also higher among persons with low incomes (85), the relationship of being a Native Hawaiian to arrests for

delinquent behavior, as with black adolescents, becomes entangled with the effects of low income and poverty on arrests for delinquent behavior.

fiu~o~tely, fiomtion on pwen~ socioeconomic status is not routinely reported with Uniform Crime Report arrest data or the National Crime

Smey victimization da@ therefore, reseaxhers must do special analyses to determine the relationships between socioeconomic status and arrests. In

the light of regular reporting of racial data, this lack of regular reporting of socioeconomic status data in the Uniform Crime Report and in the National

Crime Survey may skew interpretations of the data.

~Kercher is more res~ctive in MS review ~d concludes that “empirical research consistently finds little or no relationship be~- pmntid

socioeconomic status and the illegal behavior of teemgers whether one measures socioeconomic status by official recorded or self-recorded crimes. There

is only a strong relationship under very restricted circumstances; specifkally for young black adults and when socioeconomic status is measured by

education and employment rather than by income and occupation, and more for violent than for property crimes” (240).

~TIn tem of ~edim relative ~provaent over c~ce, ~eher ad Dishion fo~d, tie predictors for ad~fe~ce~t deli~~e~cy in rank order were 1)

composite measures of parental family management techniques; 2) child problem behavior; 3) stealing, lying, or truancy; 4) criminality or antisocial

behavior of family members; 5) poor educational achievement; 6) single measures of parental family management techniques; 7) separation from parents;

and 8) socioeconomic status. The rank order of predictors for recidivism were 1) stealing, lying, or truancy; 2) child problem behavior; 3) criminality

or antisocial behavior of family members; 4) prior delinquency; and 5) socioeconomic status (268).

28Lower class people have been shown to suffer the greatest psychological distress during economic declines (21 1).
Chapter 13—Delinquency: Prevention and Services . II-601

mediated by parental problems associated with low

socioeconomic status (163,258,259,353,389).

One explanation offered for the disproportionate

representation of black adolescents in delinquency is

the economic deprivation in which most black

adolescents live. As discussed elsewhere in this

report, approximately half (52 percent in 1988) of

black adolescents live in families with incomes

below 150 percent of the Federal poverty level

(about $15,000 per year for a family of three); this

compares with the one out of five (17 percent) white

non-Hispanic adolescents who live in families with

such low incomes .29 Further, in addition to considering basic income levels, it is important to consider

other characteristics of the social environments of

poor black adolescents, particularly those who live

in urban areas (see, e.g., (85)). Many poor black

adolescents are likely to live in areas with disproportionately high levels of neighborhood unemployment, persistent poverty, and crime (85). This may

be a factor in why several studies, even one using

adolescent self-reports (100), have found that poor

black adolescents are somewhat more likely to be

delinquent than similarly poor nonblack (white)

adolescents (220,398,458).30

It may also be important to consider differences

among black adolescents from different national and

historical circumstances. For example, Dembo has

suggested that the higher rates of family stability

among West Indians may protect against the risk of

delinquency associated with low income (85). It is

important to note that little is known definitively

about the causes of delinquency among black

adolescents, and that vast amounts of knowledge are

obscured when data on delinquency are reported

solely by racial and ethnic group, without consideration of family, neighborhood, socioeconomic, and

perhaps other, factors.

Urban/Suburban/Rural Areas--Arrest, offending, and prevalence rates are difficult to compare

among urban, suburban, and rural areas. Arrest rates

refer to the location of the police agency making the

arrest and not necessarily the location of the offense

or the residence of the offender, and offending and

prevalence rates refer to the residence of the

offender. Nonetheless, it appears that for most

offenses, serious and minor, urban areas experience

higher incidence, offending, and prevalence rates

than suburban areas, and rural areas have the lowest

rates of all (100,415). For some minor offenses,

including liquor law violations and runaway violations, urban, suburban, and rural areas have fairly

comparable arrest rates and self-reported offending

rates (100,415).

Other Factors Associated With Delinquency

Information on other-i. e., nondemographic—

factors linked to delinquency is derived primarily

from community-level research studies. The discussion that follows is based mainly on literature

reviews that examined multiple studies of factors

associated with delinquency. The specific reviews

consulted for a factor are noted in the section

devoted to that factor.

The usefulness of incomplete or controversial

information for the implementation of prevention

and treatment programs is doubtful, so only those

factors whose association with delinquency is supported by substantial empirical evidence are discussed (see table 13-7).31 32

Theoretical Bases of Studies That Explore

Why Adolescents Commit Offenses-Studies investigating why adolescents and others commit

offenses typically have some theoretical basis. Many

theories have been proposed over the years, but all

of them are based on one of three different premises

(433).

Z9SW Ch. 18, ‘ ‘Issues in the Delivery of Services to Selected Groups of Adolescents, ’ in Vol. ~.

30The latter studies used official records to measure delinquency. As noted above, arrest rates for black adolescents are disproportionately higher than

black adolescents’ self-reported involvement in delinquency. Elliott and colleagues found, however, that at the higher frequencies and for more serious

offenses, self-reports and police data coincide (100).

slAl~ough tie factors dlscu~sed here m~~y relate to se~ous offenses, tie same factors are often associated Mth minor offenses; the tknkg and the

strength of the association for serious offenses, however, may differ from that for minor offenses. Family background appears to be related to the

involvement of young children and adolescents in the commission of minor offenses but not of serious offenses. Factors related to societal pressures,

such as peer influence, appear to be more related to the involvement of older adolescents and to the commission of larceny-theft and other serious offenses.

A young person who has been exposed to poor family influences maybe more susceptible to societal influences if and when exposed to them (98).

szMost research on the correlates of offending focuses on what factors differentiate offenders from nonoffenders and contrasts offenders and

nonoffenders in one age range. Very little research examines how specific factors are correlated with specific stages in a criminal career (onsel duratiom

and cessation).
11-602. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 13-7-Selected Factors Associated With Serious Offending by Adolescentsa

Factors Relative strength of association with serious offending

Family factors

Lack of parental supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Strong

Lack of parental involvementc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Modest--strong

Parental rejection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , .Strong

Poor parental disciplinary practices . . . . . . . . . . . . . . . . . . . . . . . . . . . .Weak-modest-strong

Familial criminal behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Medium--strong

Poor marital relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Medium for serious offenses

Parental absence due to divorce or separation . . . . . . . . . . . . . . . . .Small

Large family size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Only when associated with low income and poor housing and for

males

Multivariate combination of family factors . . . . . . . . . . . . . . . . . . . . . . .Strongest--next to strongeste

Child abuse and neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Moderate-for delinquency in general: not significant for delinquency

characterized by violence

Early socially disapproved behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . .Strong--especially for serious offenses and recidivism

Attention deficit hyperactivity disorder (ADHD) . . . . . . . . . . . . . . . . . . . ,Moderate

Learning disability...........................................................,,........... . . .Only in combination with multiple other factors

Low IQ, especially lack of verbal ability . . . . . . . . . . . . . . . . . . . . . . . . . Strong

Poor school performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Moderate

Delinquent peers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Strong--during adolescent period

Neighborhood/community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Weak—strengthened when associated with other factors

Biological factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Inconclusive

Alcohol use prior to offending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Moderate

Drug use prior to offending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Moderate--weak

Guns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Increase severity of outcome

~he factors listed here are also associated with minor offenses, but the strength of the association is not identical.

bhe strength of the association of each factor with serious offending by adolescents was determined by OTA’s analysis of published reviews. When reviewers

disagreed as to their assessment of the strength of the relationship between a particular factor and delinquency, the range of various reviewers’ descriptors

(e.g., weak-modest-strong) is listed. The strength of the relationship between alcohol use and drug use prior to offending and gun use was determined

by an analysis of survey data.

cMeasures of lack of parental involvement include neglect, indifference, ignoring a child, and not taking the child on owin9s.

dM=sures of For marital relations are marital conflict, marital discord, marital disharmony, and excessive quarreling.

eMultivariate ~m~nations of family factors have the strongest relation to offending according to some researchers (268).

SOURCE: Office of Technology Assessment, 1991.

One premise, on which the current theory of

deterrence and the historical classical and neoclassical theories of criminology are based, is that

criminal behavior is freely chosen and that individuals make rational decisions to promote their best

interests. In the late 1960s, deterrence theory revived

a classical approach to controlling criminal behavior

that had been dormant after 100 years of application.

The increase in restrictive and punishment-oriented

responses to juvenile offenders (e.g., increasing the

length of incarceration for juveniles sent to training

schools) in recent years exemplifies the punishment

component of deterrence theory (246).

A second premise, on which social reaction theories, conflict theories, and Marxist theory are based,

is that crime and the characteristics of criminals are

defined by society through criminal law rather than

by the behavior of individuals (433). According to

this premise, the reason that most people convicted

of crimes are poor is because the actions typical of

poor people are labeled as crimes and not because

poverty causes crime. Furthermore, laws governing

actions most commonly committed by poor people

(e.g., armed robbery) are strictly defined and enforced, while laws governing actions typically committed by the middle and upper class (e.g., embezzlement) are not strictly defined or enforced.

The third premise, on which modem positivist

theories are based, is that human behavior, including

criminal behavior, is partially determined by forces

beyond individual control. Positivist theories (e.g.,

learning theories, social control theory, strain theory, and ecological approaches) call for use of the

scientific method to study the biological, psychological, and social characteristics of criminalsin orde r

to identify the causes of criminal behavior.33 Some

JJLearning theories Of c~behavior are based on how learnin g takes place. Izarnm“ g refers to habits and knowledge that develop as a result of

the experiences of the individual in adjusting to the environment. Social control theories focus on the restraining or controlling forces imposed on

individuals. These theories propose that individuals who commit crimes do so because of weakness of forces restraining them from doing so. Strain

theories propose that there are certain socially generated pressures or forces that drive people to commit crimes. These pressures are not evenly distributed

in society but are most severe among groups with the highest crime rates. Ecological approaches focus on the characteristics of areas.
Chapter 13-Delinquency: Prevention and Services . II-603

researchers have integrated one or more positivist

theories to explain the etiology of offending (100).

Neighborhood/Community Factors Associated

With Delinquency—It is clear that the social and

physical environments have an influence on delinquent behavior. 34 A consistent finding is that official

rates of delinquency vary with the socioeconomic

conditions of geographic areas-i. e., delinquency

rates are high in areas of low socioeconomic status

(77,163,372). Early research indicated that the

pattern of delinquency rates in inner-city areas

stayed constant over time (372), but later analysis

showed that variations did occur and reflected

demographic changes (57). An unresolved question

is why offense rates in communities change over

time and to what extent such change is a function of

changes in the communities or individuals living in

the communities (336).

Among boys of low socioeconomic status, those

who live in areas with high offense rates are more

likely to become delinquent than those who live in

areas with low offense rates (336). Self-report data

indicate, however, that although poor children who

live in poor areas are more delinquent than other

children, they are only marginally more delinquent

than children who live in more affluent areas (100).

One reason that adolescents living in poor neighborhoods have a higher rate of officially recorded

delinquency than adolescents in other types of

neighborhoods may be that they are the object of

greater surveillance by police and local residents

(163).

Only a few studies have examined the effect of

neighborhood/community on the delinquency of

individual adolescents (163,240). Most of these

studies have focused on the area’s socioeconomic

status and not included other aspects of a neighborhood/

community that might affect delinquency (240). In

contrast, one recent rigorous analysis divided the

characteristics of neighborhood/community into four

categories: 1) economic level, 2) level of community

organization/criminal subculture,35 3) level of community participation in organizations, and 4) residential stability of the community (383). Even

though this study was well-controlled for measurement errors, none of the four categories of neighborhood characteristics showed more than weak direct

and indirect effects on officially recorded or selfreported crime of adolescents (240).

Possibly, a neighborhood incrementally affects

the delinquency rate by interacting with individual

circumstances. Communities with high delinquency

rates, for example, often have a disproportionate

number of households headed by females who have

incomes at or below the poverty line and who have

to work outside the home. This may weaken parental

supervision. The weakening of parental supervision

and the presence of an antisocial peer culture in the

neighborhood may reinforce potential delinquent

tendencies and behavior (336).

Family Factors Associated With Delinquency—

Researchers have studied the association of many

factors in the family environment with delinquency.

While most family factors, for example lack of

parental involvement, have been the object of

attention for many years, the examination of the

relationship of child abuse and neglect to delinquency is relatively recent.

Selected Family Factors-Several studies have

established a strong association between certain

family variables-e. g., a lack of parental supervision—and juvenile delinquency and adult crime

(48,240,269,353,389). Evidence from official records 36 and self-reports agree that such family

characteristics have a concurrent association with

delinquency and a predictive association with later

delinquent behavior and often with adult crime

(269,389). 37

Different researchers and reviewers categorize

family variables in different ways. Therefore, no one

categorization fits all reviews. The family variables

listed in table 13-7 are as follows:

●

●

●

●

●

lack of parental supervision,

lack of parental involvement,

parental rejection,

poor parental disciplinary practices,

familial criminal behavior,

~It is fiw~t [. note t~t he ~tementio~ di~~u~~ed later ~ ~is chapterconcem~e prevention Oralteration of delinquent behavior On the individual

level. Information on the effectiveness and cost-effectiveness of community interventions to reduce delinquency and crime is sparse and inconclusive

(336).

jscnmlnal ~u&u/lure ~efer~ t. tie extent t. ~hjch a com~~ tolerates soci~ disorder nd titial behavior (383).

360 ffjc1a1 records jnclude ~est records, coufl r~ords, ad records of detention arid COITIXtiOI1.d hlstltUtlOIls.

J_@or a discussion of parents and families’ influence on adolescent health, see ch. 3, “Parents and Families’ Influence on Adolescent Health. ”
11-604. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

● poor marital relations,

. parental absence due to divorce or separation,

. large family size, and

. a multivariate combination of family factors.

This list was adapted from Loeber and StouthamerLoeber (269).38 Child abuse and neglect are not

included in this list and are therefore considered as

factors in a separate discussion below.

Any arrangement of family factors listed above

based on the strength of their relationship with

adolescent delinquency is open to question. As table

13-7 shows, agreement about the strength of the

association between each family variable and delinquency in the literature reviews OTA examined was

considerable but not complete. The lack of complete

consensus is not surprising. For one thing, the

reviews included different studies for the most part,

and the sample size, population, and findings among

the studies reviewed varied. The overlap of studies

among reviews was small, a situation due in part to

the huge literature on the topic and to different

criteria for inclusion adopted by each review.

Moreover, each review used a different method of

analysis of studies to rate the strength of the

relationship between the variable and delinquency.

Three of the literature reviews of family factors that

OTA discusses in depth were traditional “narrative’ reviews39 and did not specify their method of

analysis (48,240,353); Loeber and StouthamerLoeber used a meta-analysis (269).4

Loeber and Stouthamer-Loeber concluded from

their meta-analysis that the family variables that

were most strongly associated and were the most

powerful predictors of delinquency were the lack of

parental supervision, the lack of parental involvement, and parental rejection

41 during the adolescent

period and earlier (269).42 The authors of the other

literature reviews agreed that the lack of parental

supervision had a strong association with delinquency, and all but one concurred that parental

involvement had a strong association with delinquency. Snyder and Patterson described the strength

of relationship between family involvement and

delinquency as significant but modest, basing their

conclusion on an analysis of variance of five

longitudinal and cross-sectional studies (389). Kercher, who performed a traditional narrative review,

noted that the strength of the effect of family

supervision and family involvement varied among

the studies examined; studies using more refined

measures of attachment found stronger relationships

(240).

The authors of most of the literature reviews

agreed with Rutter and Giller’s narrative review that

the methods of disciplining and the severity of

punishment may not be as important a risk factor in

delinquency as the “extent of supervision, the

clarity of parental expectations, and the efficiency of

disciplinary methods’ (353). Loeber and StouthamerLoeber’s meta-analysis concluded that of the wide

variety of childrearing practices the meta-analysis

included under the term “discipline” (physical

punishment and deprivation, nagging and scolding,

lack of reasoning, love withdrawal, strictness and

consistency, and fairness of punishment), lax and

erratic discipline and strict and punitive discipline

were most closely, although weakly, related to

delinquency (269). Parental discipline of adolescents and younger children also showed a significant, but weak, relationship to later delinquency and

aggression (269). Snyder and Patterson’s review

also concluded that poor disciplinary practices,

which were described as lax or neglectful, erratic or

inconsistent, overly harsh or punitive, or harsh

physical punishments were significant but modest

contributions to delinquency (353).

On the other hand, Kercher placed discipline as

one of the two most important ‘‘features of family

life in current criminological research” (239). He

attributes the finding by Loeber and StouthamerLoeber that discipline has a weaker effect on

sgNot w reviews examined by O’E4 analyzed all these variables.

39A ~amafive ~evim of (he litem~ bases i(s conclusions on a subj~(ive ~ysis by (he reviewer. hong the many problems kl a narrative review

that may result in a misinterpretation of study findings is the possible lack of a systematic sumey of the literature base and differemt subjective weighings

of studies (400).

#A ~eta.anafy~i~ is a statistic~ or ~~ti~(ive ~ysis of a large collection of res~ts from individu~ s(udies for the purpose Of hltegradIlg (he

findings (159). In the meta-analysis used in the study by Loeber and Stouthamer-beber, the authors constructed a relativ~improvement+ver-chance

measure to determine the strength’of the relation between each family variable and delinquency. This measure was intended to standardize for d&rences

across studies in the base rate of delinquents and the selection ratio used by the researchers.

AIP~en~ rej~tion WaS included under the category of parental iWOlvement in the Other reVieWS eXUIlhEd.

dz~e ~omt of Supnision was associated with the frequency and the variety of del@uat offe~s (269).
Chapter 13—Delinquency: Prevention and Services .11-605

delinquency than supervision, involvement, and

affectionate ties (269) to the need for more refried

measurements of parental discipline and the necessity to control for the reciprocal effects of delinquency on discipline (240).

Snyder and Patterson suggest that poor and erratic

disciplinary practices may affect the development of

delinquent behavior directly by failing to correct for

antisocial behavior and by providing young people

with aggressive models of problem solving (389).

Such practices can also have an indirect effect on

delinquency, since youngsters exposed to aggressive

modes of discipline may adopt the same behavior in

their relations with peers and others. Such adolescents may be more likely to be rejected by most

peers and resort to associating with delinquent peers

(389).

There are varying opinions about the strength of

the linkage between familial criminal behavior and

adolescent delinquency. On the one hand, Loeber

and Stouthamer-Loeber judged parental and sibling

criminal behavior during adolescence and earlier to

be a medium strength family variable with respect to

delinquency and adult crime (269). On the other

hand, Visher and Roth consider criminal activity on

the part of parents, siblings, and even grandparents

to be strongly associated with delinquency and adult

criminal behavior (48,432). This finding agrees with

Ruttier and Giller’s labeling of familial criminal

activity as the ‘‘most stable and consistent family

characteristic’ associated with delinquency (353).

A recent analysis found that a parent’s criminal

behavior and drunkenness does not directly affect

delinquency but disrupts the family process of

control by increasing the inconsistency of discipline

and the use of force and reducing effective supervision (258).

Poor marital relations between parents during

adolescence and earlier are medium strength family

variables with respect to adolescent delinquency and

adult criminal behavior (269,353,389).43 The discord involved in some divorces and some separations, as well as the conflict between parents in intact

homes, increases the risk of adolescents’ involvement in serious, but not in minor, delinquent acts.

One of the many, as yet unproven, reasons

advanced as to why family discord increases adolescent delinquency is that the energy and time

consumed by parents in conflict diverts parents from

providing adequate discipline and supervision to

their children (48,269,353). Family discord may

interfere with the establishment and maintenance of

healthy parent-child relationships, or mothers and

fathers in conflict may provide an example of

antisocial behavior for some children to copy (48).

Parental absence due to divorce or separation has

been found to have either a small (48,269) or

inconsistent (48) association with adolescent delinquency. Neither parental absence caused by parental

death or hospitalization nor separation from parents

at an early age is significantly associated with

delinquency (48,129). In general, parental absence

appears to have a weaker linkage with delinquency

than poor marital relations does (269,353,389) and

may not be associated with delinquency directly but

rather through its connection with marital conflict

and disharmony (353).

The reviews that examined family size as a

variable found large family size was linked with

other factors in its association with male delinquency but not female delinquency (48,269,353).44

Large family size appears to be related to increased

delinquency when associated with low income and

poor housing (129), but not when associated with

middle-class families (48). It may be that large

family size is often accompanied by inappropriate

discipline and supervision, which may result from

the insufficient time and financial resources and

overcrowding that accompany low-income and poorly

housed families (48,269). Another possibility is that

childrearing may be delegated to inexperienced

older children in large, low-income families (269).

In addition, in a larger family there is increased risk

of exposure to a delinquent sibling, a variable

associated with delinquency (48,269). Another unverified possibility is that the probability of inheriting characteristics associated with criminal behavior

(e.g., low intelligence) or having a delinquent sibling

increases as the size of a family increases (48).

Insummary, it appears that family variables that

directly affect family-child interactions+. g., pa43poor ~~~1 ~elatiom ~ve &en “~ously de~ri~d ~ different s~dies (e.g., in terms of marit~ cordlict, mti@l discord, marital disharmony, and

excessive quarreling).

~~ge fmlly size in some studies was more ti~o c~ldren (269).
//-606 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

rental rejection, lack of parental supervision, lack of

parental involvement, and poor parental disciplinary

practices-appear to have a strong concurrent and

predictive association with delinquency. Family

variables that do not directly affect family-child

relations+. g., poor marital relations, divorce or

separation, and family size-appear to be less

strongly associated with delinquency and may act

indirectly by interfering with the ability of parents to

supervise or be involved with their children.

Family variables associated with adolescent offending have been investigated in combination as

well as one at a time, and the cumulative effect of

several family risk variables has been found to be a

better predictor of delinquency than any single

variable alone (269,389). A review by Loeber and

Dishion found, for example, that single family

variables improved the prediction over chance on the

order of 20 percent, while the use of multiple family

variables improved prediction over chance levels by

50 to 80 percent (268). Snyder and Patterson noted

that 10 to 20 percent more variance is “accounted

for by multivariate combinations of family variables

than any one family variable alone” (389). One

cannot definitively ascertain from available research, however, which combinations of risk factors

are most predictive of later delinquency or adult

crime (269).

Child Abuse and Neglect45--Literature reviews of

early studies of the relationship between child abuse

and neglect and delinquency emphasize that most

studies are flawed methodologically46 and that there

are extreme differences among the research efforts

(150,448). The types of behavior labeled as delinquency vary widely among the studies, as do the

definitions of child abuse and neglect.47 Most of the

studies lacked appropriate comparison or control

groups. Despite these methodological flaws, however, the weight of the evidence indicates a relationship between child maltreatment and delinquency.

In early studies of the relationship between child

abuse and neglect and delinquency that used a

retrospective design, child abuse and neglect were

consistently found to be related to delinquency

(150,448).48 In studies reviewed by Garbarino and

Plantz and Widom using retrospective designs, 8 to

88 percent of delinquent adolescents reported having been abused, with the estimates generally

ranging between 8 and 29 percent49 (150,448).

Variations in the studies reviewed included sample

size, the number of times the delinquent had been

abused, the age when queried about abuse, the

specific type of abuse, and the site of query (e.g.,

diagnostic center and school, private residential

treatment program, detention center, training

school) (150,448).

Early longitudinal studies of abused and neglected children found that about 10 to 17 percent of

individuals who had been abused or neglected as

children became delinquent (150,448).50 Only two

of the longitudinal studies reviewed had a comparison group. Garbarino and Plantz reported that one

study with a comparison group reported that almost

10 percent of the children who were abused or

neglected were subsequently reported as delinquent

compared with 2 percent of controls during the same

time period (150). Widom reported that another

study found that 15 percent of neglected children

and 10 percent of abused children committed serious

offenses in childhood as compared with 7 percent of

children defined as loved in the study (448). In this

study, parental rejection was found to be more

dsc~d abuse ~d neglmt we consider~ wpwtely from other family variables because the literature reviews evzd~ting Shldks of f@ly vtibl~

did not include the studies included in reviews of child abuse. Although studies of discipline are included in reviews of family variables associated with

delinquency, more often than not the disciplinary action is ‘‘normatively legitimate corporal punishment” which is differentiated from physical child

abuse (393). One of the many deftitions of physical abuse is ‘‘an assault on a child by a parent which exceeds the level of violence allowed by legal

and other norms” (393). For further discussion of child abuse and neglect, see ch. 3, “Parents and Families’ Influence on Adolescent Health, ” in this

volume. TIM chapter also discusses the effects of various styles of parenting.

~$$Does Violence Beget Violence? A Critid Marnination of the Literature, ” by Cathy Spatz Widoq includes a scholarly analysis of the

methodological problems of the literature on child abuse and neglect and violence (448).

dTAl~ough a me~.~ysls might ~lfiy some of tie ~sociation be~een c~d abuse ad neglect md delinquency, noncomparability of the key

variables in the literature has interfered with such an analysis (450).

~such re~spective studies identify samples of delinquent youths and then use reverse record chwks to deterrnin e the incidence of abuse or neglect

in their background.

49(x~culatiom of he rates of c~d abuse ~d neglect ~ tie gene~ pop~ation Me exhemely imprwise due to the hick Of &@, but even the high~t

estimates allow the above conclusion (150).

~such smdies follow~ up c~l&en who were abus~ or negl~t~ to S~ if ~ey we~ involved in delinquency at a higher rate than adolescents who

were not abused.
Chapter 13--Delinquency: Prevention and Services .11-607

strongly related to delinquency than child abuse or

neglect (279).

One review of studies on the association of child

abuse and neglect to delinquency characterized by

violence found a relationship between child abuse

and neglect and violent behavior in studies that

compared violent offenders with nonviolent offenders (150). A relationship between abuse and violent

behavior is also suggested by findings that delinquents who were abused and neglected are involved

in violent offenses more often than those who were

not (150). Another review found contradictory

findings among the studies reviewed (448).

A recent prospective study of the relationship

between child abuse and neglect and delinquency

has overcome many previous methodological problems (449). The findings are consistent with the

previous literature in terms of the percentage of

maltreated children who become delinquent and the

fact that the majority of maltreated children do not

become delinquent (45 1). The study found 26

percent of abused and neglected children had a

juvenile record in contrast with 16.8 percent of the

controls. Black children who were abused were

particularly at risk for delinquency (45 1). In comparison to controls, individuals who were abused or

neglected as children had more arrests as adults (29

v. 21 percent) and more arrests for any violent

offense on a juvenile or adult record (11 v. 8

percent) 51 (449).

Individual Factors Associated With Delinquency

—In addition to examining variables in the external

environment, i.e., in the neighborhood and in the

family, researchers have inquired into the contribution of individual characteristics and individual

behaviors to delinquency.

Early Expressions of Socially Disapproved Behavior(s)—Reviews of studies of the linkage between early expressions of socially disapproved

behaviors and delinquency conclude that repeated

expressions of antisocial behaviors52 by children in

preadolescence and early adolescence are strongly

associated with delinquency-especially serious

delinquent behavior and recidivism—in later adolescence (48,269,353). Studies have consistently

found high rates of delinquency among adolescents

who as children or young adolescents displayed

behaviors described as aggression, stealing, lying,

truancy, acting troublesome in school, fighting,

being aggressive-disruptive, daring, dishonest, nervous, antisocial, or destructive or evidencing poor

socialization.

One meta-analysis concluded that aggression and

stealing in childhood were better predictors of

adolescent delinquency than any other of the early

antisocial behaviors (268), The time at which the

antisocial behavior is measured apparently affects

the strength of the relationship. A few studies have

found, for example, that aggressiveness in early

adolescence is more highly predictive of delinquency at a later age of adolescence and adult

criminality than is aggressiveness in early childhood

(269).

The association between early antisocial behaviors and delinquency has been found to hold in many

places where young children can express antisocial

behavior (e.g., at home, in school, and in clinics)

when different outcome measures of official records

of delinquency as well as self-reports are used and

when different measures of the early behavior of

children (self-reports, parent ratings, teacher ratings,

and peer ratings) are employed (48,269,353). For

that reason, the ability of antisocial behaviors to

predict adolescent delinquency is somewhat generalizable. This generalizability is limited to white

males, though, because only a few studies have

involved white females, and even fewer have

examined the early behavior of black and other

populations (48,268,269,353).

Although there seems to be a general consensus

among researchers that problem behaviors in childhood are a predictor of delinquency, there is less

consensus about the relative importance of this

predictor. One reviewer rates antisocial behavior in

childhood just after poor family management as the

best predictor of future delinquency (268), Other

researchers rate antisocial behavior in childhood

before family variables (344,345). Still other researchers regard antisocial behavior in childhood

s]Abu~c~ ~d neglected ~hild~cn ~~0 &ga thci~ ~ffici~ ~fimln~ ~tivi~ approx~te]y 1 y~earlier ~tie con~ol subjects and had approximately

two times the number of offenses. The increased risk associated with childhood victimization is primarily with property times and status offenses, such

as runaway, truancy, and ungovemability (4$9).

sz~tlsocl~ ~~vlor~ by children and adolescents arc also ICIIOWII as conduct problems in the timifIoIogY litera~re and me c~ctetistic ‘f ‘he

psychiatric diagnosis of conduct disorder (see box 13-A).
11-608. Adolescent Health—Volume II Background and the Effectiveness of Selected Prevention and Treatment Services

and family variables as being of equal importance as

predictors of delinquency (1 19).

The efficiency of screening children with antisocial behaviors for some form of intervention is

partially compromised by the large number of

children who exhibit such behaviors and who do not

become adolescent or adult offenders (48). Furthermore, the adolescent who commits only one delinquent act is quite similar in behaviors to the child

who commits no delinquent act (353). On the other

hand, the child who will eventually become a

chronic delinquent or an adult criminal often differs

in behaviors from the child who does not become a

delinquent. It has been suggested by a review of the

literature that two-thirds to almost all eventual

chronic delinquents can be characterized in elementary school by their behaviors (269). However,

this conclusion does not necessarily mean that all

children who exhibit antisocial behaviors in elementary school will go on to become chronic

delinquents.

Attention Deficit Hyperactivity Disorder—

Attention deficit hyperactivity disorder (ADHD) is

a childhood disorder that has been defined in

numerous ways. The definition in the latest version

of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders,

known as DSM-III-R, is presented in box 13-A.

According to this definition, ADHD is characterized

by “developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity” (10).

ADHD and antisocial behaviors or conduct problems are highly intercorrelated, and some researchers

believe that they could be grouped into a single

behavioral disorder category that would also include

learning disabilities (125,331).53 Other researchers

believe that ADHD and conduct problems are both

biological correlates of delinquency that reflect a

developmental lag within the central nervous system

(331). However, the factors that are strongly correlated with ADHD differ from the factors that are

strongly correlated with conduct problems. A number of studies have found that ADHD is linked to

poor cognitive and academic functioning, while

early aggressiveness is linked to poor parenting

factors and low socioeconomic status (125). The

problem has a very early age of onset—from 2.9 to

5 years of age (125,331).

Cross-sectional and prospective longitudinal studies have found that children with ADHD have

relatively high rates of delinquent behavior and of

criminal behavior in later life (125,331). For example, a matched control study that followed males

from 9 years of age until they were 18 years of age

found that 20 percent of the ADHD males were

arrested during that period in comparison with 8

percent of the controls (125).

The correlation between ADHD and delinquency

was corroborated in a rigorous controlled study that

collected information through parental interviews,

teacher and peer ratings, and biological measures of

psychomotor impulsivity to assess ADHD problems

in males of 8 and 10 years of age (125). All the

measures of ADHD significantly predicted juvenile

convictions between the ages of 10 and 16 independent of measures of conduct problems and also with

additive effects. ADHD was particularly predictive

of early convictions; conduct problems were more

predictive of self-reported delinquency, adult convictions, and recidivism. Both ADHD and conduct

problems were significantly predictive of chronic

offenders.

Learning Disabilities—Adolescents with learning disabilities54 have higher rates of officially

recorded55 delinquency than adolescents without

learning disabilities (50,255,331); they also have

higher rates of recidivism and parole failure (50,255)

and commit more serious offenses at rearrest (50)

than those without learning disabilities. Although

prevalence rates for delinquent acts vary widely,

individuals with learning disabilities compose a

disproportionate segment of the delinquent population, even when factors of age, race, and socioeconomic status are held constant (50,255). The esti53Learning disabilities, which have not been well defined, are discussed in the next section below.

$t~arning dl$abilztie~ ~ve not&n we~ defined, and diagnostic criteria are not precise. The National COII.fere13U on u- Disabilities afYe~

that learning disabilities ‘is a generic term that refers to a heterogeneous group of disorders manifested by significant difficulties in the acquisition and

use of listening, speaking, reading, writing, reasoning, or mathematical abilities, or of social skills” (234). These disorders are intrinsic to the individual

and presumed to be due to central nervous system dysfunction (234). Although some experts consider learning disability a biological factor connected

with delinquency, others think the biological link needs much more investigation before reaching this conclusion (33 1).

SSAl~ough children with 1 earning disabilities violate the law at the same rate as other childrem they are overrepresented in official arrest and juvenile

court statistics (38 1); many believe that such children receive differential treatment by the judicial system (50).
Chapter 13-Delinquency: Prevention and Services . II-609

mated prevalence rate of learning disabilities in the

delinquent population ranges from less than 12

percent to more than 70 percent in different studies.

The wide range of estimates is due to the variety of

definitions of learning disabled and to different

methods of assessing the condition (50).

Many explanations for the linkage between learning disabilities and delinquency have been proposed, but no explanation has been firmly established. It is likely that a learning disability by itself

is not sufficient to foster delinquent behavior but that

a learning disability in complex interaction with

multiple factors increases the risk of such behavior

(50,255). One hypothesis is that individuals with

learning disabilities have difficulties with language,

social perception, and social relationships-attributes

that place them at higher risk of delinquent behavior,

particularly when associated with other factors

associated with offending, such as low IQ, parental

criminality. and poor parenting practices (50).

LAW IQ and Poor School Performance 56—

Reviews of numerous studies conclude that low

intelligence level as indicated by IQ57 (48,326) and

poor school achievement (48,240,268) are associated with and predictive of delinquent activity when

measured by self-reports and official records, regardless of race or social class (353).58

Delinquents generally have mean IQs of about

92—8 points lower than the mean IQ of the general

population (326). Delinquents’ lower IQ is attributed specifically to poor verbal abilities: about

two-thirds of delinquents are lacking in verbal skills

as measured by standardized tests (326). Low verbal

skills may deter a child from academic achievement,

thereby contributing to delinquency (326). Or the

lack of verbal skills may be more complex and

underlie such ‘‘personality-cognitive’ functions as

interpersonal problem-solving and moral reasoning,

which can contribute to delinquent behavior (326).

Poor educational achievement is moderately associated with delinquency regardless of race or social

class (48,240,268).59 One review found that by the

end of elementary school, low achievement, poor

vocabulary, and poor verbal reasoning are the best

predictors of future adolescent delinquency (268).

During the high school years, this review found, low

grade point average and not being promoted are the

best predictors of future adolescent delinquency and

adult criminality (268).

School failure in high school and dropping out of

school overlap logically. The literature shows that

dropouts are more delinquent than nondropouts

when in school, but delinquency among dropouts

declines after they leave school. Most researchers

agree that the offense rates of dropouts and high

school graduates converge by the rnidtwenties at the

latest (18 1).

Association With Delinquent Peers—Empirical

evidence showing that association with delinquent

peers by young adolescents is positively related to

delinquent behavior when the adolescents become

older and to criminal activity when they reach

adulthood is consistent (48,109,125,240,315).60 Indeed, involvement with a delinquent peer group by

young adolescents emerged as the strongest predictor of delinquency among older adolescents in

several studies (106,268,313).

Studies have also shown that involvement with a

delinquent peer group serves to maintain delinquent

status (48,125,315). In fact, a high percentage of

delinquent behavior is carried out with peers (1 11).

Researchers disagree, however, about whether exposure to delinquent behavior promotes delinquent

behavior, or whether delinquent behavior leads to

the choice of delinquent friends (240).

A recent analysis of the onset of delinquent

behavior sheds some further light on the debate. The

study concluded that for adolescents ages 11 to 17,

‘‘exposure to delinquent friends preceded minor

delinquent behavior in a majority of the cases and

~For a genm~ discussion of schools ad school perfo~ ce, see ch. 4, “Schools and Discretionary Time, ” in this volume.

57~te~igence is a conboversial construct most Shlditi use ‘‘intelligence quotients” (IQs) as measured by standardized tests as an indicator of

intelligence.

s8~fiough ~te~gence ad s~h~~l ac~evement ~e not tie sac, seve~ s~dies ~ve fo~d tit &ey me s&owly msociat~ (268). Poor school

perfo rrnance sometimes results from problems such as ADHD or learning disabilities that are not related to intelligence.

s~one of tie s@ies in these two reviews overlapped.

~or example, one longitudinal study found that 59 percent of males who were involved with delinquent peers at age 14 had a conviction record at

age 25 in contrast to 25 percent of other males who did not have delinquent associates (19).
II-61O . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

preceded serious delinquency in nearly all cases”

(109).61

Biological Factors—Many biological factors—

genetic, biochemical/hormonal, physiologic, and

neurophysiologic —have been investigated for their

association with delinquent behavior (331).62 The

genetic contribution to delinquency has been examined by studying twins (126,293). Studies of twins

are conducted on the premise that identical twins are

more similar in heredity than fraternal twins. If

identical twins are more similar in their delinquent

history than fraternal twins, some genetic influence

on delinquent behavior is assumed, The effect of

environment on delinquent behavior, however, cannot be discounted in studies of twins who have not

been reared apart because identical twins typically

are raised more similarly and evoke similar responses from the social environment than fraternal

twins (293). Although the weight of the evidence

from studies of twins is strongly suggestive, it is not

conclusive; studies to date have not been able to sort

out the effects of heredity from the effects of

environment.

The linkage of genetic factors to delinquency has

also been examined by studying twins and other

children who have been adopted outside of their

biological family. Adoption studies have found that

there is a positive relationship between antisocial

behavior in adoptees and antisocial behavior in

biological parents, but the studies vary tremendously in definitions of antisocial behavior and have

various methodological problems (293).

Reviewers of the literature on twins and violence

and adoptees and violence have come to different

conclusions about the linkage of heredity and

violence. Heredity has been characterized as having

some role in violent delinquent behavior (331), as

having no relationship with violent offending among

adult men (395), and as possibly contributing to

aggression in adolescence and early adult life (53).

The association of another genetic factor—

variability in the number and length of the male sex

chromosome-with violent behavior among adolescents requires further investigation (331,395).

Some studies have examined biochemical/hormonal linkages with delinquency, but the results are

inconclusive. Some studies indicate that low serum

cholesterol has some association with violent behavior in children with attention deficit disorders (331).

There are conflicting results among studies of

testosterone levels and adolescent violent behavior

(331,381,395). Evidence linking progesterone with

violent behavior during the adolescent period is

indirect (331) and based on studies of flawed design

(395).

Current research in many aspects of neuroscience

now concentrates on neurotransrnitters (substances

that are released by nerve cells to carry nerve

impulses to adjoining cells). Some of the several

substances that have been found to be neurotransmitters are associated with inhibitory effects on

brain function and others are associated with excitatory effects upon brain function. Studies suggest that

either inhibitory neurotransmitters, particularly serotonin, or excitatory agents, or both, may be

involved in the genesis of aggressive behavior

patterns. The balance of inhibitory and excitatory

neurotransmitter activity may dictate the likelihood

of violent behavior under certain circumstances, and

this mechanism may be the final common pathway

by which other variables, such as cholesterol or

testosterone levels or the presence of violenceinducing illicit substances, achieve their effects

(331,395). Research has been conducted on the

association of many other biological factors and

delinquent behavior (329), but the results are inconclusive. Thus, no single biological variable can be

specifically linked with delinquency (53), although

evidence about the association of biological factors

and adolescent delinquency is suggestive (53,93,329).

A sufficient body of evidence has not yet developed,

and it is particularly difficult to use scientific

sampling, control group comparisons, and other

validity checks when conducting research on the

linkage of biological factors and delinquency.

61 Elhott hw ~~o noted tittie ~uence of ewly Pwent ~~g ~d school bond~g is c~e]~ ~u@ the type of friends chosen dtig ~ly

adolescence. Adolescents who are isolated from family and conventional society are more likely to turn to peer groups who often are groups who are

tolerant of and even encourage delinquent behavior (i.e., gangs) (97).

620ne of the ~e~odolo@c~ problems ~ conductfig rese~ch on de~uency is tit tie populatio~ in much of the research on the association of

violence and biological factors are samples of adjudicated offenders who have been placed in clinical treatment settings. Thus, the findings of such

research are hard to generalize. They may apply only to such delinquents rather than to delinquents as a whole. Or the studies may measure the association

of biological traits with arrest or conviction rather than the association between biological factors and violence.
Chapter 13—Delinquency: Prevention and Services . II-611

Alcohol or Illicit Drug Use Immediately Before

Offending63 —Available evidence indicates that many

delinquent acts appear to be committed while, or

immediately after, the perpetrator has been drinking

beverage alcohol (without the concomitant use of

any other drug). Different sources vary somewhat in

their findings regarding the strength of the association between the consumption of beverage alcohol

and the commission of delinquent acts.

In 1987, the Bureau of Justice Statistics within the

U.S. Department of Justice conducted a self-report

interview survey of 11- to 25-year-old offenders in

long-term, State-operated juvenile institutions (415).

This survey found that nearly 9 percent of the

institutionalized offenders under age 18 reported

having committed the offense for which they were

institutionalized while under the influence of alcohol (415). In 1979, Elliott and researchers conducting the National Youth Survey of 14-to 20-year-olds

in the general population had somewhat different

findings (105). They found that alcohol alone was

used immediately prior to 24 percent of aggravated

assaults (including gang fights), and it was used to

a lesser extent in the commission of motor vehicle

thefts, larcenies, and robberies (105). Differences

between these two surveys’ findings may be accounted for by a number of factors: the 8-year

difference in survey administration, different populations sampled, and differences in survey techniques,

Various hypotheses have been proposed to explain the association between the intake of alcohol

and the subsequent commission of delinquent acts,

but no one hypothesis has been confirmed. One

hypothesis is that alcohol may reduce inhibitions

and provoke the expression of delinquent behavior

(77). Another hypothesis is that alcohol may reduce

anxiety or build up the requisite courage to commit

a planned offense (105).

In some cases, alcohol use before an offense may

reflect typical alcohol use for the individual committing the offense. The 1987 survey of institutionalized

offenders by the Bureau of Justice Statistics found

that about three-fourths (76 percent) of the institutionalized offenders under age 18 had drunk alcohol

at least once in the year prior to their current offense

and that more than half (55.5 percent) of them had

drunk alcohol one or more times a week before

admission to the facility (415).

Sources of information on the association between the use of illicit drugs alone and the commission of delinquent acts disagree as to the importance

of the association. The Bureau of Justice Statistics’

1987 survey of 11- to 25-year-old offenders in

long-term, State-operated juvenile institutions found

that 15.7 percent of the offenders under age 18

reported having committed the offense for which

they were institutionalized while they were under

the influence of illicit drugs alone (415). On the

other hand, the 1979 National Youth Survey of

14- to 20-year-olds in the general population found

that robbery was the only offense which was

immediately preceded by drug use alone in more

than 10 percent of the incidents (105). Elliott and his

colleagues who conducted the National Youth

Survey are careful to point out that alcohol or drug

use is not necessarily the cause of any delinquent

behavior.

According to the Bureau of Justice Statistics’

1987 survey of institutionalized 11- to 25-year-old

offenders, it appears that more offenders are affected

by using a combination of alcohol and drugs before

they commit an offense than by only drinking

alcohol or taking drugs (415). This survey found that

more than 23 percent of institutionalized offenders

under age 18 used both illicit drugs and alcohol

immediately before they committed the offense for

which they were institutionalized (415).@

In Summary, the Bureau of Justice Statistics’ 1987

survey and the 1979 National Youth Survey agree

that the use of alcohol or illegal drugs is associated

with a substantial percentage of serious delinquent

acts. However, neither alcohol nor illegal drugs

alone or in combination is involved in most delinquent acts, nor do adolescents use these substances

only when committing offenses.

Possession of a Gun--Guns are often used while

committing delinquent acts in the United States,

particularly those that result in death. To OTA’s

knowledge, however, no research has been conducted to determine whether, and if so, to what

extent, the presence of a gun increases the probabil-

~~For a discussion of alcohol and drug use by adolescents, see ch. 12, ‘‘Alcohol, Tobacco, and Drug Abuse: Prevention and Services, ’ in this volume.

fAAS just no[ed, the Percentage of institutiotiizcd offenders who used both illegal tigs ad ~cohol immediately before ~eY cotittd ‘e ‘ffeme

for which they were incarcerated was higher than the percentage of those who used alcohol only (8,5 percent) or illegal drugs only (15.7 percent) (415).
11-612 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 13-8—Use of a Weapon by Institutionalized Offenders Under Age 18 Who Were

Sentenced for a Violent Offense, 1987a

Offenders sentenced for:

All Other

violent Sexual violent

offenses Homicide b

assault c Robbery Assault offenses

Used a weapon . . . . . . . . . . 40.994. 77.8% 5.3% 44.0% 43.9% 28.1%

Gun . . . . . . . . . . . . . . . . . . . 19.7 56.9 1,5 23.7 15.4 13.0

Knife . . . . . . . . . . . . . . . . . . 10.1 17.8 2.6 11.2 9.9 9.5

Other d . . . . . . . . . . . . . . . . . 11.1 3.1 1.2 9.1 18.6 5.6

Did not use a weapon . . . . 59,2?/’ 22.3% 94.7% 56.O% 56.1% 71.9%

Number of offenders . . . . . 8,194 563 955 3,204 2,985 488

asurvey respondents were residents of long-term, State-operated juvenile facilities. Detail may not total 100 percent

beeause of rounding.

bf+om~ide in~udes murder and all forms of manslaughter.

csexual assault iwludes rape and other sexual assaults.

%is category includes weapons such as axes, ice picks, scissors, clubs, baseball bats, ropes, vehicles, and objects

used for strangulation or suffocation.

SOURCE: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, unpublished data from

the “Survey of Youth in Custody, 1987,” prepared by A.J. Beck, S.A. Kline, and L.A. Greenfeld, Washington,

DC, 1990. -

. .

ity that a delinquent act will occur. It is clear,

however, that the use of a gun worsens the outcome

of a violent act that would have occurred anyway.

The Bureau of Justice Statistics’ 1987 survey of

11- to 25-year-old offenders in long-term, Stateoperated juvenile institutions found that about 41

percent of the offenders under age 18 who were

sentenced for a violent crime used a weapon in the

commission of that crime (see table 13-8). The vast

majority (77.8 percent) of institutionalized offenders

under age 18 who were sentenced for homicide

(murder or manslaughter) used a weapon, and more

than half (56.9 percent) used a gun (415).

Federal law prohibits the sale of handguns and

handgun ammunition to individuals under the age of

21 and the sale of rifles, shotguns, and ammunition

for them to individuals under the age of 18 (Title 18

of the U.S. Code section 922, subsection 1). State

laws also limit the ownership, purchase, and possession of firearms by minors. As noted elsewhere in

this Report, 40 percent of 8th and 10th graders

responding to the 1987 National Adolescent Student

Health Survey reported having used a gun sometime

during the year prior to the survey; 35 percent of the

respondents who had used a gun in the last year had

used a gun more than 10 times (12).65 Almost 40

percent of 10th graders (and almost half of male 10th

graders) said that they could get access to a handgun,

and 1.6 percent reported carrying a handgun to

school during the year before the survey.66

Nationwide, the number of adolescents identified

as murder offenders and the use of guns by

adolescent murder offenders have been increasing

(see table 13-9). In 1976, 1,859 10-to 18-year-olds

in the United States were identified as murder

offenders; 993 (53 percent) of them used guns and

866 (47 percent) used other weapons (41 1). In 1988,

1,92610- to 18-year-olds were identified as murder

offenders; 1,136 (59 percent) of them used guns and

790 (41 percent) used other weapons. Thus, from

1976 to 1988, the number of 10- to 18-year-olds

identified as murder offenders increased by about 4

percent, and the number of murders where guns were

used by 10- to 18-year-olds increased by 14 percent,

although the size of the adolescent population

decreased (41 1).

The number of adolescents who were murder

victims and the number whose murder resulted from

65s& ch. 5, ‘‘Accidentia,l Injuries: Prevention and %TviCM,” in this volume. The question did not distinguish between possible legal and illegal use

of guns; rather the question was stated broadly (“During the past year, about how many times did you use a handguq rifle, or shotgun for any reason

[including hunting or target shooting]?”) (12). Results were reported in the category of ‘exereise safety and high-risk sports,” although the questionnaire

included the question about guns in a more general list of questions about high-risk behaviors (including questions about taking medicine prescribed

for someone else; driving or riding on a go-cm snowmobile, or all-terrain vehicle; using alcohol or drugs while swimmhg or boating). Responses listed

as pertaining to ‘‘access to weapons’ were limited to carrying various types of weapons to school and the pereeived availability of handguns.

66Fifteen percent reported carrying a knife to school, and 8 percent reported Carrying aKIOth~ WMpOn (12).
Chapter 13—Delinquency: Prevention and Services . II-613

Table 13-9-Use of Guns and Other Weapons by Adolescent Murder Offenders,

1976 and 1988

Adolescent murder offenders, 1976 Adolescent murder offenders, 1988

Used Used another Used Used another

Offender’s age Total a gun weapon Total a gun weapon

10 . . . . . . . . . . . . .

11 . . . . . . . . . . . . .

12 . . . . . . . . . . . . .

13 . . . . . . . . . . . . .

14 . . . . . . . . . . . . .

15 . . . . . . . . . . . . .

16 . . . . . . . . . . . . .

17 . . . . . . . . . . . . .

18 . . . . . . . . . . . . .

4

15

12

39

95

215

385

527

567

1

9

6

22

38

125

207

289

296

3

6

6

17

57

90

178

238

271

1

7

14

41

98

221

373

571

600

1

3

8

21

63

137

244

377

282

0

4

6

20

35

8 4

129

194

318

Total . . . . . . . . . . 1,859 993 866 1,926 1,136 790

SOURCE: U.S. Department of Justice, Federal Bureau of investigation, unpublished 1976 and1988 data from the

Uniform Crime Reports, Washington, DC, December 1989.

Table 13-10-Use of Guns and Other Weapons To Kill Adolescent Murder Victims

Ages 10 to 18,1976 and 1988

Adolescent murder victims, 1976 Adolescent murder victims, 1988

Victim’s Killed by Killed by Killed by Killed by

age Total a gun another weapon Total a gun another weapon

10 . . . . . . . 29 14 15 27 17 10

11 . . . . . . . 18 7 11 3 2 12 20

12 . . . . . . . 54 2 7 2 7 38 20 18

13 . . . . . . . 47 3 0 17 51 2 9 2 2

14 . . . . . . . 65 40 25 78 5 9 19

15 . . . . . . . 101 55 46 194 102 92

16 . . . . . . . 204 150 54 237 192 45

17 . . . . . . . 296 212 84 340 276 64

18 . . . . . . . 324 222 102 435 330 105

Total . . . . 1,138 757 381 1,432 1,037 395

SOURCE: U.S. Department of Justice, Federal Bureau of Investigation, unpublished 1976 and 1968 data from the

Uniform Crime Reports, Washington, DC, December 1989.

the use of guns also increased from 1976 to 1988

(411). 67 AS shown in table 13-10, in 1976, there were

1,138 victims of murder from 10 to 18 years of age;

757 (67 percent) of them died from the use of a gun,

and 381 (33 percent) of them died from the use of

other weapons. In 1988, there were 1,432 victims of

murder from 10 to 18 years of age; 1,037 (72

percent) of them died from the use of a gun, and 395

(28 percent) of them died from the use of another

weapon.

The lethality of guns for adolescents in the United

States is confined by mortality data from the

National Center for Health Statistics within the U.S.

Department of Health and Human Services. These

data indicate that in 1987,65 percent of the homicide

deaths among U.S. adolescents 10 to 14 years of age

involved the use of a gun, and 71 percent of the

homicides among U.S. adolescents ages 15 to 19

involved the use of a gun (404). Furthermore, 80

percent of the homicide deaths among black males

67A~ ~ot~ ~~ve, u~om c~e Rep~~ dab we based on crime repfis arid may not refl~t the ~verse of homicides or other crimes. b additioq

there are other differences behveenavailable Uniform Crime Reports and available vital statistics data. For example, 1988 vital statistics data were not

available at the time this Report was being prepared; readily available vital statistics data are for 10- to 19-year-olds rather than 10- to 18-year-olds; and

vital statistics data include homicide by legal intervention. However, Uniform Crime Reports numbers are similar to (though as would be expected, lower

than) vital statistics data. National Centers for Health Statistics’ mortality data indicated that in 1987, there were 2,104 homicide deaths among 10- to

19-year-olds (404), compared with 1,432 murders reported to the LJniform Crime Reports in 1988. Vital statistics data for 1987 included 16 homicides

as a result of legal intervention.
11-614 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

ages 15 to 19 were associated with guns (404).68 The

United States has a much higher number of gunrelated homicides among adolescents than do other

industrialized countries. Among males ages 15 to

19, in 1986, there were 1,043 gun-related homicides

(out of a total of 1,432; thus, 73 percent69) in the

United States; there were 6 (29 percent) gun-related

homicides out of a total of 21 in Canada, and there

were 2 (10 percent) gun-related homicides out of a

total of 21 in Japan (140a).

The Importance of Interactions Between Age and

Factors Related to Delinquency

The interaction of specific factors and delinquency depends on the developmental status of the

child or adolescent (268). Preliminary research

indicates that the best predictors of delinquency

when a child is 6 years of age are family characteristics and that the best predictors from 9 years onward

are early childhood antisocial behaviors (268). At

age 10, parent criminality appears to be the best

predictor of delinquency, and at age 15, grade point

average becomes the best predictor (268).

Interactions between age and a number of factors

related to delinquency influence not only whether

delinquency occurs but also what course delinquency takes if it occurs (353). Children who exhibit

problem behaviors at an early age70 tend to be the

most delinquent and aggressive at later ages—

particularly children who were delinquent when

unusually young and who had a broad spectrum of

interpersonal and social difficulties (e.g., lack of

parental supervision, low intelligence, and low

socioeconomic status (353).

Interactions Among Factors Associated

With Delinquency

Although the exact mechanism of interaction is

not understood in most cases, the interaction among

factors with respect to delinquent behavior appears

to be profound. A few of the many examples of

factors that are thought to interact are described

below.

●

●

●

●

Certain family variables that have a direct

effect on family-child relations+. g., parental

rejection, the absence of parental supervision,

the lack of parental involvement, poor parental

disciplinary practices-appear to be fairly

strongly and directly associated with delinquent behavior.71 Other family variables-poor

marital relations as expressed by family discord, family disruption, and family sizeappear to be less strongly associated with

adolescent delinquency and may act indirectly

by interfering with the ability of parents to

appropriately supervise, or be involved with,

their children or adolescents (269). Homes

where parents provide only weak control over

their children’s behavior seem to facilitate

adolescents’ adhering to a delinquent peer

group (106,320).

A child who has ADHD and is impulsive and

hyperactive may be difficult to handle. Parents

who might be capable of supervising a child of

normal temperament may not have the ability

to be good parents for an impulsive or hyperactive child. Low socioeconomic status, poor

parental health, social isolation, marital discord, and large family size are other factors that

could further aggravate the situation (269).

Child maltreatment and delinquent behaviors

may be causal in both directions and maybe the

result of a common etiology in nonfunctional

families and among cultural practices that

legitimatize family violence (150).

Neighborhood factors (e.g, high neighborhood

delinquency rates) seem to be indirectly associated with delinquency and to operate in conjunction with family factors and peer factors

(353,383).

Factors Associated With Continued Official

Delinquent Activity

The previous discussion for the most part has

focused on factors that are correlated with or

predictive of an adolescent’s decision to engage in

delinquent behavior. Many factors have also been

MAS noted in Ch. 18, ‘ ‘Issues in the Delivery of Services to Selected pOpUkttiOnS, ’ in Vol. III, homicides are the leading cause of death among black

males ages 15 to 19 in the United States. Firearms have been responsible for 75 to 80 percent of alt black male adolescent homicides since 1968. Between

1984 and 1987 the fwarm-relatedhomicide rate increased 66 percent from 29.6 to 49.2, which accounts for 95 percent of the increase in the total homicide

rate for the 1984-87 period among black males 15 to 19 years of age (40).

69Note tit ~ese dam we fmm tie us, vital statistics system, ~d not from the IJniforM crime Reports.

ToStudies ~ve ex~~ned tie Omet of problem ~~viors in children as yo~g ~ 5 to 10 y~s ad older. The interval between onset of problem

behaviors and later delinquency varies among the studies.

TIFor a discussion of the general effect of different p~enting styles, s~ ch. 3, ‘‘Parents and Families’ Influence on Adolescent Health, ’ in this vchme.
Chapter 13—Delinquency: Prevention and Services . //-615

identified that are predictive of continued officially

recorded delinquent activity, some of which are also

associated with initial involvement in delinquent

behavior.

Factors that are predictive of continued official

delinquent activity include the age of first court

contact, inconsistent discipline in the home, expulsion or suspensions in school, diagnosis of need for

special education services, referral to protective

services for abuse and neglect, parental substance

abuse and criminality, sibling criminality, being

behind grade level in school, and alcohol or drug use

(170,439).

In addition, there are system factors such as prior

probation, prior out-of-home placement for abuse

and neglect, prior efforts to run away from home or

out-of-home placement, number of court adjudications or referrals, and number of felony adjudications or referrals. All of these factors are highly

correlated with one another, and usually a set of 8 or

12 of these variables is predictive of continued

official delinquent activity (170,439).

Summary: Factors Associated With Delinquency

Understanding what factors put adolescents at

risk for delinquent behavior and the strength of the

relationship between such factors and delinquency

would be useful in the development of interventions

to prevent delinquency or to treat young offenders.

Various demographic factors have been identified as

risk factors for delinquency, but definitive knowledge about the strength of their linkage with

delinquency is lacking. It is clear that delinquency

rates generally increase with the age of the adolescent, peaking from 15 to 17 years of age and then

declining for most offenses. It is also known that for

most offenses, urban areas experience higher delinquency rates than suburban and rural areas.

Male adolescents are more involved in almost all

categories of offenses than female adolescents, and

black adolescents are more involved in almost all

categories of offenses than white adolescents, but

the gender/delinquency and race/delinquency relationships appear stronger if one looks at arrest

records than if one looks at victim survey data and

self-report data. Furthermore, gender differences in

arrest rates appear to be narrowing, with arrest rates

for adolescent females changing at a greater rate than

arrest rates for adolescent males. The strength of the

race/delinquency relationship as measured by arrest

rates can be questioned, because 1) low income and

living in urban areas are associated with delinquency

and 2) low income and living in urban areas are more

typical of black adolescents than other adolescents.

The strength of the linkage between most nondemographic factors and adolescent delinquency is

similarly open to interpretation. The strength of the

linkage between the factors listed in table 13-7 and

delinquent behavior varies not only among the

factors and age of the individual but also among

studies. The statistical associations of delinquency

and some factors—family factors (e.g., parental

rejection, lack of parental supervision, lack of

parental involvement, familial criminal behavior,

and poor disciplinary practices), early socially

disapproved behaviors, low IQ (particularly poor

verbal ability), and associating with delinquent

peers during the adolescent period-is significant

and well-established in a relative sense. Other

factors that also seem to be associated with adolescent delinquency include child abuse and neglect,

learning disabilities and problems such as ADHD,

poor school performance, and drug or alcohol use.

Some neighborhood and community factors are

associated with delinquent behavior only if other

factors are present and, even then, may have a low

association with delinquency. The role of guns in

delinquency is unclear, although the use of guns by

adolescents who commit homicide and their use

against adolescent homicide victims has been increasing. Alcohol and drug use seem to precipitate

the commission of delinquent acts, but early delinquent behavior also precedes initiation of alcohol

and drug use.

In the design of prevention and treatment strategies, it is extremely important to recognize that few,

if any, risk factors for delinquency act independently. Many of the risk factors for adolescent

delinquency are interrelated in ways that are still

not well understood. It is clear that no one factor by

itself is correlated with or predicts delinquency very

well, but rather for most adolescents, delinquency is

the result of the interaction of multiple risk factors

(including individual, familial, social, and situational factors), each of which incrementally increases the risk of delinquent behavior. The importance of each factor also depends on the age of the

individual.

An extremely critical question is why not all of the

adolescents who have been exposed to any one risk
//-616 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 13-B—Factors That Protect Adolescents Exposed to Risk Factors for Delinquency

A striking finding of studies of risk factors associated with offending is that many adolescents who are exposed

to risk factors do not become delinquent. A longitudinal study in England by West and Barrington found that at least

half of the high-risk adolescents in the study who did not become delinquent were at the age of 22 “socially

impaired’ in other ways-for example, they were social isolates, unemployed, abnormally nervous, withdrawn, and

unhappy (443,445).2 A few young men in this study, however, were living productive lives and were socially

adjusted (443,445). The authors posited that some of the differences in individual reactions were due to differences

in the seriousness or chronicity of the environmental risk factors and some to the differences in individual

temperaments.

Other studies have found that a positive temperament, including positive mood and a tendency to evoke

positive responses from others, high IQ, positive school and work experiences, high self-esteem, some degree of

structure in the environment, and one good relationship with a parent or other adult reduce the risk of delinquency

and are related to positive (nondelinquent) outcomes in children exposed to risk factors associated with offending

(295,353). Additional factors identified as having protective value include advanced self-help skills, more internal

locus of control, higher self-esteem, and an informal network of family and friends who are available for support

in times of crisis (295). Overall, a picture emerges of the resilient child as having an easy temperament and a higher

IQ, being more autonomous, having a good relationship with at least one adult, and being more successful and

involved in school.3

lliighrisk was defti as having a parent or sibling who M a ~record and exposure to two other risk factors, including a family

on social welfare and pennanent separation from one or both parents by the age of 15 (443).

2’IMS tig led Imta and Giller to suggest that for many recidivists, delinquency maybe one aspect Of a head ~e Of p~

problems (353).

3For-rd~ussion of resi~ent c~~q M inch. 1$ “IWS in the Delivery of services to Sel~ti &OUpS Of AdOhXXntS,” ~VO1.

m.

factor become offenders. What protects them from the number and characteristics of adolescents inbecoming delinquent? As noted-in box 13-B, some

evidence suggests that having a good relationship

with at least one adult and having a supportive

school environment are among the factors that

contribute to ‘‘resiliency’ among children exposed

to risk factors. Further research on this topic could

provide informed directions for interventions.

Consequences of Adolescent Delinquency

Any attempt to evaluate the consequences of

adolescent delinquency on adolescent offenders, on

victims, and on society is problematic because the

dimensions of the problem of adolescent delinquency have not been established. As noted earlier,

the volume and distribution of delinquent acts and

volved in delinquency in any one year are not

definitively known. Furthermore, data sources and

studies that directly address the issue of the consequences of adolescent delinquency-e. g., exact

national mortality and morbidity attributable to

delinquent acts by adolescents—are not available.72

Clearly, though, society and individuals bear

many costs as the result of adolescent delinquency,

some of which may not be measurable. In addition

to the economic and physical harm that delinquency

causes individuals of all ages,73 there are unmeasured, and perhaps immeasurable, costs due to

adolescent delinquency, particularly violent delinquent acts. These include the cost associated with

the pain, suffering, the reduced quality of life of

72A rewnt @ysis of the cost of injury provides some evidence on effects of homicide and other intentional injuries (340). Thftt @YsiS notes tit

19,830 deaths in the United States in 1985 were the result of homicides and that about 130,869 persons were hospitalized as the result of injuries

intentionally inflicted by others. (The data to categorize intentional injuries other than those rquiring hospitalization are not available.) The authors do

not specify ages of those who committed the homicides and inflicted injuries serious enough to require hospitalizatio~ or the ages of their victims.

Valid information on injuries sustained as a result of crime is also presented in a report on all physical tifies resulting fmm a rape, robbery, or assault

and reported to the National Crime Suwey (420). That report does not add to information on personal consequences of adolescent delinquency, since

the age of the offender is not provided.

73~e extent t. w~ch ado]es~ents ~victims of crime ~d del~uency is discussed ~lOW in me section entitk,d “Adolescents ~ Victims Of Crime

and Delinquency. ’
Chapter 13—Delinquency: Prevention and Services .11-617

victims and their families, and the fear of violence

experienced by members of society that restrains

them from pursuing their normal activities of living.

Violent delinquent acts also result in a high death

toll, high costs for the hospital and other care of

injured persons, and the prevalence of long-term

disabling conditions. The trauma centers of many

hospitals, particularly in large metropolitan areas,

are facing financial crises, in part, because of

shootings and stabbings of individuals, many of

whom are adolescents and most of whom are

reported to have no insurance coverage (437).74

At present, there is no solid foundation upon

which to base estimates of the costs of offending in

adolescence. The most critical deficiency is the lack

of data on the costs of offending disaggregated by

age+. g., Are burglaries committed by adolescents

as costly as those committed by adults? Do aggravated assaults committed by adolescents result in

more serious health impairments than those committed by adults?—and the lack of self-report data that

would allow researchers to ascertain what proportion of offenses are committed by adolescents as

opposed to adults. Arrest rates might provide some

basis for making such estimates, but we do not know

whether the likelihood of arrest varies by age+. g.,

Are adolescent burglars more or less likely to get

caught than adult burglars?

Only partial data are available for use in estimating the costs of offending by offenders of all ages.

The Federal Bureau of Investigation in the U.S.

Department of Justice provides estimates of economic losses due to robberies, burglaries, larceny/

theft, motor vehicle theft, and arson in its annual

Uniform Crime Reports (409). Estimates of the

economic costs and the time lost from work due to

robbery, rape, assault, and theft are also available

from the National Crime Survey conducted by the

Bureau of Justice Statistics in the U.S. Department

of Justice (414). The National Crime Survey also

provides estimates for medical expenses due to

robbery and assault. Many costs are not in the

Uniform Crime Reports or National Crime Survey

estimates, however, including the costs associated

with most minor offenses, the cost of premature

death, the costs of private security devices and

services, losses from tax revenues for illegal activities, and the cost of the criminal justice system.

Estimates of the cost of offending are highly

variable. For 1980, Siegel reported Federal Bureau

of Investigation estimates that the cost of organized

crime was $130 billion and the cost of white collar

crime $100 billion (38 1). Conklin reported estimates

from various sources that would suggest that the

Federal Bureau of Investigation figures reported by

Siegel should be 50-percent lower than they were

(77). The Bureau of Justice Statistics presented

estimates of the total receipts of criminal activity,

ranging from $27 billion (less than the estimates

reported by Conklin for white collar crime alone) to

$137 billion (a little higher than the Federal Bureau

of Investigation estimate for organized crime reported by Siegel) (415). Even allowing for the fact

that the ‘‘costs” of crime may be much greater than

the “receipts” generated, the latter range of estimates for receipts of criminal activity, a range of

$110 billion, is terribly large. Even if age-specific

data were available, it would seem best—given these

variations in estimates of the costs of crime (or the

gains from crime)--to avoid using them as a basis

for estimating the costs of offending in adolescence.

Annual operating expenditures on juvenile confinement in public and private juvenile facilities

alone exceeds $2 billion per year (418). State

spending on juvenile services varies greatly: Southern States spend the least per incarcerated adolescent

and Northeastern States the most (414).

Some juvenile corrections agencies receive partial financial assistance through Federal and State

educational, vocational, and welfare funding.75 A

recent California legislative analysis reported, for

example, that over $150 million annually in Aid to

Families With Dependent Children funds is spent on

group homes and foster placements for juvenile

court clients (246).

74& noted in ~~, 5 ~d 6 ~ ~~ ~o]ume, hospi~ disc~ge dam me not coded by ~use of inj~, ~d emergency dep~ent ~d faClhty data We

not available on a systematic basis; thus, it would be difficult to determine systematically the amount of care for intentional injuries afforded to

adolescents without health insurance coverage. Demographic data that adolescent victims and perpetrators of violent crime are also those Iess likely to

be insured (see chs. 16 and 18 in Vol. III) suggest that anecdotal evidence from hospital emergency departments, such as that reported by the Wushingfon

Posr, is accurate (437).

Tssm ch. 19, ‘ ‘The Role of Federal Agencies in Adolescent Health, ‘‘ in Vol. IU for a discussion of various Federal programs related to adolescent

health.
11-618 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Adolescents as Victims of Crime

and Delinquency

In 1988, as shown in figure 13-6, adolescents and

young adults ages 12 though 24 experienced the

highest victimization rates of all age groups for the

violent offenses of robbery, rape, and assault committed by persons of all ages. Indeed, adolescents

ages 16 to 19 have the highest rate of being victims

of violence (423). Young males are far more often

the victims of violent acts than females in the same

age groups (423).

As shown in figure 13-7, adolescent and young

adults ages 12 through 24 also experience the

highest victimization rates of all age groups for theft

in 1988. Whereas the victims of violence were most

often young males, the victims of theft were often

just as likely, if not more likely, to be young females.

Young blacks are overrepresented among the

victims of most offenses committed by people of all

ages. Blacks of all ages are also more likely to be the

victims of all violent crimes, particularly homicide,

than are whites or members of other minority groups

(415). Mortality data indicate that black male

adolescents ages 10 to 19 are more likely to die from

homicide than are white males in the same age group

(404). In 1985,689 black males from 10 to 19 years

of age died from homicide, as compared with 657

white males in this age group. The higher number of

Figure 13-6—Victimization Ratesa for Rape,

Robbery, and Assault by Age and Sex, 1988

Number of offenses experienced by

victims/100,000 population 10,000

8,00 0

6,00 0

4,00 0

2,00 0

0 IL -m--

12-15 16-19 20-24 25-34 35-49 50-64 65+

Age of victims

_ Male = Female

-he victimization rate is the number of offenses experienced bv a aiven

population per some population base during a give: time perf&t. “

SOURCE: U.S. Department of Justice, Office of Justice Programs, Bureau

of Justice Statistics, Crimina/ Wctimization in the United States,

1988 (Washington, DC: forthcoming).

Figure 13-7—Victimization Ratesa for Theft

by Age and Sex, 1988

Number of thefts experienced by

victims/100,000 population

‘6’000~-‘------–—— 14,000- -

12,000- -

10,000” -

8,000- -

6,000- -

4,000--

2,000- -

o – -Eza

12-15 16-19 20-24 25-34 35-49 50-64 65+

Age of victims

= Male = Female

~he victimization rate is the number of offenses experienced by a given

population per some population base during a given time period.

SOURCE: U.S. Department of Justice, Office of Justice Programs, Bureau

of Justice Statistics, Crimird b7dimization in the United States,

1988 (Washington, DC: forthcoming).

deaths among blacks is startling in light of the fact

that there were almost 5.5 times as many white males

as black males ages 10 to 19 in 1985 (402). The

leading cause of death among black adolescents ages

15 to 19 in 1987 was homicide, while the leading

cause of death among white adolescents ages 15 to

19 in 1987 was motor vehicle injuries (see figure

13-8 and figure 13-9). Although homicide is not the

leading cause of mortality for either white or black

10- to 14-year-olds, black 10- to 14-year-olds are

still disproportionately affected by homicide.

Young blacks from 12 to 19 years of age are also

considerably more likely to be victims of robbery,

rape, and assault committed by people of all ages

than are young whites ages 12 to 19 (see figure

13-10). In the case of theft, the pattern is somewhat

different. Black adolescents ages 12 to 15 are

somewhat more likely to be victims of theft than

white adolescents of those ages, but blacks ages 16

to 19 are much less likely to be victims of theft than

white adolescents of those ages (see figure 13-1 1).

As in the case of delinquency, it is hard to

disentangle the factors of race, location, and poverty

in analyses of victimization. Adolescents who live in

inner cities experience higher victimization rates

than those who live in the suburbs (446), and a large

proportion of black and Hispanic adolescents live in

inner cities (157).
Chapter 13—Delinquency: Prevention and Services . II-619

Figure 13-8—Percent Mortality Due to Seven

Leading Causes of Death for Black Adolescents

Ages 10 to 14 and 15 to 19, 1987

Accidental injuries,

motor vehicle

Accidental injuries, other

Homicide

Suicide

Cardiovascular disease

Congenital anomalies

Malignant neoplasms

.-

1-=””’ ‘“ ‘k

_4/kk. /.?..?

-T.——

0 10 10--- 30 40

Percent mortality

i

50

_ Ages 10-14 [=~~ Ages 15-19

SOURCE: National Center for Education in Maternal and Child Health, The

Hea/th of Arnerica’s Youth (Washington, DC: September 1990).

Figure 13-9-Percent Mortality Due to Seven

Leading Causes of Death for White Adolescents

Ages 10 to 14 and 15 to 19, 1987

Accidental Injuries,

motor vehicle

Accidental injuries, other

Homicide

Suicide

Cardiovascular disease

Congenital anomalies

Malignant neoplasms

o 10 20 30 40 50

Percent mortality

= Ages 10-14 ~1~1~ Ages 15-19

SOURCE: National Center for Education in Maternal and Child Health, The

Heaffh of Arnerica’s Youth (Washington, DC: September 1990).

It is clear, however, that adolescents themselves

pose a risk to adolescents. Individuals ages 12 to 19

are by far the major victims of the violent offenses

of robbery, rape, and assault committed by individuals ages 12 to 20.76 In 1987, more than 60 percent of

the 1,711,840 reported violent offenses of robbery,

rape, and assault committed against victims 12 to 19

years of age were committed by offenders ages 12 to

20 (419).77

Another category of victim is the adolescent who

views delinquent behavior, particularly violent acts.

Figure 13-10-Victimization Ratesa for Rape,

Robbery, and Assault by Age and Race, 1988

Number of offenses experienced by

.- -- - victims/100,000 population

1 U,uuu

8,00 0

6,00 0

4,00 0

2,00 0

0

12-15 16-19 20-24 25-3435-4950-64 65 +

Age of victims

~he victimization rate k the number of offenses experienced by a given

population per some population base during a given time period.

SOURCE: U.S. Department of Justice, Office of Justice Programs, Bureau

of Justice Statistics. Cn”minal L4ctimization in tie United .%tes,

1988 (Washington, DC: forthcoming).

Figure 13-1 l—Victimization Ratesa for Theft

by Age and Race, 1988

Number of thefts experienced by

victims/100,000 population 14,000 ~ - -— -—-–--— —

12,000

10,000

8,00 0

6,00 0

4,00 0

2,00 0

0

I

12-15 16-19 20-24 25-34 35-4950-64 65+

Age of victims

= White _ Black

aThe Victimization rate of victims is the number of offenses experienced by

a given population per some population base during a given time period.

SOURCE: Office of Justice Programs, Bureau of Justice Statistics, Criminal Victimization in the United States, 1988 (Washington, DC:

forthcoming).

Preliminary research indicates that significant numbers of children and adolescents have seen violent

acts, such as shootings and stabbings (38,158). The

76~e fmu~ of ~~ OTA RePofi is on 10- ~u@ 18_y~_~lds. some of tie &@ pre~nt~ fi this discussion are for Other age gTOUpiIlgS btXiNISe dii~

for 10- through 18-year-olds are not readily available.

77NatioMl dam relafig ~th the age ad race of offenders to tie age ~d raw of their vic~s are not av~able. ‘rhus, while it 1s kIIOWIl tit the gr~t

majority of violent offenses against whites are committed by whites (79 percent of robberies, rapes, and assaults, and 88 percent of murders) and that

the great majority of violent offenses against blacks are committed by blacks (82 percent of robberies, rapes, and assaults, and 94 percent of murders),

the ages of victims relative to the victimizers within races are not known (408,419).
11-620 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

early findings also indicate that viewing violence is

deleterious to the normal emotional and intellectual

development of children exposed to violence (38).

Prevention of Adolescent Delinquency78

When considering approaches to preventing delinquency among adolescents, it is important to note

methodological and other problems in the literature

evaluating past prevention efforts. One is the problem of different definitions of delinquency, noted in

the first section of this chapter. The definition of

delinquency is critical when designing, implementing, evaluating, and comparing prevention programs.

Another critical issue is the paucity of evaluations

of many interventions to prevent delinquency, particularly of programs developed and implemented

by schools and communities in response to pressing

social problems. Programs developed by universitybased researchers have generally been more rigorously evaluated (455). However, a general problem

is that the evaluations that are conducted are

typically performed by the same organizations and

individuals who design and implement the interventions.

A major problem in all methods used to evaluate

prevention and treatment interventions is that the

researchers in delinquency have typically but incorrectly assumed that programs that fall under the

same general rubric (e.g., group homes) are all

providing the same type of service to a uniform

degree to the adolescents involved. As a result, only

outcomes are evaluated, although processes that

affect the implementation or strength of an intervention may have a greater influence on the program’s

effectiveness than the program’s overall intervention strategy per se (177,362). Systematic documentation or investigation of outcome and process

factors in evaluation reports is rare, which makes it

impossible to tell whether a strategy failed because

it was implemented badly, its impact was limited by

mediating processes, or the underlying theoretical

assumptions were wrong.

Another issue of importance is that although

information gleaned from the knowledge of factors

linked to delinquency has potential for designing

preventive strategies, many programs do not make

use of such information. In devising prevention

strategies, it would be useful to incorporate knowledge about the relationship of particular factors, and

knowledge of the development of delinquent behavior. Interventions should not be expected to be

equally effective across all stages of child and

adolescent development. As an obvious example,

family approaches might be expected to have better

outcomes with younger adolescents than with older

adolescents.

Strategies for the primary and secondary prevention of adolescent delinquency are discussed below.

Table 13-11 displays several types of primary and

secondary prevention interventions.

Primary Prevention of Delinquency

Primary prevention of adolescent delinquency

means identifying individuals at risk for delinquent

behavior because of their general life situations (e.g.,

children in stressed families) or identifying environments at risk for delinquent activity (e.g., school

settings) before the delinquent behavior has occurred, and intervening to reduce the eventual

amount of delinquent behavior in that group or

setting .79

Family-Based Primary Prevention80

Provision of Family Support Services–-The

provision of family support services refers to the

provision to families of a broad array of social

support services, including day care, medical care,

counseling, family needs assessment, and referrals

to other social service agencies. Although numerous

studies have examined the effects of family support

on infants and disadvantaged families (40,71,72,278,

318,330), only a few have examined the long-term

effects of day care and other family support interventions on later delinquency and antisocial behavior.

A notable exception is the Yale Child Welfare

Research Program (364,365), an intervention that

provided to low-income mothers and their first-born

78~S Section iS b=~ on ~ papa enti~~ “Review Of ~O~S for tie ~evention ~d Treament of Delinquency, ” prepared for OTA under contract

by Edward Mulvey, Michael A. Arthur, and N. Dickon Reppucci (295).

% many health areas, primary prevention is not limited to high-risk individuals.

SOS~ce, ~ not~ ~m~m, ~rf~y fictio~g is s~ngly relat~ to de~uency, ~terv~tion witif-es has received wide endorsement N a

locus for preventive intervention (29,55,186,267,269,389).
Chapter 13—Delinquency: Prevention and Services . II-621

Table 13-1 l—illustrative Primary and Secondary

Preventive Interventions for Delinquency

Primary prevention

Family-based

● Family support

. Parent skill training

School-based

● Preschool programs

● Cognitive-behavioral programs

. Social process interventions

Community-based

. Community watch organizations

. Adolescent support organizations

● Youth recreation

Secondary prevention

. Vocational and alternative education programs

● Family therapy and family communication skills training

SOURCE: Office of Technology Assessment, 1991.

children a coordinated set of social work, pediatric,

child care, and psychological services for 30 months

following the child’s birth. Ten years following the

end of intervention, when they were 12.5 years of

age, boys whose families were involved in the

program were found less likely to exhibit predelinquent behavior problems, such as truancy, than

comparison boys whose families were not involved

(364,365). These long-term results may not be

generalizable because they were based on comparisons of only 15 matched experimental and control

low-income families, none of whom were suffering

from serious health or emotional problems.

The Yale Child Welfare Program cited evidence

for approximately $40,000 in benefits per year after

a total program cost per child of $20,000 (364). The

analysis on which these figures were based, however, was not comprehensive enough to represent a

complete picture of the cost-benefit ratio (30).

Parent Skill Training—Parent skill training

involves teaching child development and parenting

skills to parents. Documentation that this is an

effective primary preventive strategy for delinquency is limited. The only evidence comes from a

small number of reports which found that the

siblings of delinquent youths whose parents received parent skill training were less likely to exhibit

problem behaviors (20) and delinquency (244) than

were siblings of delinquent youth whose parents did

not receive such services. These data suggest,

however, that parent training may be effective for

adolescents at high risk of delinquency.

Some studies have assessed parent training as a

component of larger prevention packages. An intervention with low-income Mexican Americans with

children ages 1 to 3 (227) and a carefully assessed

delinquency prevention project based in eight,

inner-city Seattle schools (186) were found to have

positive attitudinal and behavioral outcomes for the

parents and children. The Seattle project also

reported that children in the experimental classes

were less likely than children who were not in such

classes to have started drug use or delinquent

activity by the fifth grade (185). In neither of these

programs, however, can the effects of parent training

be separated from other aspects of the intervention.

A consistent finding is that high-risk parents, i.e.,

those subject to multiple stresses, often do not

complete a family training program or a program

with a family training component (89,90,227,435).

School-Based Primary Prevention

Preschool Programs81—Head Start is the Federal Government’s comprehensive child-development program designed to enhance the social

competence of low-income 3- to 5-year-olds. Along

with educational instruction, the program delivers

health and dental care, immunizations, and hot

meals to its preschoolers while connecting children’s families with needed social services to help

them achieve self-sufficiency.

On balance, followup evaluations of Head Start

programs indicate that many of the programs produce short-lived improvements in children’s IQ and

academic performance and long-term improvements

in school functioning, including a reduced need for

special education placement and an increased likelihood of grade promotion and graduation (183,465).

Because there is an association of factors that affect

school functioning with delinquent behavior, many

Head Start programs can be said to have an indirect

preventive effect on delinquency.

Followup evaluations on the effects of Head Start

in directly preventing delinquency, however, are

sparse. One exception, a longitudinal evaluation of

81A~ noted ~ tie ~ectlon on fwton associated ~lth delinquency, a large body of resemch has shown that 10W IQ, I@ g disability, and school failure

are related to and often precede official and self-reports of delinquent behavior. School-system-level interventions intended to prevent delinquent

behavior have only recently been tried (126,286), bolstered by research showing that school processes and climate are related to academic achievement

and rates of delinquent behavior by students (137,352). For a general discussion of how schools affect adolescents, see ch. 4, ‘‘Schools and Discretionary

Time, “ in this volume.
II-622 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

the Perry Preschool Project, found evidence of

reductions in delinquency, adolescent pregnancy,

and crime (43,44,361). Fifty-eight 3- to 4-year-olds

who were participants in the Perry Preschool Project

were followed up through age 19, as were matched

controls. In comparison to the control group, program participants at age 19 were less likely to have

been arrested at all, to have had five or more arrests,

to have had special education placements in school,

to have dropped out of high school, or to have been

on welfare. Participants also had lower rates of

adolescent pregnancy and adult arrests and higher

rates of adult employment and postsecondary school

enrollment (43,44,36 1). The program appeared to

have a greater effect on adult arrests than on juvenile

arrests.

The evaluation of the Perry Preschool Project

reported that the program resulted in benefits to

taxpayers of approximately $28,000 per child participant, about six times the annual program operation

cost of about $5,000 per child (361). The analysis

included a broad range of calculated benefits and

costs and discounting for the time difference between costs and long-term benefits (30,43).

Cognitive-Behavioral Skills Training Programs--

Cognitive-behavioral interventions are based on the

idea that delinquency sometimes results from an

inability to develop and maintain positive social

relationships due to deficits in social skills (59,288,

391). 82

Evaluations of cognitive-behavioral skills training programs have shown that such programs yield

consistent, short-term improvements in problemsolving abilities (e.g., 92,175,379,380,441), particularly for younger, disadvantaged children. Evaluations of such programs also provide evidence that

such programs produce behavioral improvements

(37,349,379,380), but the evidence for long-term

behavioral improvements is not clear (92,175,288).

Cognitive-behavioral skills training has also been

used as a secondary preventive intervention with

children who have conduct disorders, and investigators have found that changes in behavior at home, at

school, and in the community are evident up to a year

later (235).

An interesting approach that incorporates many of

the techniques used in cognitive-behavioral strategies has been mounted in Massachusetts, the aim

being to change adolescents’ attitudes toward the

use of violence (323). Using a standard curriculum

of information provision and role-playing, the Violence Prevention Curriculum Project specifically

addresses the issue of anger and the control of

violence. This program is attractive for its focus and

direction, but interpreting the only evaluation of its

overall effectiveness is somewhat problematic because the curriculum was published and evaluated

by the same organization (455). The evaluation

found that the curriculum had a statistically significant impact on students’ knowledge and locus of

control. 83 Marginal, but not statistically significant,

differences were found for positive self-esteem and

for self-reports of arrest. The final report emphasizes

the problems of implementing the rigorous study

design and concludes that the findings should be

viewed as preliminary.84

Social Process Interventions--The major focus

of school-based social process interventions is to

change the social structures and processes of schools

to encourage greater involvement and commitment

among students (54,61,133,168,188). Some of the

interventions also incorporate social skills training.

Evaluations of a project that trained seventh grade

teachers in inner-city schools to apply proactive

821nterPer$oM/ ~ogni~ve ~rob/e~.So/}ti~g ~cps) progams focus on processes such as interpre~ social cues and Others’ kltentiOnS, gen~lklg

alternative solutions to social problem situations, evaluating the likely outcomes of different solutions, and means-ends thinking (379). Behavioral social

skills training (MST) interventions focus on teaching specific behaviors such as entering a peer group, accepting criticism, giving compliments, and

resisting peer pressure (288). Many programs incorporate aspects of both ICPS and BSST (37,59,288). These are generally presented as a part of a school

curriculum and done in small groups of students.

8s’1’’wen~.five com~c{s were mem~ed in a s~ey, includ~g fms~tio~ tolerance, self-esteem, impulse COIl&Ol, bCUS Of COn&Ol, Self-repOfied

behaviors, fighting, life stress, peer attitudes, school climate, family conflict style, knowledge and attitudes about violence and its consequences, and

sociodemographics. Locus of control describes individuals’ sense of control over their environment. People with an internal locus of control believe they

are the predorninal source of desirable outcomes; those with an external locus of control believe that others, or chance events, determine the occurrence

of desirable outcomes.

S4D~g development of tie school-based c~~lum, tie developers d~ided that a school-based intervention done was hSUffiCleIIL and a

community-based component was developed to reinforce nonviolent options learned in the classroom. Thus, the Violence Prevention Progrmw a Health

Promotion Program for Urban Youti was initiated in 1986 by the Boston Department of Health and Hospitals. Community educators are using as many

community settings as possible to deliver the ‘‘violence prevention’ message. An outside evaluation team is now analyzing outcome data from this

intervention (455).
Chapter 13-Delinquency: Prevention and Services . //-623

classroom management, interactive teaching, and

cooperative learning strategies reported generally

positive results regarding teacher behavior and the

relationship of the adolescents to the school environment after 1 year (187,189). Students in experimental classes had fewer disciplinary actions and days

suspended and reported less frequent drug use at

school than students in control classes but did not

differ in self-reported school delinquency (1 87, 189).

Although many studies have reported that changes

in teacher and classroom procedures have positive

results on classroom behavior (52,54,61,133,134, 168,

188,442), very few studies (e.g., 48a) have demonstrated that such interventions can have a positive

effect on subsequent achievement and delinquency.

Community-Based Primary Prevention

Community organization interventions to prevent

delinquency are based on Shaw and McKay’s

pioneering work that showed that community disorganization is related to higher rates of offending

(371). As noted earlier in the section on factors

associated with offending, the relation appears to be

indirect (116,383). As noted below, there is a paucity

of evidence on the effectiveness of all types of

community-based preventive interventions, a situation which is probably due to the primitive state of

measurement connected with assessing variables at

a community level, and the difficulty of teasing out

the many interactions among community, family,

and individual level factors.

Community Watch Organizations--Neighborhood and Block Watch organizations and citizen

patrols such as the Guardian Angels are attempts to

decrease offending through community involvement

(42,15 1,3 17,348). While such programs reduce crime

and fear of crime (42,317), they are hard to organize

and have been found to be less effective in highcrime neighborhoods (290,348,384,385). Evidence

on the effectiveness of these programs in terms of

reducing delinquency is sparse. A recent evaluation

of neighborhood watch programs in inner city areas

concluded that such programs, by themselves, rarely

reduce delinquency and crime in inner cities areas

(290). They appear, however, to help support a

broader strategy that includes reducing school dropout rates, providing job training, and providing job

opportunities in inner city neighborhoods (290).

Adolescent Support Organizations---Adolescent support programs provide multiple services,

attempting to be responsive to the particular life

situation of the individuals who come to them for

help,85 Evaluations of such targeted communitybased programs offering a supportive place for

adolescents to go with a variety of problems-e. g.,

Argus Community in the South Bronx, Delaney

Street in San Francisco, or House of Umoja in West

Philadelphia—are sparse and not methodologically

rigorous (290). Informal assessments (i.e., assessments without formal control groups) of high-risk

adolescents in the Argus Community, the House of

Umoja, and the Dorchester Youth Collaborative

suggest that enrollees in these programs have been

less likely to commit delinquent acts than similar

high-risk adolescents in the general community

(290).

Youth Recreation—Numerous youth recreation

programs such as the Police Athletic League, Boys’

Clubs, and the Fresh Air Fund provide constructive

activities for youth and theoretically reduce their

involvement in antisocial activity (45). Although

organized sports may have tremendous potential for

promoting competence and preventing delinquency

(56,8 1,337), this potential has never been systematically assessed. A few studies have shown a relationship between participation in organized athletic

programs and lower levels of delinquent activity,

particularly for working class boys (356,363).

Secondary Prevention of Delinquency

Secondary prevention of adolescents for delinquency means attempting to keep adolescents who

have already shown indications of troublesome

behavior (e.g., school problems) from engaging in

delinquent acts such as theft or assault. (The

distinction between secondary prevention programs

and treatment programs may at times be arbitrary

because the populations enrolled in some programs

are sometimes heterogeneous. In any one program,

some participants may only have indications of

troublesome behavior, while others may have committed delinquent acts. Some programs that target

adolescents with self-reported delinquency and official delinquency-for example, some diversion

programs-are discussed in the section on treatment

programs below.)

85~eSe ~roPS -~So & ~~nsidcred Secon&q prevention ~teNention5, because some of tie attend~s are adolescents at high risk of delinquency

(e.g., adolescents who have school problems or adolescents who have committed one or more delinquent acts).
II-624 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Vocational and Alternative Education Programs86

Hope for vocational training and other alternatives to traditional school programs is based on the

consistent finding that adolescents with behavior

problems are frequently doing poorly in school, are

not engaged by common classroom procedures, and

are lacking in job-related skills (172,382). Evidence

from a number of evaluations shows that when

vocational education programs carefully integrate

classroom and work experience, are perceived by

students as being relevant to their interests, and are

closely monitored, the programs reduce school

dropout rates and increase learning and school

attendance among adolescents at high risk of delinquency (168).

For the most part, the direct effect of the

vocational and alternative education programs on

delinquency has not been evaluated.87 Exceptions

include a series of rigorous followup studies of male

adolescents who had just been expelled or dropped

out of high school and then received a comprehensive intervention that combined job placement,

remedial education, and psychotherapy. All aspects

of the intervention were administered by one therapist. Services, which began 24 hours after the males

left school, were individualized, intensive, and

flexible as to time, place, and activity (277,375,376,

377,378). Data from these followup studies showed

that recipients of this vocational and psychotherapeutic

intervention had adjusted well in terms of employment, schooling, and marital status, and that delinquency was clearly lower among these adolescents

than among adolescents in a control group. Even

after 15 years, the males who had received the

treatment showed much better social adaptation with

respect to family life, employment success, and

avoidance of legal difficulties than those in the

control group. The generalizability of the studies is

limited, however, because the researchers compared

only 10 participants with 10 control adolescents and

used a very talented therapist. Nonetheless, this

study is unique in illustrating that long-term effects

are possible and suggesting the importance of

multiple components of treatment.

Family Therapy and Family Communication

Skills Training

Family therapy and family communication skills

training has been found to be effective in reducing

problem behaviors among conduct-disordered children of treated families (2,32,144,235,236,3 14). The

effects are maintained up to 1 year and occasionally

longer, and programs have been found to be effective

among children with conduct problems varying in

severity of dysfunction (235).

Family therapy and family communication skills

training does have several limitations. One is that it

is not effective for some types of children and

parents-e. g., parents who are dysfunctional or

parents who have reached the limits in coping with

a child with a conduct disorder (235). Furthermore,

the method has yet to demonstrate either a long-

-lasting effect on delinquent behavior or success with

severely antisocial adolescents.

Summary: The Ef..ectiveness of Adolescent

Delinquency Prevention Efforts

Although efforts at primary prevention of delinquency are relatively new, recent research has

provided some evidence that primary prevention

programs at an early age may have an enduring

effect in terms of reducing delinquent behavior in

early adolescence. For any given approach, the

evidence on effectiveness is inconclusive and at

times indirect, but the cumulative evidence from a

variety of approaches—parent training programs,

family support interventions, and school-based interventions-is encouraging. There are, however,

too few controlled trials to draw definitive conclusions. Given what we know about the complex,

socially embedded nature of delinquency and the

realities of service provision, it is unreasonable to

expect that any single preventive approach would be

uniformly applicable and efficacious.

The overall record of strategies for efforts at

secondary prevention of delinquency is less impressive. One intensive and flexible vocationally oriented program that included psychotherapy, remedial education, and job placement clearly reduced

86For ~ ~u~~ion of ~~h~~l~ ~d ad~]e~ent h~~ ~~ ~h. 4, “S~hool~ ~d Discretio~ Time, >$ in ~~ “~l~e.

87For ~xmple, ~~er ~temtive Proum such ~ ci~ L@ts in w~~gtom ~ (397a) md & Phoenix PrograxI in AILN)Q OhiO (290) appear to

be successful in involving failing students with behavior problems, but have not been evaluated in academic and vocational mining programs, correcting

their educational problems, or reducing behavioral problems. Preliminary evaluations indicate success in increasing the school attendance rate of failing

students and the Phoenix Program has shown a decline in recidivism rates (290).
Chapter 13—Delinquency: Prevention and Services . II-625

Photo credit: Education Week

Adolescents who do well seem to have strong and

developmentally appropriate social support, preferably

from their families, but if not from their families, from some

other adult or adults.

delinquency in the long term (375,377). The quality

of the findings suggests that such programs may be

a promising way to prevent delinquent behavior, but

the program that was evaluated had a very small

sample size, which hinders application of findings to

other populations. Promising early evidence suggest

that organizations providing multiple elements—

e.g., advocacy, mentoring, nutrition, social support,

employment training, and/or employment placement to high-risk adolescents—result in multiple

advantages to high-risk youth. These advantages

include less involvement with delinquency than

similar high-risk adolescents (290). However, more

scientifically rigorous evidence is needed for definitive conclusions about the effectiveness of these

interventions in preventing adolescent delinquency.

Following their review of prevention programs on

behalf of OTA, Mulvey and his colleagues concluded that three general lessons can be drawn (290).

One lesson is that policymakers at all levels should

seriously plan for service provision as an ongoing,

rather than ‘‘one shot, ’ enterprise. For adolescents

who appear to have an identifiable propensity for

antisocial behavior, interventions should be conceptualized as a series of possible treatments for a

problem that is likely to appear again in a different

form as the adolescent becomes older and new issues

and challenges arise.

A second major lesson would seem to be that

successful prevention programs appear to take a

broadly based approach, addressing behavior in its

social context. Because delinquency is not unidimensional or independent of a variety of social

forces, interventions must address multiple issues of

the youth’s family, school, and peer life to show any

real progress. There is little evidence that any

service, regardless of its modality or theoretical

rationale, can produce impressive results when

applied in isolation. Early intervention programs

that provide comprehensive care to families, cognitive behavioral curriculums that are coupled with

changes in the school environment, and individual

interventions that work with the adolescents’ home,

school, and peer environment appear to provide

more impressive results than programs that are

focused on a single facet of an adolescent’s life.

The third clear lesson is that preventive services

(e.g., family support services) are not delivered

uniformly and that it is counterproductive to continue to evaluate them as if this were true. Comparing services only according to their avowed theoretical approach or stated program type appears to be a

task with limited return. Better measures of particular program dimensions independent of theoretical

justification or basic program type (such as intensity

or comprehensiveness of service delivery) as well as

operational measures of program operation are

clearly needed.

Services and Interventions for

Adolescents in the Juvenile

Justice System88

The source of almost all services and interventions explicitly aimed at reducing adolescent delinquency once it has been officially detected is the

juvenile justice system, which includes law enforceas~s discussion is based partially on a paper entitled ‘ ‘Review of Programs for the Prevention and Treatment of Delinquency, ’ w~ch was PreP~~

under contract for OTA by Edward Mulvcy, Michael A. Arthur, and N. Dickon Repucci (290), and on a paper entitled “Juvenile Justice: A CritiC~

Examination’ prepared by B. Krisberg under contract to the Carnegie Corporation of New York and the Carnegie Council on Adolescent Development

in support of the OTA study on adolescent health (246).
II-626 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Table 13-12-Age at Which Criminal Courts in

Different States Gain Jurisdiction of Young Offenders

Age of offender

when under criminal

court jurisdiction States

16 years . . . . . . . . . . . . .

17 years . . . . . . . . . . . . .

18 years . . . . . . . . . . . . .

19 years . . . . . . . . . . . . .

Connecticut, New York, North Carolina

Georgia Illinois, Louisiana, Massachusetts, Missouri, South Carolina, Texas

Alabama, Alaska, Arizona, Arkansas, California, Colorado, Delaware, District of

Columbia, Florida, Hawaii, Idaho, lndiana, lowa, Kansas, Kentucky, Maine,

Maryland, Michigan, Minnesota, Mississippi, Montana, Nebraska, Nevada, New

Hampshire, New Jersey, New Mexico,

North Dakota, Ohio, Oklahoma, Oregon,

Pennsylvania, Rhode Island, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Federal districts

Wyoming

SOURCE: L.A. Szymanski, “Upper Age of Juvenile Court Jurisdiction

Statutes Analysis,” National Center for Juvenile Justice, Pittsburgh, PA, March 1987.

ment officers and others who refer delinquent and

maltreated juveniles to the courts, juvenile courts

which apply sanctions for delinquent offenses and

oversee the execution of child protective services,

juvenile detention and correctional facilities, and

agencies that provide protective services and care

(e.g., foster care) for juvenile victims of abuse and

neglect. The discussion that follows focuses primarily on the handling of adolescents by juvenile courts

and juvenile detention and correctional facilities.

What Is the Juvenile Justice System?

The juvenile justice system is actually 50 distinct

statewide juvenile justice systems, State statutes that

establish the legal authority for the delivery of

juvenile justice services vary widely from State to

State. The upper age of juvenile court jurisdiction

differs from State to State (see table 13-12), as does

the scope of misconduct leading to juvenile court

intervention (see table 13-1 3). Washington State, for

example, excludes status offenses from court authority, whereas States such as California merely limit

the range of sanctions to be used with status

Table 13-13-Reasons for Referral of Delinquency

Cases to Juvenile Courts, 1987

Reasons for referral Number of cases Percentage

Serious violent offensea 

. . . . . . . . .

Murder and nonnegligent

manslaughter . . . . . . . . . . . . . .

Forcible rape . . . . . . . . . . . . . . . .

Robbery . . . . . . . . . . . . . . . . . . . . .

Aggravated assault . . . . . . . . . .

Serious property offensea 

. . . . . . .

Burglary . . . . . . . . . . . . . . . . . . . . .

Larceny-theft . . . . . . . . . . . . . . . . .

Motor vehicle theft . . . . . . . . . . . .

Arson . . . . . . . . . . . . . . . . . . . . . . .

Minor delinquent offenseb . . . . . . .

Simple assault . . . . . . . . . . . . . . .

Stolen property offenses, ,.,..

Trespassing . . . . . . . . . . . . . . . . . .

Vandalism. . . . . . . . . . . . . . . . . . .

Weapons offenses . . . . . . . . . . .

Other sex offenses . . . . . . . . . . .

Drug law violations . . . . . . . . . . .

Obstruction of justice . . . . . . . . .

Liquor law violations. . . . . . . . . .

Disorderly conduct . . . . . . . . . . .

Other delinquent acts . . . . . . . . .

Total delinquency . . . . . . . . . . . . . .

64,000

1,500

4,000

21,500

37,400

498,000

131,700

311,600

48,600

6,100

583,000

99,700

27,900

50,200

84,300

20,000

18,200

73,700

80,900

16,300

47,800

63,700

1,145,000

5.6°A

0.1

0.3

1.9

3.3

43.5

11.5

27.2

4.2

0.5

50.9

8.7

2.4

4.4

7.4

1.7

1.6

6.4

“7.1

1.4

4.2

5.6

100.0

NOTE: Detail may not add to total because of rounding.

asetious offenses are Federal Bureau of Investigation Part 10ffWWeS (i.e.,

murder and nonnegligent manslaughter, forcible rape, robbery, aggravated assault, burglary, Iarcenyflheft, motor vehicle theft, and arson).

Individual Part I offenses may not be considered serious by other

definitions, however.

bMinor offenses are Federal Bureau of Investigation Part II Of fWW3S.

Individual Part II offenses may not be considered minor by other

definitions, however.

SOURCE: H.N. Snyder, T.A. Finnegan, E.H. Nimich, et al., prepublication

draft of “Juvenile Court Statistics, 1987,” National Center for

Juvenile Justice, Pittsburgh, PA, 1990.

offenders (246). Some States have Ml-time juvenile

court judges, whereas others rotate judges in and out

of juvenile court assignments. Juvenile court judges

vary dramatically in their legislatively mandated

powers and the extent of their judicial training and

experience (35 1).

The manner in which most juvenile courts process

delinquency cases is illustrated in figure 13-12 in

simplified form (388). Police are the primary source

of referrals to the juvenile court, 89 but school

authorities, social welfare agencies,90 and parents

8~e police me me ~iti~ decision about adolescents whom hey have r~o~ed u commining offenses. h some ]ocd~ vh_hldy ~, ad kl OdltWS

only half, the young people stopped by the police are arrested (453,458). Police may informally warn and verbally rep rimand adokscents who they do

not arrest, or they may refer them to nonjudicial agencies (e.g., youth service bureaus and community-based organizations) or to their guardians.

W~ some cases, ~ adole~cent is a del@uent, ~ abused c~ld, a you~ ti need of spcci~ education services, arfda welfare recipient. Such adolescents

may be referred to juvenile courts, despite other needs that maybe more pressing. Social service agencies may adopt selection criteria that exclude clients,

particularly older adolescents with histories of mental illness and aggressive behavior. However, public correctional agencies cannot refuse lo take

custody of adolescents lawfully committed to their care.
Chapter 13—Delinquency: Prevention and Services . II-627

Figure 13-12-Juvenile Court Processing of Delinquency Cases, 1987

Police

958,000 840/o

a

Petitioned a

531,000 460/0

Placement

2,000<1 “/0

I Probation

}L&!?N&’

Waived b

11,000 20/0

Adjudicated c

Placement

99,000 300/0

1 Probation

I 191,00057’%0

333,000 630/. Other

28,000 90/o

m,

I I Placement

Nonadjudicated 3,000 20/0

187,000 350/o Probation

44,000 240/o

r

Other

23,000 120/0

Dismissed

116,000 620/.

I I I I

Source of I Intake I Intake I Judicial I Judicial

referral decision disposition decision disposition

aA petition is filing a document in j~enile court alleging that a juvenile is a delinquent, a status offender, or dependent.

A petition requests that the court assume jurisdiction over the juvenile or that the juvenile be transferred to criminal

court for prosecution as an adult.

bA waived ~s.e is One that is transferred to the criminal COIJrt.

CAn adjudicat~ case is one in which the court has eflterOd a judgment.

SOURCE: H.N. Snyder, T.A. Finnegan, E.H. Himick, et al., prepublication draft of “Juvenile Court Statistics, 1987,”

National Center for J

also refer cases.

91 Between referral and court intake delinquency petition. Of formally petitioned cases, ,

some delinquency cases (20 percent in 1987) are 35 percent are either dismissed or handled without a

held in detention facilities (388). At court intake, an juvenile court adjudication hearing and 63 percent

intake officer makes a decision about whether or not have a juvenile court adjudication hearing. As figure

to file a delinquency petition (i.e., to process the case 13-12 shows, the possible dispositions of adjudiformally by the courts). About half the cases (54 cated or nonadjudicated cases are similar to nonpeti- percent in 1987) are handled informally at the intake

level and the adolescent is dismissed, referred to tioned cases, except that a small number of nonadjudicated cases, generally cases involving the most social service agencies, placed on probation, or

placed in secure confinement (388). Intake officers serious offenses, receive special hearings and are

also recommend to judges whether adolescents transferred or waived to the *al court system.

should be detained pending their case being heard by

a judge. The juvenile courts tend to use informal, diversionary case dispositions. In 1987, only 30 percent

At the next stage, judges or their designated of the delinquency cases referred to the courts

assistants (referees) decide on the legal merits of the resulted in formal adjudication and only 9 percent

91~e data ~ thiS ~d he Succeed@ S~ti~~ we my f~m a nonprobabili[y s~ple of 1,]33 COUftS wim jurisdiction Ova rOUg~y 49 perCent Of

the Nation’s at-risk youth population-the National Juvenile Court Data Archives (388). The National Juvenile Court Data Archives uses a complex

weighting procedure to generate national estimates based on data from the reporting jurisdictions. Because the data are not based on a probability sample,

the sampling error or confidence intervals around the statistics presented are unknown.
II-628 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

ended with a placement in a private or public

residential facility.

Who Are the Adolescents in the Juvenile

Justice System?

Adolescents Referred to the Juvenile Courts

Adolescents may be referred to the juvenile courts

for delinquent offenses or because they are victims

of neglect or abuse (418).92 Those referred for

delinquent offenses are usually referred by the

police. Not surprisingly, therefore, the numbers and

types of delinquency offenses for which juveniles

are arrested are similar to the numbers and types of

offenses for which adolescents are referred to the

juvenile courts.93 In 1987, for example, serious

violent offenses made up only a small fraction of

delinquency offenses for which juveniles were

arrested or referred to the court; serious property

offenses made up a larger fraction; and minor

offenses made up the largest fraction (see table

13-1 3).94

Juveniles referred to juvenile courts for delinquent behavior are demographically similar to

juveniles who are arrested. In 1987, for example, the

overall delinquency case rate95 and overall arrest

rates increased consistently from 10 years of age up

to 17 years of age, with drug law violation cases

showing the sharpest increase in the older age

groups (388).96 The delinquency case rate was much

higher for males than for females for all categories

of delinquent offenses. Females received less severe

dispositions than male adolescents who are arrested

for similar delinquency offenses (136,387,396). In

contrast, females who are arrested for status offenses

receive harsher punishment than male status offenders (65,252,374).

Racial differentials in overall delinquency case

rates are similar to those in arrest rates. In 1987, for

example, the delinquency case rate for nonwhites

was 76 percent higher than the rate for whites, with

the greatest difference (209 percent higher) in

offenses against persons (388). Differences in socioeconomic status and family structure have also been

found among adolescents processed by the courts.

State and local studies have reported that most

court-processed adolescents come from lowincome, female-headed households (247,387,458).

Several observers have expressed concern that the

juvenile courts appear to handle nonwhite adolescents much more harshly than their white counterparts. The majority of delinquency cases involving

white juveniles are handled informally (i.e., ‘‘not

petitioned”), while the majority of cases involving

nonwhite juveniles are handled formally (i.e., ‘ ‘petitioned’ (388). Furthermore, delinquency cases

involving nonwhite juveniles are more likely to be

waived to criminal court than are delinquency cases

involving whites (428). It is important to note that no

one has conducted an analysis of differential referral

patterns that takes into account different levels of the

seriousness of the offense. As noted above, arrested

black adolescents have been found to commit

somewhat more serious offenses than white adolescents. It is unclear whether the level of seriousness

would totally account for the differences in treatment by the juvenile courts.97

WFor adiscussion of m~treated adolescents and the existing child welfare semices, seech. 3, ‘‘Parents and Families’ Influence on AdolescentHealth,’

in this volume.

93~e ~W~rs me not identim], ~ ~~ ~cause the upper age of juve~e cow j~sdiction is defined by s~tute b each State. h some States, the

upper age of juvenile court jurisdiction is 16 years of age. Thus, while arrest data maintained by the U.S. Department of Justice, Federal Bureau of

Investigation includes mests for all 17-year-olds, not all 17-year-olds are under juvenile court jurisdiction. In 1987, 1,520,325 adolescents from 10 to

17 years of age were arrested for delinquent offenses, but only 1,145,000 delinquency cases of adolescents 10 years of age and over were processed in

courts with juvenile jurisdiction (41 O).

%In 19g5, tie ~actionof s~~s Offemes Cmes ~dled by the Nation’s juve~e co~ was about twice as high m the fraction of serious ViOlent OffellSeS

handled (425).

9S~e deflnquency ~a~e ~are is the n~~r of del~uen~ cues ~r 1,000 adolescents age 10 or above who raided in the United States ad were ~der

the jurisdiction of a juvenile court. It is important to note that these data do not include status offenses (388).

%~ 1985, the ~~ age for refem~ of delinquency Offemes Wm 17, but tie p@ age for referr~ for s~~s offenses WM 15 md decreased for older

adolescents (425). This age-spec~lc pattern may reflect juvenile justice practices more than adolescent behavior. Juvenile justice ofllcia.ls often use status

offense labels to deal with the minor delinquency of younger adolescents. Similar misconduct by older adolescents may be treated as delinquent

violations. Also, the juvenile justice system is less willing to intercede in family or school conflicts as adolescents approach the age when they can legally

leave school or their families.

mR~i~ ~d e~c differences in institutionalization patterns are discussed bdow.
Chapter 13—Delinquency: Prevention and Services . 1/-629

Adolescents in Juvenile Detention and

Correctional Facilities

Types of Juvenile Justice Facilities—As noted

in box 13-A, custodial facilities for juvenile offenders (and other minors under the jurisdiction of the

juvenile or family courts98) can be classified along

several, often overlapping dimensions that include

purpose, term of stay, type of environment (institutional or open), and sponsorship (public or private)

(424,428).

Juvenile detention facilities, which are usually

called juvenile detention centers or juvenile halls,

typically hold juveniles who have been arrested for

short periods prior to adjudication (424). Such

facilities may also be used for juveniles who have

been found to be delinquent and are awaiting transfer

to long-term placements or who have been sentenced

to short periods of confinement (424). Juvenile

detention facilities typically provide a physically

restrictive environment. Shelters are usually shortterm facilities that hold juveniles who are awaiting

transfer to other placements, but they offer an

environment that is not physically restricted.

Juvenile correctional facilities are facilities for

the commitment and supervision and treatment of

juvenile offenders whose cases have been adjudicated (424). Long-term residential facilities that

serve adolescent offenders (and other adolescents)

range from training schools, which typically have

strict physical and staff controls, to facilities such as

ranches, forestry camps or farms, halfway houses,

and group homes. Ranches and forestry camps or

farms tend to be less restrictive than training schools,

and residents in halfway houses or group homes are

allowed extensive access to community resources

(424).

Juvenile facilities that have institutional environments typically impose restraints on residents’

movements and limit access to the community.

Juvenile facilities that have open environments

allow greater movement of residents and more

access to the community (428). Public juvenile

facilities are under the direct administration and

operational control of a State or local government

and staffed by governmental employees. Private

facilities are either profitmaking or nonprofit and

subject to governmental licensing but under the

direct administrative and operational control of

private enterprise; these facilities may receive substantial public funding in addition to support from

private sources (428).

Number of Adolescents in Juvenile Justice

Facilities-In the course of a year, about 700,000

adolescents are confined to public and private

juvenile justice facilities (418,424).9 In addition

there are about 479,000 juveniles in adult jails, some

because they were waived to adult criminal court

(254,43 1). The vast majority (83 percent) of adolescents in all juvenile facilities are incarcerated for

nonviolent offenses (79).

Most of the adolescents in public juvenile facilities are in custody for delinquent offenses. About 90

percent (94 percent in 1987) of the adolescents who

are in public juvenile facilities are in custody for

offenses that would be considered crimes if committed by an adult (418). Most of the rest (5 percent) are

held in custody for status offenses such as running

away or buying liquor. A very small percentage (1

percent) are held in public juvenile facilities because

they were dependent, neglected, or abused juveniles

or emotionally disturbed or mentally retarded juveniles over whom a juvenile court assumed jurisdiction to ensure adequate care, or because, without

having been adjudicated by a court, they were

referred as ‘‘voluntary admissions’ to the facility by

parents, school, or a social agency (418,424).

Private juvenile facilities serve a somewhat different population. A little more than half (55

percent) of the adolescents in private juvenile

facilities are in custody for delinquent offenses

(about 34 percent for delinquent offenses that would

be considered crimes if committed by an adult and

about 21 percent for status offenses). Almost all of

the remaining 45 percent of the adolescents in

private facilities are dependent, abused, neglected,

98~orS my & ~dcr the j~~diction of@ ~ufl~ for re~$om ~elated to juvenile del~quency, for example, ~ause hey Mve been abandoned,

neglected, or abused by their parents. Juvenile facilities may also be used for minors who are mentally disturbed or mentally retarded, as well as minors

who are admitted by their parents or a social agency as ‘‘voluntary admissions’ (418).

991n 1987, ~ estfiated 590,000 juve~les were placed in public juvenile detention and co~ctional facilities, and perhaps ~otier 115,000 ill private

facilities (446). This statistic is difficult to correlate with m-rests (1,520,325) and referrals to juvenile court (1,145,000) for the same year. The statistics

on arrests and referrals to juvenile court pertain to offenses, and the statistics on facilities refer to intakes regardless of the number of offenses committed

by any individual, or whether any individual has been admitted multiple times. In additiou adolescents maybe detained in juvenile facilities prior to

or after the disposition of their cases in the juvenile court.
11-630. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

emotionally disturbed, or other minors over whom a

juvenile court has assumed jurisdiction to ensure

adequate care (429).

Trends in the Population Makeup of Juvenile

Justice Facilities-Between 1977 and 1987, there

was a 43-percent increase in custody rates in public

and private juvenile justice facilities combined (see

table 13-14).

A change also appears to be occurring in the

population makeup of juvenile facilities. Although

the number of juveniles in both public and private

facilities increased from 1985 to 1987, data taken on

a single census day in 1985, 1986, and 1987,100

suggest that the number of juveniles held for serious

(index) violent and property offenses has decreased

(418,428). 101 The number of adolescents held in

public and private juvenile facilities for offenses

other than serious violent or property offenses,

particularly alcohol- or drug-related offenses, increased 36 percent and 50 percent, respectively,

from 1985 to 1987 (418,428).

Demographic Characteristics of Adolescents in

Juvenile Justice Facilities--The demographic characteristics of adolescents in juvenile facilities correspond to those of adolescents arrested and to those

of adolescents referred to juvenile court. Adolescents ages 14 to 17 makeup by far the largest number

of juveniles held in public and private juvenile

facilities (429). The vast majority of adolescents in

juvenile facilities for offenses that would be a crime

if committed by an adult are males (89 percent). The

majority of adolescents in custody in public facilities

for status offenses are females (418); the majority of

adolescents in private facilities for status offenses

are males (428).

Nonwhite adolescents are disproportionately represented in both public and private juvenile justice

facilities, but the discrepancy is greater in public

facilities. On census day in 1987, almost 60 percent

of the 53,503 juveniles in custody in public juvenile

facilities were nonwhite or Hispanic, including 39

percent who were black (but not Hispanic), 15

percent who were Hispanic, and 3 percent who were

of other racial or ethnic minority origins (see figure

Table 13-14-Juveniles in Custody in Public and

Private Juvenile Detention, Correctional, and Shelter

Facilities, 1977-87a

Number of juveniles Percent in custody/100,000 juveniles change

1977 1979 1983 1985 1987 1977-87

U.S. total . . . . . . . 247 251 290 313 353 +43%

Public . . . . . . . . . 149 151 176 185 208 +40%

Private . . . . . . . . . 98 100 114 128 145 +48%

aRate9 aremmWt~forjWeniles ages 10tothe upper age ofjuvenilecourt

jurisdiction in eaeh State.

SOURCE: B. Krisberg, T. Thornberry, and J. Austin, Juvem’/es Taken Mo

Custody.’ Developing Natiorra/ Stafisks (San Francisco, CA:

National Council of Crime and Delinquency, 1989).

13-13). By comparison, less than 40 percent of the

38,143 juveniles in private facilities on census day

in 1987 were nonwhite or Hispanic (see figure

13-14).

Nonwhite and Hispanic juveniles in public juvenile facilities were more likely to be placed in

institutional environments than in open environments (see figure 13- 13). Furthermore, there was a

15-percent increase in the number of black adolescents and a 20-percent increase in the number of

Hispanic adolescents held in public juvenile facilities from 1985 to 1987 (418).

Researchers have not been able to estimate

precisely the possibly differential effects of adolescent behavior and system processing in producing

the disproportionate nonwhite and Hispanic presence in the juvenile justice system. Socioeconomic

status, family, and community variables may also be

factors. Although prejudiced justice system workers

may be in part responsible, more subtle and intractable forces may also be at work. Real and perceived

differences about the existence of community-based

alternatives for inner-city adolescents, the strength

of family supervision, and the extent of gang activity

and drug trafficking in minority communities might

lead some court officials to place adolescents out of

their homes for reasons of child protection rather

than for punitive purposes (246).

In sum, a juvenile held in a public juvenile justice

facility-- short- or long-term, detention or correcl~e Cemus &y is tie day on which the U.S. Bureau of tie Census .wuveys more than 3,500 public and private institutions that provide custody and

care for adolescents (41 8).

IOl~e de~line ~ppem unu~u~ s~ce the nw~r of ~ests for se~ous violent ~d serious prope~ offe~es incr~ed from 1983 to 1987, and from

1985 to 1987, However the two sets of data are incomparable. As noted earlier, arrest data describe number of offenses, and data on juveniles in f’aeilities

describe number of people. In additio~ the trend data cited on juveniles in facilities are derived ffom one census day, unlike the arrest data which are

derived from an annual report.
Chapter 13—Delinquency: Prevention and Services . II-631

Figure 13-13—Distribution of Juveniles in Public Juvenile Justice Facilities on Census Day

by Racial and Ethnic Groupa b

Total public facilities Public facilities with

institutional environments

in 1987,

Black (non-Hispanlc) Black

39%

e

\ Hispanic Hlspanic

(black y:: white) ‘~(black and white)

I

16%

‘~ Other nonwhite

White (non-Hispanic)

44%

3%

‘ \ \

White ‘ ‘- --

(non-Hispanic)

41%

‘~ Other nonwhite

3%

Public facilities with

open environments

Black

(non-Hispanic)

m

Hispanic

34% ., (black and white)

\ ,

10%

Other nonwhite

3%

i

I \ //

\

White’” -- -”

(non-Hispanic)

52%

aThe total population in public juvenile justice facilities on census day 1987 was 53,503. More than 90 percent of the juveniles in pubficjuvenile jUSt ice facilities

are in custody for delinquent offenses (see text).

bA~ording to the office of Juvenile Justi@ and Delinquency Prevention, the vast majority (91 percent) of admissions to public juvenile facilities in 1987 were

to facilities with institutional rather than open environments; 67 percent of admissions to public juvenile facilities were to long-term facilities and 33 percent

were to short-term facilities.

SOURCE: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention, “Children in Custody: Public Juvenile

Facilities, 1987,” Juvenile Justice Bulletin, October 196S.

tional, in an institutional or open environment-is

likely to be from 14 to 17 years of age, male, from

a minority group, and held for committing a

delinquent offense that would have been a crime if

committed by an adult, most likely a serious

property offense (418). A juvenile held in a private

juvenile justice facility-short- or long-term, detention or correctional, in an institutional or open

environment—is likely to be from 14 to 17 years of

age, male, white, and held for committing a status

offense or for reasons unrelated to delinquency

(428).

The attributes of juveniles in long-term public

juvenile facilities are somewhat different. An adolescent offender in a long-term public juvenile

justice facility is likely to be from 15 to 17 years of

, .

age, male, white, and held for committing a serious

property offense (417). The majority of adolescents

under age 18 placed in long-term public juvenile

facilities for serious property offenses are white, but

the majority of adolescents held for serious violent

offenses are black (417). Very few, indeed only 2

percent of those under age 18, are held in long-term

public juvenile facilities for status offenses. In

addition, the adolescent in a long-term public

facility is likely to either have a seventh or eighth

grade education or have completed only some high

school, to have lived only with his mother while

growing up, to have had a family member incarcerated at some time, to have previously been on

probation, and to have been committed to a correctional institution at least once in the past (417).
II-632 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Figure 13-14-Distribution of Juveniles in Private

Juvenile Justice Facilities on Census Day in 1987,

by Racial and Ethnic Groupa b

Black

(non-Hispanic)

, / 27%

/’

(m

Hispanic

(black and white)

~hi~e~

(non-Hispanic)

63%

aThe totai po~lation in private juvenile justice facilities on census day in

1987 was 38,143. A little more than half of the juveniles in private juvenile

justice faalities are in custody for delinquent offenses (see text).

bA~ording to the offi~ of Juvenile Justice and Delinquency Prevention,

the great majority (82 percent) of admissions to private juvenile justice

facilities in 1987 were to facilities with open rather than institutional

environments; 59 percent of admissions to private facilities were to

long-term facilities and 40 percent were to short-term facilities. Racial and

ethnic breakdowns by type of private facility are not available.

SOURCE: U.S. Department of Justice, Office of Justice Programs, Office

of Juvenile Justice and Delinquency Prevention, Children in

Custody, 1987: A Comparison of Pubk and Private Juvenile

Custody Facilities, prepublication draft, Washington, DC, 1989.

The Effectiveness of the Juvenile

Justice System

The aims of the juvenile justice system—though

the systems in each State vary-are

the protection and safety of the public

for the protection of the best interest

under the jurisdiction of the court.

In the case of juvenile offenders,

contending ideologies that underlie

to provide for

and to provide

of each minor

there are two

efforts to advance these aims-treatmentl02 and punishment. In

theory, the juvenile justice system is based on the

notions that juveniles are more capable of reform

and less responsible for their actions than adults.

Consequently, the concept of retribution and punishment might be expected to be less pronounced in the

juvenile justice system than it is in the adult criminal

justice system.

In practice, it would appear that services based on

both treatment and punishment are used to varying

degrees in most State juvenile justice systems, but

little information is available on the specific services

provided, particularly in institutional juvenile facilities. The disparity in ideologies and the need to

balance them has led to disagreement on exactly

what should be measured to evaluate the effectiveness of the system in general and the effectiveness of

specific treatment interventions, as well as about the

most appropriate measurement techniques.

In the discussion that follows, OTA has considered three measures in evaluating the effectiveness

of the juvenile justice system as a whole:

. effects on adolescents while they are in the

juvenile justice system;

. effects on the public while adolescent offenders

are in custody;

. effects on the public and adolescent offenders

after adolescent offenders leave the system.

As noted earlier, the focus of this discussion is the

juvenile courts and juvenile detention and correction

facilities.

Effects on Adolescents While They Are in the

Juvenile Justice System

To what extent are the best interests of adolescents protected during the period they are in the

juvenile justice system? This question can be

answered by considering two measures:

● sensitivity to adolescents’ developmental status

and

● protection of legal rights.

The extent to which the juvenile justice systemin particular, juvenile courts and juvenile detention

and correctional facilities-exhibits sensitivity to

the developmental status of adolescents during the

processing of cases varies. The juvenile court can be

said to be effective in protecting the best interests of

adolescents who have not reached the age of

majority in that its central premise is that juveniles

should be treated differently from adults. The

juvenile court’s jurisprudence assumes that juveniles possess somewhat less responsibility for their

actions than adults (467) and thus often handles

cases involving juveniles on an informal basis

(388,415). Nonetheless, the juvenile justice system

today is more formal and punitive in its treatment of

adolescent offenders than it was 20 years ago. From

the early 1970s to 1987, the proportion of adolescents referred to court after being taken into custody

loz~e te~ treatment and rehabilitation are often used synonymously in he criminology literature. From some perspectives, of course, punishment

is also rehabilitative.
Chapter 13—Delinquency: Prevention and Services . //-633

by the police increased from about 50 percent to 62

percent, the use of diversion and probation declined,

and the proportion of juveniles arrested and referred

to adult courts rose from 1 percent to 5 percent

(250,409). Furthermore, juvenile confinement rates

(i.e., the number of juveniles in custody per 100,000

juveniles) increased by 43 percent between 1977 and

1987 (see table 13-14).

The processing of cases in the juvenile justice

system does not operate with a consistent understanding of adolescent development. In general,

younger adolescents (usually below age 13) are less

likely to be detained or placed out of their homes

than their older counterparts (387). Status offenders

are an exception. Younger status offenders are

slightly more likely to be held or placed out of their

homes than older status offenders, which may reflect

the court’s child protection philosophy. The age at

which the death penalty can apply to a juvenile,

however, remains controversial.103

State juvenile justice systems vary in the extent to

which they manage adolescents on the basis of age

or maturity. In as many as 20 States, juveniles

awaiting adjudication continue to be held in adult

jails despite a Federal mandate in the Juvenile

Justice and Delinquency Prevention Act of 1974 that

juveniles be held in separate facilities (392).l04 Once

their cases have been adjudicated, juveniles can be

housed separately from adults (e.g., Illinois) or

mixed with adult offenders (e.g., Texas), and juveniles who are being tried as adults can be placed in

a juvenile facility (e.g., Illinois) or in an adult jail

(e.g., California). Adolescents held in adult facilities

are often physically and sexually abused by inmates

and staff (254), and suicide rates among adolescents

in jails are higher than for adolescents held in

juvenile facilities (360). Thus, it is important for

adolescents to be held in juvenile rather than adult

facilities.

Whether the juvenile justice system is effective in

protecting the legal rights of adolescents awaiting

adjudication is problematic (130). Some adolescents

lack access to appropriate counsel,105 closed hearings may not be protective,106 and the quality of

some juvenile court judges has been questioned (see

246).

Whether the juvenile justice system protects

adolescents who have been adjudicated delinquent

and institutionalized in juvenile facilities is also

problematic. Despite years of litigation pertaining to

the issue, adolescent offenders’ right to treatment,

i.e., benefits, assistance, and therapeutic programs,

remains unsettled (254).107 Thus, it is not surprising

that, as discussed in detail later, the juvenile justice

system has not been effective in providing necessary

health services to adolescent offenders with preexisting problems or in preventing the development of

additional health conditions, It is also questionable

whether educational services provided to adolescents in juvenile facilities are adequate (254).

Effects on the Public While Adolescent Offenders

Are in Custody

A critical measure of the effectiveness of the

juvenile justice system from the public’s standpoint

is the extent to which the public is protected for the

period that adolescent offenders are in custody in

juvenile detention and correctional facilities. There

are no data on the incapacitative effect of the

juvenile justice system on society at large, but

clearly, those adolescents who are institutionalized

are not able to commit offenses against the noninstitutionalized public.

10JIu Wilkins V. Missouri (57 U.S. Law Weekly 4973) (1989), the U.S. Supreme Court refised tO set a hi@er minimum age for executions than 15,

which was established in an earlier ruling, despite briefs filed by the American Bar Association, the Nationrd Council on Crime and Delinquency, the

Children’s Defense Fund, among others, urging that age 18 should be the constitutional minimum age.

104 State Poficles regwding hold~g juvefiles in ~ult j~ls me hig~y diverse, ~p~because states Vwas to the upper age for juvenile court jurisdiction

(see table 13-12).

IOSMost adolesmnts ~dled by juvefile ~o~ come from low.~come f~ies (245,387,457), ~d they rely heavily on public defenders ad assigned

counsels for legal representation. In appointing public defenders and assigned counsels to adolescents, however, the training and perfO rmance of these

individuals is not always considered (246). Furthermore, many adolescents and their families have been reported to waive their right to any counsel

without full comprehension of the consequences of that decision (176,360).

106Juvefile ~o~ hold closed he~ngs for Cmes ~volv~g adolescents ~ pm to s~eld adolescents fmm negative publicity in high prOflle CWeS. They

have not been particularly successful in doing this and some experts think the hidden nature of juvenile court operations contributes to perceptions that

the court is overly lenient, Where open hearings have been tried, there have been few negative consequences for juveniles (360).

10? AWordlng t.~~fl ad others, mi~~ ~ea~ent ~cludes ‘ ‘tie right to f~edom from ~w~e ti state custody ~d RX@X hilt yOUth be

provided adequate food, shelter, and clothing; academic, vocational and physical educatio~ medical care, social services, and psychiatric services;

supervision by trained staff; recreation, and the opportunity for phone calls and visits” (254).

20; (t j(; ill 21 (Jr, .{
II-634 . Adolescent Health—Volume II Background and the Effectiveness of Selected Prevention and Treatment Services

Concerns about the need to protect the public

from serious violent offenders are probably greater

than concerns about protection from other juvenile

offenders. It is important to recognize, however, that

most serious violent juvenile offenders do not

remain in the juvenile justice system but instead are

more likely to be transferred to adult court for trial

and sentencing (415). From the early 1970s to 1987,

the proportion of juveniles arrested and referred to

adult courts rose from 1 percent to 5 percent (250).

Effects on the Public and Adolescent Offenders After

Offenders Leave the Juvenile Justice System

The juvenile justice system as a whole would be

considered effective for both the public and adolescent offenders if the adolescents leaving the system

were socially well adjusted. Some theorists have

argued that formal adjudication and the threat of

further punishment suppress further delinquent behavior (296); other theorists have claimed that

official processing may actually increase delinquency (444). Neither of these positions has received conclusive empirical support.

Indeed, an evaluation based on the measure of

adolescent offenders’ social adjustment following

release from juvenile detention and correctional

facilities is currently not possible, because few State

juvenile justice systems routinely collect any data on

confined adolescents after they leave the system.

The only data collected currently-and only by

some systems—are data on how many adolescent

offenders receive high school equivalency certificates based on the general educational development

(GED) test, how many hours of community service

are performed, or how much restitution is paid to

victims.

The most common indication that adolescents

who had been in the juvenile justice system are

socially adjusted is lower subsequent delinquency or

criminality as measured by recidivism—that is, the

falling back into delinquent or criminal behavior

after punishment. Recidivism has face validity as a

measure of subsequent delinquency or criminality,

but it is important to note that there is no standard

measure of recidivism. Many measures are used

including rearrest, readjudication, and reincarceration, each of which is a distinctly different outcome

(338). Furthermore, assessing the extent to which

recidivism reflects changes in individuals’ behaviors or in system responses is difficult, if not

impossible (246). Data are limited on all measures

because most State juvenile justice systems do not

routinely collect any type of recidivism information.

Those that do collect such information use measures

of recidivism that are not comparable among jurisdictions.

One of the few empirical studies that collected

data on multiple measures of recidivism had inconclusive results regarding the effectiveness of juvenile justice systems in decreasing subsequent delinquency and criminality of adolescents in juvenile

institutions (25 1). That study collected followup

data on rearrests, reconviction, and reincarcerations

of individuals who had formerly been in the juvenile

justice systems in Massachusetts, Pennsylvania,

Utah, Florida, Texas, Illinois, Wisconsin, and California.

Overall, the followup data indicated that a large

proportion of the individuals who had formerly been

in juvenile justice systems in the aforementioned

States were subsequently arrested. A somewhat

smaller proportion of them were convicted within 12

months, and at least half of them were reincarcerated

within 36 months (251).108 These data suggest that

the effectiveness of the juvenile justice system in

deterring subsequent delinquency and criminality is

questionable.

Several hypotheses have been advanced to explain why many offenders who have been confined

to juvenile institutions appear to improve in terms of

serious delinquency or criminality. One is that court

interventions may have deterrent or rehabilitative

effects (249,296). Another is that the improvements

may be simply statistical artifacts and maturation

effects (274). Self-report data show that the duration

of serious and violent offense careers among adolescents, whether or not the adolescents have been

arrested or confined, is very short (96). At present,

there is insufficient empirical evidence to choose

among these competing hypotheses.

108 Twelve.mon~ fol]oWps of ~emests fo~d tit rates of re~est ranged from I-oughly 50 percent in Massachusetts and Pennsylvania to over 70

percent in California and Utah (251). Rates of reconviction ranged from 43 percent to 53 percent, and a 36-month followup of reincarceration rates showed

wide variation from 25 percent to over 60 percent (251).
Chapter 13—Delinquency: Prevention and Services II-635

The Effectiveness of Specific Treatment

Interventions for Delinquent Adolescents

Interventions for treatment of delinquent adolescents are of two general types:

interventions provided in institutional environments, which tend to greatly restrict residents’

freedom of movement and access to the community (e.g., training schools and ranches), and

interventions provided in community environments or in juvenile facilities with open environments (e.g., shelters, halfway houses, and

group homes) (415).

Available evidence on the effectiveness of specific institutionally based and community-based

treatment interventions for delinquent adolescents is

reviewed below,

Evaluations of the effectiveness of specific treatment interventions for delinquent adolescents exhibit several problems. One problem is that although

most evaluations rely on recidivism as a measure of

the effectiveness of specific interventions, different

evaluations define recidivism in different ways;

numerous evaluations merely report ‘‘success’

rates without defining the term success.

Another problem is that the effects of a specific

treatment intervention on a delinquent adolescent

are often difficult to distinguish from the effects of

other aspects of the adolescent’s involvement in the

juvenile justice system, particularly if an adolescent

has been brought to the point of adjudication.

Still another difficulty in evaluations of the

effectiveness of specific treatment interventions for

delinquent adolescents is that most evaluations

appear to assume, often incorrectly, that juvenile

offenders are a single, homogeneous category (16,

308,346) and that programs that go by the same

general name (e.g., group homes) provide the same

type of service (74,264).l09 The effectiveness of

treatment for delinquent adolescents is believed by

many criminologists to be the result of an interaction

between offender characteristics and treatment types

(295). Evaluations of treatment interventions for

delinquent adolescents would be easier to conduct,

and interpretations clearer, therefore, if treatment

designs matched or tracked the specific type of

treatment with the particular characteristics of the

individual adolescent offender or family.

Institutionally Based Treatment Interventions

Treatment interventions provided for delinquent

adolescents in institutional environments, such as

training schools and ranches, may be used for

adolescent offenders who have been officially adjudicated by a court. Unfortunately, the weight of the

evidence does not lend much support to the idea that

an effective technology of treatment for delinquent

adolescents in institutions has been developed.

There is some indication that institutionally based

treatment interventions that primarily emphasize

comprehensive control and supervision and are

grounded in an ideology of punishment are ineffective at reducing recidivism particularly for very

difficult adolescents (173,174).

Many States also have proposals or programs for

"boot camps"—also known as shock incarceration

programs-to make the time spent in an institution

an unpleasant, but potentially discipline-inducing,

experience. These programs are primarily for young

nonviolent offenders serving time on their frost

felony convention (427a). Evidence for the effectiveness of such programs is anecdotal, and a clear

assessment of their relative value is not possible at

this time. There is some evidence, however, that

boot camp recidivism rates are approximately the

same as these of comparison groups who serve a

longer period of time in a traditional training school

or who serve time on probation (423a).

Whether institutionally based treatment interventions that, for the most part, reject the concept of

punishment and are oriented to treatment of adolescent offenders through psychological change are

effective at reducing recidivism is not known.

Although the question has been studied, the results

to date have been inconclusive. Three rigorous

reviews of such interventions had three different

findings: a finding of little evidence of effectiveness

(253); a finding of an overall positive effect (152);

and a finding that ‘‘appropriate’ correctional treatments are more effective than criminal sanctions,

inappropriate treatment, or unspecified treatment

and that they cut recidivism rates in half on the

109~ere ~ve ken Seveml ~romlS~g ~[[emp~ t. d~ferentiate trees of de~quents ( 1,307,324,327) and dime~ions of pm~ams, but OIdy a few studies

(221) have made any systematic attempt to relate types of delinquents to treatments in terms of effectiveness, and these studies have been

methodologically flawed.
II-636 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

average (14).110 Despite the sophistication and

comprehensiveness of these analyses, it seems that

interpretations of the available data appear to rest as

much on the depth and style of analysis as on the

actual data (295).

There is some evidence that particular rehabilitative treatment strategies provided to adolescent

offenders in institutions are more effective than

others. Overall, studies have found that behavioral

approaches such as point systems, token economies,111 behavioral contracting (14,152,222), cognitive problem-solving and skill development (367),

and family therapy interventions (32) are more

effective in reducing recidivism than are peer group

counseling (169) or individual therapy (152,173).

That evaluations of treatment interventions for

delinquents provided in institutional settings have

not shown particularly impressive results is perhaps

not surprising. Making any treatment intervention

for delinquent adolescents work in an institutional

environment presents a set of formidable challenges

(339). For various reasons, motivating incarcerated

adolescents and staff to participate actively in an

intervention is extremely difficult. One reason is that

the adolescent offenders who are placed in institutional environments are often young people for

whom much else has not worked. Moreover, some

institutional environments have an overwhelming

ethos of social control that can easily compromise

even the most sound approach to behavioral change.

Community-Based Treatment Interventions

Treatment interventions provided for delinquent

adolescents in community environments or in juvenile facilities with open environments (e.g., shelters,

halfway houses, group homes) may be used for

adolescent offenders of various types.

Innovative community-based treatment interventions range from diversion programs, which seek to

limit delinquent adolescents’ involvement with the

juvenile justice system beyond their initial contact

with the police, to variations on standard community

probation, which may entail minimal supervision, to

residential placements, which may differ only slightly

in terms of atmosphere and community access from

institutional placements (74). Adolescents who participate in diversion programs are usually delinquents whose offenses are not severe (i.e., official or

self-reported status offenders or minor offenders).

Most participants in the other types of communitybased treatment programs described below are

official serious and chronic offenders whose cases

have been adjudicated.

Diversion Programs for Delinquent Adolescents112—Diversion programs seek to reduce the

number of juveniles processed by the juvenile

justice system by limiting the number passed into

courts and custodial facilities and limiting the

number at each stage of processing by diverting

juveniles to other social control institutions (e.g., the

family, schools, child service agencies) or communitybased services.

The evidence on the effectiveness of diversion

programs in preventing continued adolescent involvement in the juvenile justice system is mixed.

Several evaluations of diversion programs nationwide have indicated that such programs have had

little effect on subsequent arrest rates of adolescents

in the programs (242,368). A carefully done comparative study of four different diversion programs also

showed no difference between diverted and processed youth on either self-reported or official

delinquency after a year (91). In addition, adolescents who previously would have been warned and

released were diverted into community programs,

paradoxically expanding rather than reducing the

number of juveniles handled by the system (21,47,321).

However, some diversion programs have been

reported to be successful (e.g., 31,46). One series of

carefully designed and implemented studies (82,83,84)

consistently showed the effectiveness of an 18-week

intervention by paraprofessionals using behavioral

contracting and advocacy strategies in reducing

rearrest rates for up to 2 years following program

1‘0’ ‘Appropriate’ community-based treatments were identifkt by the authors of the study as 1) treatments in which the more intensive service option

was delivered to higher risk cases; 2) all behavioral treatments except those involving delivexy of services to lower risk cases; and 3) nonbehavioral

treatments that clearly stated that c rirninogenic need (i.e., dynamic risk factors that are predictive of criminal involvement) was targeted and that

structured intervention was used (14).

11 I Token economje$ reward offenders for competence with points redeemable for money ~d desirable goods.

1 lzDiverslonprograms spcific~ly those tit we &geted atadolescents who have not beenofflci~y clmsifiedas offenders, are sometimes considered

,

secondary prevention programs. Indeed, most diversion is done by police and otdy a small proportion of police contacts with adolescents ever result in

an arrest and further processing (270). Although such adolescents do not satisfy the legal deftition of delinquency, they do satisfy the behavioral

definition and are therefore included in this section on specific treatment interventions.
Chapter 13—Delinquency: Prevention and Services . //-637

involvement (82). However, the 18-week intervention did not reduce self-reported delinquent behavior

(83). Another study found significant decreases in

recidivism rates among adolescents in diversion

programs in Colorado (334).

Another well-designed study found positive effects of an intervention that integrated identified

antisocial adolescents (who were referred by schools

and the juvenile court before they progressed into

the juvenile justice system) into activities with

nondisturbed peers (132). This soundly designed

study found reduced self-reported and official delinquency in targeted youths who participated in

groups with higher numbers of nonreferred youths

run by experienced group leaders. 113 Although the

sample was small, the soundness of the design and

concurrent evidence of positive modeling effects

from other investigations (e.g., 355) suggest replicating the intervention.

Restitution Programs-Restitution programs can

decrease an offender’s likelihood of readjudication

(357,359). Restitution programs require adjudicated

offenders either to pay their victims directly to

compensate for the victim’s loss or to perform a

specified amount of public service. Sometimes,

restitution programs also involve direct mediation

between the offender and victim (212,357). Despite

the promise of such programs, overall questions

remain about the conditions necessary for restitution

programs to work.

Group Homes----Of the residential placement

options in community treatment, one of the most

popular is the group home. One model of a group

home is the Teaching Family Model—a model in

which a trained couple live with about six chronic

delinquents and administer a systematic behavioral

system of points and privileges to guide the adolescent’s behavior. The adolescents typically attend

local public schools (327). This model appears to

reduce adolescents’ behavior problems during treatment, but these effects disappear after adolescents

leave the group home (49,241,327).

Wilderness Camping Programsl14—Wilderness

camping programs have not been sufficiently evaluated (295) to justify claims of their effectiveness

(173). A few studies have shown positive effects

(238,456), but, in general, the programs have failed

to show lasting reductions in recidivism rates or to

document the relevance of these programs for the

subsequent adjustment of participants in their communities. They appear to have potential benefit for

some participants, but the nature, extent, and conditions under which positive outcomes occur is

unknown.

Intensive Probation Programs--Intensive probation programs in lieu of institutional placement

are becoming more widespread (17,18). The most

recent evaluation of these efforts (34) compared the

outcomes of serious and chronic adolescent offenders assigned to intensive probations with those of a

similar institutionalized control group. After 2 years,

the recidivism rates, as measured by arrests and

self-reported delinquency, were similar, although

the control group’s charges were more serious. The

intensive supervision programs, however, are reported to cost less than one-third as much as the

average State commitment (34). In 1986, for example, the intensive supervision programs were reported to cost an average of $26 per day for each

participant as compared with commitment costs of

an average of $88.54 (34).

Family Therapy and Family Communication

Skills Training—Family therapy and family communication skills training has been used as a

treatment for families of delinquent adolescents.

Several studies have shown that, in the short term,

family systems approaches cut recidivism rates by

half in comparison with more traditional forms of

psychotherapy (client-centered relationship therapy,

psychodynamic therapy) and no treatment comparison groups (2,166) and have a greater impact on

child and family functioning than other types of

therapy (198,236,314).

Preliminary results from an evaluation of a

multisystemic psychotherapeutic 15 approach to treat113 Feldm hm ~o~ed tie impo~mcc of ~ ~xw-ienc~ and WeU.~ined adult leader in programs that involve adolescents (132).

1 ldAl~ough a variety of Org animations offer somewhat different outdoor experiences for adolescents, all of the approaches rely on the natural stresses

and contingencies provided by the wilderness to encourage personal development and group cooperation.

115~e ~ultisys(emic appro~hto psycho~erapy diffe~ from more traditio~ approaches in tit allelemen~ of the identified client’s eCOIOgiCd SyStem

(including schools, sports teams) are included in the treatment as needed. Treatment approaches are flexible rather than theoretically rigid and maybe

delivered in settings other than the clinician’s office (e.g., adolescents’ homes and schools). In additiou the multisystemic approach emphasims the

utilization of theoretical findings in developmental psychology (197).
II-638 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

ing the families of delinquent adolescents show

marked reductions in family dysfunction and official

delinquency; further exploration of such intensive

interventions seems warranted (197). Since most

family interventions for delinquency have experienced nearly a 50-percent dropout rate (186),

however, the targeted child’s and family’s characteristics, as well as methods for making adherence

more attractive to families, are all factors that must

be investigated further if these initial developments

in family approaches are to be expanded. It is clear

that dropout families tend to have older children

(141), to be poorer and more stressed, to be headed

by single parents (275,335), and to have fewer social

supports (89,438). Patterson and his colleagues have

also been less successful with older, chronic delinquents than with younger, aggressive children (275,

335).

Comparison of Community-Based and

Institutionally Based Treatment for

Delinquent Adolescents

A major debate in the juvenile justice field centers

on the relative advantages of community and institutional treatment for juvenile offenders. Although a

meta-analysis of community-based treatment programs for delinquent adolescents produced consistently positive effect sizes (170), available studies

comparing the effectiveness of community-based

and institutionally based treatment have produced

conflicting results (1 13,271,296).

Probably the most relevant natural experiments

were interventions first attempted by Massachusetts

and later by Utah, Pennsylvania, and Vermont.

These four States deinstitutionalized adolescent

offenders and returned them to their communities or

transferred them to small, community-based residential facilities.ll6 Evaluations found that the

deinstitutionalization of adolescent offenders was

not followed by an increase in the frequency or

seriousness of juvenile crime in Massachusetts and

Utah (245,248,382) or in the other States (382).

Studies of the Massachusetts experiment found that

the community circumstances to which the adolescents returned affected their adjustment to reinstitutionalization (75). Adolescents who returned to

communities with alternative, nonresidential programs were half as likely to be rearrested as

adolescents who were merely placed on informal

probation (75). Moreover, adolescents who returned

to social networks that included delinquent peers

were more likely to be rem-rested than adolescents

who reported having a positive relationship with at

least one law-abiding adult (74).

Two recent methodologically sophisticated studies that have produced some seemingly sounder

results may clarify the situation with respect to the

relative advantages of community-based and institutionally based treatment interventions for delinquent

adolescents. One of the studies examined the outcome of 11 different dispositions ranging from

outright release to a combination of more than 2

months detention with 2 years probation (460). This

study found several counterintuitive interactions

among length of treatment, type of treatment, and

setting. Shorter periods (under 1 year) of supervision

without treatment appeared more effective than

extended supervision; both short-term (under 2

months) institutional treatment and longer term

(over 2 years) community-based treatment were

relatively effective in reducing recidivism. The other

study examined community-based and institutional

residential interventions and found that ‘ ‘appropriate’ community-based treatment (as defined in a

previous footnote) produced stronger effects on

recidivism than did institutionalization (14). In this

study, all community interventions were nonresidential. Types of community treatment were not

differentiated from each other in the main analyses,

because preliminary analyses indicated that the

different community settings had recidivism results

that were statistically indistinguishable; as a group,

they were found to be more effective than the

institutional settings (14). The methodological sophistication (e.g., a clearer definition of treatment

and control of other influences on recidivism) of

these two studies increases confidence that communitybased treatments for delinquent adolescents are

more effective at reducing recidivism than are

punishment or treatments in institutions, as long as

the treatment is appropriate and extensive.

There are few rigorous analyses of the costeffectiveness of various juvenile justice interventions. Some observers consider the question of the

cost-effectiveness of the different approaches to be

an open question (243,342,382). Other observers

116~SachuSe~ts pl~ed abut 15 ~rcent of you~s comfitt~ to he Dep~ent of You~Facilities in locked facilities; the remaining 85 pmCenl were

managed in small group homes, foster care placements, day treatment programs, and intensive supervision programs (245,248).
Chapter 13—delinquency: Prevention and Services . //-639

contend that substantial fiscal savings are realized

through the extensive use of community-based

programs in lieu of training schools (e.g., 245,248).

Controlled studies that take into account the total

cost for equivalent treatments, including startup

costs, in community and institutional settings are

needed to address this issue.

Health Care in Juvenile Justice Facilities

By almost any yardstick, the juvenile justice

system in this country has not been effective in

providing necessary health services to incarcerated

adolescent offenders. Though most available information on health care in juvenile justice facilities is

over 10 years old, the few more recent studies do not

suggest major improvements in health care provided

to incarcerated adolescents. The composite picture

that emerges from a review of the research is one of

continuing inattention and neglect of the health

status of incarcerated adolescents. As discussed

further below, adolescents entering detention and

correctional facilities tend to have poorer health

histories than their nonincarcerated counterparts and

are frequently suffering from significant health

problems at the time of admittance. Once admitted

to a correctional facility, they face substantial health

risks within the facility and may be unable to obtain

appropriate medical treatment when they are ill or

injured.

As reported by two independent series of investigations, incarcerated juvenile offenders tend to have

medical histories that show higher rates of perinatal

problems, previous hospitalization, trauma (including head trauma), parental abuse, and neurodevelopmental problems than are found among nondelinquent youth (260,261,305,370). Existing inventories

of the health problems of incarcerated youth reveal

that juvenile offenders have a broad range of

preexisting health conditions before incarceration

(9,461). That many of these preexisting conditions

may not have been appropriately treated is suggested

by at least one study, which found that 34 percent of

adolescent offenders (as compared with approximately 8 percent among nonoffending adolescents)

did not have a consistent source of health care (260).

The health problems of adolescents entering

juvenile facilities and of adolescents after they are

incarcerated are discussed further below. Also discussed is the quality of health care in juvenile

custodial facilities, primarily institutional.

Photo credit: Office of Technology Assessment

The health care of adolescents in juvenile confinement is

a serious cause for concern because adolescents in

confinement have a greater than average number of health

problems, because their health problems may increase

during confinement, and because only 1 percent of eligible

juvenile justice facilities have been accredited as meeting

existing voluntary standards for providing health care.

Health Problems of Adolescents Entering Juvenile

Justice Facilities

Nutritional problems and physical illnesses are

quite common among adolescents entering juvenile

justice facilities. Studies have identified high rates

of iron deficiency (a marker of poor nutritional

status), upper respiratory tract infections, psychosomatic problems indicative of stress (headaches,

sleep disturbances, abdominal complaints, lethargy,

and poor appetite), dental and skin problems, minor

trauma, and congenital malformations, among other

problems (7,193,347).

Many adolescents entering juvenile justice facilities have significant mental health problems—

particularly depressive disorders, which are often

accompanied by feelings of hopelessness and low

self-esteem (217). Various studies have estimated

that 15 to 23 percent of adolescents entering juvenile

facilities have mental health problems (67,233,28 1).

It is important to note, however, that the aggregate

rates of mental health problems among juveniles
11-640. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

entering juvenile facilities are not different from

those in the U.S. adolescent population.117

Adolescents entering juvenile facilities do tend to

have a higher level of experience with drugs and

alcohol than the general adolescent population, and

nearly universal use of tobacco (60,193,228,266,422).

There is some evidence that female adolescents

entering juvenile justice facilities are more sexually

active than other female adolescents, possibly accounting for high rates of sexually transmitted

diseases at the time of admission. 118 Virtually all of

the detained female adolescents in a 1981 study in

New York City were sexually experienced by the

time they were age 15, whereas only 25 percent of a

national noninstitutionalized urban sample had a

similar level of experience (194,464). In a 1985

study of female adolescents detained in King County,

Washington, 81 percent of the females complained

of vaginal discharge and only 8 percent had no

genitourinary symptoms (39). Although none of

these adolescents were diagnosed with syphilis, 48

percent had trichomoniasis, 20 percent had chlamydia infection, 18 percent had gonorrhea, and 4

percent had early signs of cervical cancer. In another

study of adolescents detained in New York City

during 1983-84, gonorrhea was diagnosed in 18

percent of the females and 3 percent of the males,

while syphilis was detected in 2.5 percent of the

females and 0.6 percent of the males (3).

Health Problems Experienced by Adolescents

During Incarceration

If adolescents admitted to juvenile justice facilities are already comparatively unhealthy at the time

they are admitted, once inside an institutional

correctional facility, they frequently are exposed to

additional risks.

Suicide poses a significant risk for adolescents

who are incarcerated in juvenile and adult institutions (289). In 1984, the estimated suicide rate for

juveniles incarcerated in public correctional facilities was 22.6 deaths per 100,000 adolescents in the

population at risk—a rate of suicide 2.5 times higher

than the rate for adolescents in the general population (9,292).119 In addition, 12 percent of juvenile

correctional institutions reported at least one death

by suicide within a 5-year period (15). Minors

appear to be at especially high risk for suicide if they

are detained in adult jails (9,354).

Confinement in juvenile correctional facilities

may expose adolescents to institutional procedures

that can have adverse health consequences (79).

Lack of sufficient staff, for example, may encourage

inappropriate use of psychotropic drugs or physical

restraints to control behavior. Inadequate supervision may increase the hazard of suicide or assault.

And isolation or disciplinary procedures may be

abusive or excessively punitive in some facilities

(9).

One major health problem for adolescents during

incarceration in residential facilities appears to be

trauma, although this problem has not been wellstudied. A 1985 study found that about half of the

residents of one coeducational training school required medical attention for traumatic injuries-onethird of which resulted from fighting or self-inflicted

wounds (462). More than one-quarter (28 percent) of

the injured adolescents in the 1985 study required

attention at an off-campus facility, andone-ftith(21

percent) of injuries needed radiologic or laboratory

studies; 4 percent of the injuries necessitated hospitalization (462).120 In another study, 37 percent of

the subjects described deliberately harming themselves (without suicidal intent) during the period of

their incarceration (216).

Quality of Health Care in Juvenile Justice Facilities

Given the preexisting physical and mental health

problems and the documented health risks confronting adolescents committed to juvenile facilities, an

important question is: What is the quality of care

provided in these institutions? Addressed below are

the studies that have investigated this question, the

standards that have been promulgated in an effort to

enhance the quality of care, and selected financing

barriers (i.e., in Medicaid) to expanding the provision of care in juvenile correctional facilities.

Finally, issues regarding continuity of care when

117For a discussion of tie pmv~ence of mental health problems among U.S. adolescents, X% ch. 11, “Mental Health Problems: Prevention and

Services, ‘‘ in this volume.

I lsFor a discussion of tie prev~ence of sexualIy transmitted diseases wow adolescents, we ch. 9, ‘‘AIDS and Other Sexually Transmitted Diseases:

Prevention and Services, ” in this volume.

llgFor a discussion of adolescent s~cide, see ch. 11, “Mental Health Problems: Prevention and Services,” in this volume.

lzOFor a discussion of accidental injuries among adolescents, s= ch. 5, “Accidental Injuries: Prevention and Services, ” in this volume.
Chapter 13—Delinquency: Prevention and Services . //-641

adolescents are released from juvenile justice facilities are discussed.

Studies of Quality of Care in Juvenile Correctional Facilities-At least three separate studies

have investigated aspects of the quality of care and

concluded that many juvenile correctional facilities

provide inadequate health and medical care for the

adolescents in their charge.

One of the three studies explored how well

medical specialists in one residential facility detected health problems of juveniles during evaluations at the time of admission (262). This study

found that medical providers at the facility frequently failed to identify important health status

information, including data relevant to their fields of

expertise (e.g., pediatrics, neurology, and psychiatry)

The other two studies explored the availability of

health services for juvenile offenders in custody.

One, Anno’s 1984 analysis of responses to questionnaires sent to 600 juvenile facilities, found that only

two-thirds of the 215 responding facilities met the

American Medical Association’s standards for frequency of sick calls121 and the use of qualified health

care personnel (15). Although almost three-quarters

of institutions (72 percent) completed full health

appraisals within a week of each adolescent’s

admission, 40 percent of the institutions did not

routinely provide medical screening on admission,

and more than half (58 percent) of the facilities used

nonphysician staff to conduct screenings. Threefourths (76 percent) of the facilities holding minors

awaiting adjudication and one-fifth (18 percent) of

the facilities holding minors who already had been

adjudicated did not provide ongoing mental health

services. Fewer than half (42 percent) of institutions

provided dental services on a continuing basis.

The other study that explored the availability of

health services for juvenile offenders was a statewide survey of 25 institutional facilities in Georgia

(219). This study found that the frequency of sick

calls at these facilities varied from 4 days a week to

once every other week, although 1 day per week was

the most common. Although other findings of this

survey were not quantified, the study investigators

did raise concerns about inappropriate use of hospital emergency rooms, nonstandardized screening,

high staff turnover and low morale, confusion about

the legal and medical rights of incarcerated adolescents, and inadequate medical care budgets.

Standards for Health Care-As noted above,

two of the three studies that have investigated the

quality of care provided in juvenile correctional

facilities used existing sets of standards as a basis for

comparison. The American Academy of Pediatrics

wrote one of the first sets of standards for the health

care of juveniles in juvenile facilities in 1973 (5).

The American Medical Association developed a set

of standards for health services in juvenile facilities

in 1979 (8). In 1984, 20 national professional health

care organizations developed a comprehensive set of

standards for the provision of health care in juvenile

correctional settings. These ‘‘Standards for Health

Services in Juvenile Confinement Facilities” were

drafted and released by the National Commission on

Correctional Health Care.122 They specify that

health services in juvenile correctional facilities

should be equivalent to those available in the

community (79).123

Compliance with any of the existing standards for

the health care of juveniles in juvenile confinement

facilities is completely voluntary. As of 1990, only

about 32 of the more than 3,000 juvenile facilities in

the country were accredited by the National Commission on Correctional Health Care-and those 32

were predominantly in Los Angeles, California, and

the State of Washington (64).

Thus, voluntary standards for the health care of

juveniles in juvenile confinement facilities apparently have not been successful in fostering improvements in the quality of health care provided in

juvenile facilities. Intervention by the judicial

121~~c~ ~alfS tic ~enodic ~pP~fi[ieS ~rovid~ by ~Sti~tiom for health sta~s checks ~d for persons to declare illness or health problems ~d be

relieved from the daily schedule in order to receive health assessments or treatment. The standard adopted by National Commission on Correctional

Health Care for accreditation of juvenile custodial facilities requires sick calls to be conducted by a physician or nurse at the site of the institution’s clinic

(300). Under this standard, a facility of less than 50 juveniles must have its clinic open for sick call at least once per week. Facilities with 50 to 200

juveniles in residence must open their clinics at least thee times during the week. For facilities with a resident juvenile population over 200, clinics must

be open for sick call 5 days per week. OTA did not evaluate the validity of the National Commission on Correctional Health Care standards.

i~~~erc are also other volutq model standards for the heahh care of inmcerated juveniles (298).

IZJNone~ele$~, ~ome ~uestlon tie ad~uacy of tie swdwds. They do no~ for ex~ple, prohibit tie he~ti c~e Professional ‘rem Cooperattig d *e

., .

inappropriate use of medical procedures for punitive and control purposes (79).
II-642 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

branch is another approach to forcing improvements. The issue of whether incarcerated juveniles

have a constitutional right to treatment, however, is

unsettled. On the one hand, the U.S. Supreme Court

has never decided whether incarcerated adolescents

have a constitutionally based right to treatment, and

some Federal courts have ruled that incarcerated

children do not enjoy the right to treatment (79,254).

On the other hand, many Federal courts have held

that denial of adequate medical and mental health

care violates the Eighth and Fourteenth Amendments to the U.S. Constitution (79). Accordingly,

Federal courts have required some juvenile correctional facilities to provide routine and emergency

medical and mental health care (79). One might

expect alleged deficiencies in health care within

juvenile correctional facilities to be a common

subject of litigation. Yet legal challenges to the

quality of care in juvenile justice facilities are fairly

rare occurrences.

124

Medicaid Barriers—Many factors contribute to

the problems surrounding health care delivery in

juvenile correctional institutions. Fiscal pressures

faced by juvenile correctional facilities have been

reported to be among them (9). In this respect,

current Federal restrictions on Medicaid reimbursement are significant, especially since few incarcerated adolescents can be expected to have private

health insurance.

Existing Federal regulations do not permit Medicaid to pay for medical and health-related services

provided in publicly funded juvenile correctional

institutions (42 CFR 435.1009). Health care in

juvenile correctional institutions is supported exclusively by State and county governments, frequently

as a line item expense in an institution’s total

operating budget (217). Within a particular institution, therefore, health and medical needs compete

with other organizational needs. Medical care personnel may be forced to ration evaluation and

treatment resources. Paying for the costs of a simple

hospitalization, especially if any operative procedure is involved, may seriously compromise an

institution’s budgetary capability to provide for the

health and medical needs of other youth.

Continuity of Care-If the quality of care within

many juvenile correctional facilities is often inadequate, adolescents, upon leaving the institutions,

seem to face yet another problem. In a juvenile

correctional facility, continuity of care optimally

includes discharge planning by medical staff to

assure uninterrupted provision of health care for the

adolescent. Service fragmentation prevents full implementation and coordination of care during an

adolescent’s transition from an institution back to

the community (9). Upon release from a correctional

institution back to the community, for example, a

juvenile may become eligible for the Medicaid

reimbursement denied during incarceration. The

switch from one source of funding for health care to

another source at the time of an adolescent release

into the community may complicate the coordination of service delivery. Many incarcerated adolescents are moved among different community placements and have no regular source of health care.

Thus, their health care after discharge may be left to

the vagaries of circumstance.

Summary: Services and Interventions for

Adolescents in the Juvenile Justice System

As a country, the United States spends billions of

dollars annually on its juvenile justice system. An

important question to consider, therefore, is whether

the funds that are allocated are obtaining the desired

results of protecting the public safety and providing

for the protection of the best interests of each

adolescent in the juvenile justice system for delinquent offenses.

One measure of the juvenile justice system’s

effectiveness is whether it serves adolescents’ best

interests while they are in the system. OTA’s

analysis suggests that services and interventions for

adolescents in the juvenile justice system are frequently not provided with an understanding of the

developmental status of adolescents and a recognition of the legal rights of adolescents (e.g., access to

legal counsel).

Another measure of the effectiveness of the

juvenile justice system is how well it serves the

public safety and adolescents’ best interests after

they leave the juvenile justice system. The juvenile

justice system would probably be considered effective if adolescent offenders were deterred from

subsequent delinquency and criminality after con1240~y 4 ~mcent of ~c 215 juve~e facilities ~Ton@ to ho’s 1984 s~ey mentioned akve repofied having had a lawsuit regarding the

adequacy of health care fded against them in the preceding 5 years (15).
Chapter 13—Delinquency: Prevention and Services ● II-643

tact with the system. Because of a lack of data on,

and unstandardized means to measure, adolescent

offenders’ social adjustment following their release

from juvenile facilities, however, the effectiveness

of the juvenile justice system as a system in deterring

subsequent delinquency and criminality cannot be

accurately evaluated .

Some data are available on the effectiveness o f

specific interventions for treating adolescent delinquents and reducing recidivism, although measure -

ment problems, such as unstandardized measures o f

recidivism, limit definitive conclusions. Interven -

tions for treating delinquent adolescents tend to be

either community-based or institutionally based .

Institutionally based treatment interventions for

delinquent adolescents are those provided in institutional environments such as training schools. There

is some limited evidence that behavioral approaches

to treatment in institutions-for example, the use o f

point systems, token economies, and behaviora l

contracting (14, 152,222), cognitive problem-solving

and skill development (367), and family therapy

interventions (32)---are more effective in reducing

recidivism than nondirective peer group counseling

(169) or traditional individual therapy interventions

(152,173).

Community-based treatment interventions for delinquent adolescents include diversion programs

that attempt to keep delinquent adolescents out of

residential placements. The effectiveness of diversion programs may be overstated because of the

inclusion of first-time offenders in the programs

(343). Nonetheless, some programs with clearly

defined and well-implemented interventions that

incorporate behavioral and family-based chang e

strategies have produced clear reductions in subse -

quent arrest rates (82), though not in self-reported

delinquency behavior (83).

Another community-based treatment intervention

that a well-designed study found to be effective in

reducing delinquency was an intervention tha t

involved integrating adolescents identified as antisocial with nondisturbed peers (132). Replication of

the processes that may have produced these positive

effects certainly seems warranted.

Other evidence of the effectiveness of communitybased treatment interventions for delinquent adolescents comes from evaluations of family therapies

(2,144, 166, 198,314). Two caveats are that several of

the evaluations of these strategies failed to assess

long-term impact on delinquency, and that these

strategies are often plagued by high dropout rates

(186),

Family group homes appear to reduce behavior

problems during treatment, but these effects disappear after adolescents leave their group home

(49,241). Wilderness programs in general have

failed to show lasting effects (238,456), or document

the relevance of these programs for the juveniles and

their subsequent adjustment in their own communities. Similarly, restitution programs appear successful for some juvenile offenders in some circumstances (357), but questions remain about the

conditions necessary for restitution to work. Lastly,

a recent evaluation of programs found that recidivism rates of adolescents assigned to intensive

probation programs were similar to those of institutionalized adolescent offenders (34).

The general lessons noted earlier in the summary

related to the effectiveness of delinquency prevention programs pertain to treatment interventions as

well. Overall, longer or more intensive communitybased treatment interventions and/or treatment interventions that improve family functioning, incorporate some form of behavioral intervention, and

modify delinquents’ social networks seem the most

promising, provided that they are appropriate to the

juveniles’ needs and strengths. Although institutionally based treatment may be necessary for some

juvenile offenders, community-based treatment seems

to be appropriate for many more youth than institutional treatment.

An example of how the best interests of adolescents are not well served in the juvenile justice

system are the shortcomings in the provision of

health care services to adolescents in custodial

facilities. Existing studies suggest that health care

services in juvenile correctional facilities are inadequate. The availability of health care is very

important for adolescents in juvenile custodial

facilities because many adolescents enter juvenile

facilities with significant physical and mental health

problems, and confinement in juvenile institutions

increases the range of health problems they acquire.

Health care standards for accreditation of custodial

facilities do exist, but the standards are voluntary

and only a very small percentage of custodial

facilities are accredited. Another factor that appears

to have a major impact on the lack of adequate care
II-644 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

for adolescents in custodial juvenile facilities is the

fiscal limitations in such institutions, for example,

restrictions on Medicaid payment.

Major Federal Policies and Programs

Pertaining to Adolescent Delinquency

Although juvenile justice is primarily a State and

local issue, there has also been considerable involvement in juvenile justice issues by the legislative ,

executive, and the judicial branches of the Federa l

Government .

Legislative and Executive Branch Policies

From the early 1960s until 1974, the Federal

Government’s legislative and executive focus wa s

on delinquency prevention and early intervention. In

the early 1960s, a Presidential Committee on Youth

Crime funded large-scale delinquency preventio n

programs in major urban areas, and later in th e

1960s, a Presidential Commission on Law Enforce -

ment and Administration of Justice recommende d

an emphasis on prevention diversion and deinstitutionalization. In 1968, Congress enacted legislation tha t

called for grants to States and localities to improve

juvenile justice and delinquency prevention pro -

grams to be administered by the U.S. Department of

Health, Education, and Welfare [now the U.S .

Department of Health and Human Services and the

U.S. Department of Education]. That same year

(1968), Congress also passed the Omnibus Crime

Control and Safe Streets Acts that involved the U.S.

Department of Justice in juvenile justice for the first

time .

The 1974 Juvenile Justice and Delinquency Pre -

vention Act (Public Law 93-415) represented a

major step in enlarging the Federal Government’s

role in juvenile justice. After nearly 5 years o f

exhaustive investigations, the Subcommittee o n

Juvenile Delinquency of the U.S. Senate Judiciary

Committee concluded that the existing juvenil e

justice system was failing miserably in several ways

(401) .

125Congress responded by enacting the Juve -

nile Justice and Delinquency Prevention Act. Tha t

act established an Office of Juvenile Justice an d

Delinquency Prevention (OJJDP) in the U.S. De -

partment of Justicel26 and a program of Federal

grants to the States administered by OJJDP to

provide technical assistance to help them come into

compliance with the act’s provisions. The 1974 act

required States to remove status offenders and

nonoffenders (e.g. , abused and neglected youth )

from secure confinement and to separate adult and

juvenile offenders as a condition of receivin g

Federal tiding. It also mandated new data collec -

tion and research efforts, including the disseminattion of the findings of research and all data related to

juvenile delinquency .

By 1978, the budget of OJJDP had increased to

over $100 million per year from $14.5 million in

1975 (153). At that time, OJJDP played a major role

in helping jurisdictions implement a 1980 amend -

ment to a Juvenile Justice and Delinquency Prevention Act which required the complete removal o f

juveniles from jails and police lockups.

From 1981 to 1989, the focus of the Federa l

juvenile justice program on prevention, diversion ,

and assisting groups that litigated the rights o f

adolescent offenders shifted to concern over violent

offenders, pornography, missing children, an d

school safety (333). Throughout this period, th e

Office of Management and Budget also proposed the

elimination of funding for OJJDP.

For 8 consecutive years, Congress restored a n

appropriation for OJJDP over the objections of the

U.S. Department of Justice and the Office o f

Management and Budget. Nonetheless, the tota l

allocation to OJJDP decreased during this perio d

and in 1989 sas $66,692,000 (430). In 1990 ,

although the President’s budget recommended a

large cut in funding for OJJDP, Congress appropriated $72,482,000. Virtually all of this amount is

devoted to projects related to adolescents. 127

In the last decade or so, the focus of most Federal

initiatives within OJJDP has shifted from a delinquency prevention model to a criminal justice model

emphasizing: 1) vigorous prosecution of seriou s

juvenile offenders, 2) a new focus on the plight o f

missing children, 3) mandatory and harsher sentencing laws, 4) programs to reduce school violence, and

5) national crusades against drugs and pornography

lzs~ong Othm issues, the su~o~ttee hefigs focused on the continuing problems of children held in jails, StatUS offendecs housed together tith

violent offenders, the lack of trained persomel, and inadequate prevention resources.

lzs~o 19, “me Role of Feder~ Agencies in Adolescent HealtQ’ in Vol. III, describes OJJDP’S CUITent ~JOr Xtivities.

lzTFor fifier discussion, see ch. 19, ‘ ‘The Role of Federal Agencies in Adolescent Health,” in VO1. ~.
Chapter 13—Delinquency: Prevention and Services ● //-645

(246,332). The wisdom of this approach has been

questioned by many in the criminology field (246).

OJJDP’s priorities for fiscal year 1990 are serious

juvenile delinquency, illegal drug use, youth groups

(gangs), and missing and exploited children (430).

OJJDP’s priorities appear to reflect a belief that

the problems related to the prevention of delinquency are too large and intertwined with other

social service elements for OJJDP to manage in light

of its relatively small budget. OJJDP has suggested

that other Federal agencies who have experience

with adolescents could apply their efforts to delinquency prevention efforts before problems become

juvenile justice issues.

Within the U.S. Department of Health and Human

Services, several agencies are developing programs

concerning adolescent involvement in delinquent

activities. Among these agencies are the Centers for

Disease Control in the Public Health Service and the

Administration for Children, Youth, and Families in

the Office of Human Development Services. The

Injury Control Division of the Centers for Disease

Control has mounted studies of violence, for example, that include adolescent violence. In fiscal year

1989, however, the Injury Control Division spent

only $1.3 million on projects related to violence

(355a).

Judicial Branch Policies

In the last 25 years, the U.S. Supreme Court has

handed down a series of decisions related to juvenile

court rules. One of these was the landmark decision

In re Gault [387 U.S.1 (1967)]. In this decision, the

Supreme Court specified a detailed set of rights that

must be accorded juveniles. The Gault decision

focused on notification of charges, protection against

self-incrimination, the right to confront witnesses,

and the right to have a written transcript of the

proceedings. A more recent Supreme Court decision, Schall v. Martin [467 U.S. 243 (1984)], upheld

the constitutionality of preventive detention of

juveniles for their own protection and for the

purpose of preventing pretrial crimes.

Whether juveniles in correctional facilities have a

constitutional right to health care treatment is not

resolved. As of the end of 1990, the U.S. Supreme

Court has not ruled on that issue. Some lower

Federal courts, however, have ruled on issues related

to health care and treatment. Examples of rulings by

lower Federal courts, include the following:

●

●

●

●

An incarcerated child has the right to receive

adequate treatment, including medical and

mental health care, as well as the right to be free

from brutal and oppressive conditions [Inmates

of Boys’ Training School v. Affleck, 346 F.

Supp, 1354 (D. R.J. 1972); Morales v. Turman,

364 F. Supp. 166 (E.D. Tex. 1973); Nelson v.

Heyne, 355 F. Supp. 451 (N.D. Ind. 1972),

aff'd, 491 F. 2d 352 (7th Cir. 1974), cert.

denied, 417 U.S. 976 (1974); Gary H. v.

Hegstrom, No. 77-1039-BU (D. Or. Dec. 17,

1984); Swansey v. Elrod, 386 F. Supp. 1138

(N.D. Ill. 1975)].

Juveniles must have sufficient medical staff

and nursing staff to provide effective preventive and curative care for the health of all

juveniles [Morales v. Turman, 388 F. Supp. 53

105 (E.D. Tex. 1974)].

Juveniles should be flee from the administration of psychotropic medication in an indiscriminate, unsupervised, unnecessary, or excessive manner [Morales v. Turman, 388 F.

Supp. 53105 (E.D. Tex. 1974)].

An individual’s constitutional right to treatment includes the right to individualized treatment for drug and alcohol dependency (79).

(Gary H. v. Hegstrom, No. 77-1039-BU (D. Or.

Dec. 17, 1984)].

Conclusions and Policy Implications

Consideration of adolescent delinquency in this

country raises numerous issues important to public

policy: How serious a problem is adolescent delinquency? Is it getting worse, or better? What causes

adolescents to commit delinquent acts? Can delinquency be prevented? When delinquency occurs,

what should the societal response be—punishment

or treatment? As this chapter demonstrates, despite

the longstanding national concern about delinquency among U.S. adolescents, the answers to

these questions have not been resolved. The methodological limitations of available studies are partially

responsible for the lack of definitive knowledge on

delinquency, as are controversies regarding the

definition and measurement of delinquency. Because of the ideological differences among observers, certain issues pertaining to adolescent delinquency are unlikely ever to be resolved definitively.

Nonetheless, available information provides some

direction for public policy decisions,
II-646 . Adolescent Health—Volume II Background and the Effectiveness of Selected Prevention and Treatment Services

The number of U.S. adolescents who commit

delinquent acts is one measure of adolescent delinquency. Available evidence indicates that most

individuals in the United States admit committing

some delinquent act during their adolescence. The

precise number of adolescents who commit specific

types of offenses is difficult to determine. According

to National Youth Survey data from 1976, about 21

percent of adolescents commit at least one serious

delinquent act (i.e., aggravated assault, forcible rape,

and robbery) during adolescence, and about 5

percent report committing multiple serious offenses.

On the positive side is evidence that most adolescents’ engagement in delinquency-even serious

delinquency —is of short duration. Evidence from

the National Youth Survey is dated, however, and

was obtained from adolescents who lived in an

environment rather different from the current one.

The number of delinquent acts committed by U.S.

adolescents in the aggregate is another measure of

delinquency. Here again, however, the precise number is difficult to determine. One reason is that there

are a number of different measures of delinquency;

another reason is that the measures differ widely in

their findings. Data indicative of the state of the

problem are that in a single recent year (1987), there

were 1.7 million arrests, approximately 1.4 million

referrals to juvenile courts, and 700,000 admissions

to custodial facilities among 10- to 17-year-olds.128

In the aggregate, arrest rates for delinquent acts have

declined in this country since the mid- 1970s. However, arrest rates for aggravated assaults by U.S.

adolescents have increased since the mid- 1970s and

arrest rates for murders by U.S. adolescents have

risen in the past 4 years, suggesting that violence by

adolescents is increasing.

Some limited self-report data confirm the rise in

aggravated assaults, but more comprehensive data

are needed to confirm or to contradict the trend in

violence by adolescents. A periodic longitudinal

survey of adolescents with questions about problem

behaviors could yield information on adolescents

involved in delinquent behavior and the number of

delinquent acts committed by adolescents.

What causes adolescents to commit serious delinquent offenses? It is clear that not one but many risk

factors contribute to an adolescent committing

serious offenses. On the whole, however, the risk

factors for delinquency are not completely understood.

Certain demographic characteristics-being in

the age group 15 to 17, being male, being black, and

having access to an urban area-are more associated

with serious delinquency than others. The relationship of race to delinquency is unclear. When one

examines self-reports of serious offenses, racial

disparities are much smaller than those typically

reported in arrest statistics. Furthermore, about half

of black adolescents live in poor or near-poor

families, many of them in urban areas typified by

high rates of crime and limited educational or

employment opportunities; 129 and adolescents of

low income and adolescents who live in urban areas

are more likely to commit serious delinquent acts

than other adolescents.

Early socially disapproved behaviors, low IQ

(particularly poor verbal ability), associating with

delinquent peers, and family factors that include

parental rejection and lack of parental supervision

have been identified as factors increasing the risk of

serious adolescent delinquency, and the importance

of the association between them and adolescent

delinquency has been definitively established. The

vast literature on risk and protective factors provides

strong clues on the factors in the social environment

that can be modified, with the strong probability that

much of delinquency can be prevented.

Although much is known about several factors

associated with delinquency, there are several reasons why definitive information is not available

about risk factors. First, most of the research that has

been conducted to date has focused on individual

constitutional factors and parental behaviors. Even

among these factors, the importance of the relationship between many suspected risk factors, (e.g.,

biological factors) and delinquency is not known.

Furthermore, most of the research on family factors

has focused on parental behaviors in white families.

There has been little investigation of parental

1281t is ~po~t t. ~otc tit ~ese ~~ ~present ~ests, refe~~s, ad admissions, not individ~s. Some individtis invoIved in the juvenile justice

system may have more than one arrest referral, and admission. Further, as noted earlier, some admissions to juvenile facilities are for reasons unrelated

to delinquency.

lz~sk f~tors~ofiont~ by~ypooradole~ents ~dadole~en~ inraci~~de@ic minority groups are discussed inch. 18, ‘ ‘Issues in the ~five~

of Services to Selected Groups of Adolescents, ” in Vol. III.
Chapter 13—Delinquency: Prevention and Services . II-647

behaviors in black and other minority families, and

the relationship of family factors and the risk of

adolescent delinquency in such families is uncertain.

Second, although it is clear that official rates of

delinquency vary with the socioeconomic conditions of a community, few studies have investigated

the processes by which the socioeconomic environment of the community affects the delinquency of

individual adolescents. The economic and social

environment of the community and perceived economic and social differences (for example, the

perception that opportunity in mainstream society is

blocked leading to devaluation of mainstream views)

are likely to be associated with adolescent delinquency.

Third, although the same factors identified as risk

factors characterize many adolescents who do not

commit serious delinquent acts, the reasons why

many children and adolescents are apparently ‘‘protected’ from the adverse effects of certain risk

factors have not been fully investigated.

Last, and perhaps most important, the interactions, including the temporal order, among all risk

factors are not certain. More comprehensive models

that include individual, familial, and community

factors, including economic and social factors, are

needed to explain and predict delinquency.

Despite incomplete knowledge about the causation of adolescent delinquency, some programs

designed to prevent delinquency, while not widely

duplicated or tested, have shown promising results

in relatively rigorous studies. Overall, successful

approaches to prevention can be characterized as

those that have the following characteristics:

●

●

●

they are appropriately supportive of children

and adolescents and their families130

;

they are intensive (i.e., they involve the commitment of considerable time, personnel, and

effort); and

they are broad-based (i.e., they intervene in a

number of the systems—including family,

school, and peer—in which the child and

adolescent is involved, and use multiple services (e.g. educational, health, and social) as

appropriate for the individual child and adolescent).

The most promising primary prevention efforts

appear to be conducted early in life for high-risk

children. These include the Perry Preschool Program

and a broad-based prevention intervention that

included parent-skill training. promising secondary

prevention approaches, conducted during adolescence after antisocial behavior has become apparent,

include the intensive psychotherapeutic and vocational placement and remedial educational intervention evaluated by Shore and his colleagues and the

integration of identified antisocial adolescents into

activities with nondisturbed peers. These models

deserve additional implementation accompanied by

rigorous evaluation. Rigorous evaluations of future

preventive interventions based on the knowledge

about risk and preventive factors, and additional

basic research on the causes of delinquency, are

essential to advance knowledge in this field.

Also in need of attention as preventive factors are

limits on access to guns and educational interventions intended to help adolescents avoid becoming

victims.

The role of guns in adolescent delinquency has

not been well researched, but it is clear that the use

of guns can exacerbate the outcome of violent

delinquent offenses by adolescents, as well as

criminal acts by adults. The use of guns by adolescents to commit homicide and the use of guns by

people of all ages to murder adolescents have

increased in this country since 1976. Additional

action may be needed to decrease U.S. adolescents’

access to guns, given that existing Federal legislation already prohibits the sale of rifles and shotguns

to individuals under the age of 18 and handguns to

those under age 21. Limiting access to guns by

adults also warrants consideration. The nature of

these actions requires further investigation.

Victimization of adolescents is a problem that has

received little attention, but adolescents, especially

black adolescents, are more likely than Americans in

other age groups to be victims of crimes, especially

offenses committed by other adolescents. More

precise data on adolescent victims is needed, along

with approaches to preventing victimization that are

broader than approaches that focus on perpetrators

(e.g., educating adolescents to avoid victimization).

U.S. adolescents who commit offenses and are

placed in juvenile facilities-perhaps 700,000 per

130 See Ch. 3, “Parents and Families’ Influence an Adolescent Health, ‘‘ in this volume for a discussion of models of appropriate parenting.
II-648 . Adolescent Health—Volume II Background and the Effectiveness of Selected Prevention and Treatment Services

year-may at frost glance seem least deserving of

society’s attention. In fact, societal views of the

relative merits of rehabilitative treatment and punishment change over time. Currently, many Federal

and State governments appear to be taking a more

punitive approach. The debate is difficult to resolve

in the absence of definitive comparative evaluations,

but existing evidence indicates that less punitive

approaches (e.g., the use of open rather than closed

facilities, community-based rather than institutionally based treatment efforts, rehabilitative treatment

efforts rather than routine incarceration) are at least

as effective as more punitive approaches for many

adolescent offenders. Specific rehabilitative treatment interventions that show promise are similar to

the most effective preventive approaches in being

appropriately supportive of the adolescent and his or

her family, intensive, and using multiple services

and settings.

Three points about the U.S. juvenile justice

system are very clear. First, black adolescents are

more likely to be treated harshly by the juvenile

justice system—i.e., more likely to be arrested,

confined, and housed in secure correctional facilities—

than are white, non-Hispanic adolescents. Hispanic

adolescents are similarly more likely to be incarcerated than white non-Hispanic adolescents. The

imbalance of minorities in the juvenile justice

system is currently being examined by a number of

national organizations at the request of the Federal

Government, so any further governmental action on

this issue should probably await the findings of these

studies. Second, health care in juvenile justice

facilities does not appear to meet the needs of

adolescents in custody. Additional in-depth analyses

of the causes and consequences of inadequate health

care are needed before specific changes in policy are

made; in the interim, the Federal Government could

act now to make Medicaid available to incarcerated

adolescents. Finally, the legislatively mandated role

of OJJDP (the Office of Juvenile Justice and

Delinquency Prevention) in delinquency prevention

is precarious. The executive branch has requested

elimination or a substantial decrease in appropriations for the office for many years and has

reoriented the office’s policy with regard to juvenile

justice away from basic research and delinquency

prevention to serious and violent offenders and other

issues. Perhaps it is time for a reexamination,

perhaps by an objective, expert group, of the role of

OJJDP vis-a-vis that of other Federal agencies

involved in the prevention and treatment of delinquency.

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Chapter 14

HOMELESSNESS:

PREVENTION AND SERVICES
Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663

Background on Hopelessness Among Adolescents ● . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663

Causes of Hopelessness Among Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663

Hopelessness for Adolescents in Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663

Hopelessness for Adolescents on Their Own . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665

Service Needs of Homeless Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 666

Homeless Adolescents in Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 666

Homeless Adolescents on Their Own . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671

Major Federal Policies and Programs Pertaining to Hopelessness . . . . . . . . . . . . . . . . . . . 678

Emergency Aid to the Homeless and the McKinney Homeless Assistance Act . . . . . . 679

Ckanston-Gonzalez National Affordable Housing Act ● . . . . . . . . . . . . . . . . . . . . . . . . . . . 681

Runaway and Homeless Youth Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 682

Barriers to Care Under the Runaway and Homeless Youth Act . . . . . . . . . . . . . . . . . . 683

Effectiveness of Runaway and Homeless Youth Services . . . . . . . . . . . . . . . . . . . . . . . 685

Missing Children’s Assistance Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687

Anti-Drug Abuse Act of 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .687

Collaborative Efforts Among Federal Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 688

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 688

Chapter 14 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 690

Boxes

Box Page

14-A. A 13-Year-Old’s Recollection of Life in a Homeless Shelter . . . . . . . . . . . . . . . . . . 668

14-B. Bridge Over Troubled Waters: An Agency Serving Runaways and

Homeless Street Youth . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 684
Chapter 14

HOMELESSNESS: PREVENTION AND SERVICES

Introduction

The traditional stereotype of the homeless person

—that of the white, older, skid-row alcoholic-no

longer describes the “typical’ homeless person.

During the last 10 to 15 years, the characteristics of

the homeless have changed. Today, the homeless are

younger, include a larger portion of women, and

include more people who suffer from mental disorders (59). Perhaps the most alarmin g change in the

homeless population in recent years has been the

dramatic rise in the numbers of homeless families

with children.

This chapter focuses on the problems and service

needs of homeless adolescents and on the services

available to address the needs of these individuals.

First, it discusses the causes of hopelessness for

adolescents and the problems and service needs of

homeless adolescents. Then it presents information

on Federal programs and the recent legislative

history of congressional efforts to address the

hopelessness crisis. The chapter ends with a discussion of conclusions and policy implications pertaining to hopelessness among adolescents.

Nobody really knows how many children and

adolescents are homeless, either living in homeless

families or on their own. The U.S. Department of

Health and Human Services (DHHS) estimated in

1984 (on the basis of 1976 data) that there are as

many as 1 million homeless and runawayl adolescents each year (71), and in the absence of more

recent national data, this estimate continues to be

used (71). Efforts were made by the U.S. Bureau of

the Census to count homeless people in the 1990

census, but even those efforts are unlikely to result

in an accurate count of the number of homeless and

runaway adolescents.

Background on Hopelessness

Among Adolescents

As suggested above, some adolescents become

homeless with their families and others become

Photo credit: Sasha Bruce Youthworks Inc.

Homeless adolescents can be homeless on their own or

with their families. Children in some States may be

removed from families that are homeless on the grounds of

abuse or neglect, because being unable to provide a home

may be perceived to be evidence of neglect.

homeless on their own. The etiology of homelessness among these two groups of adolescents and the

service needs of adolescents in the two groups are

somewhat different.

Causes of Hopelessness Among Adolescents

Hopelessness for Adolescents in Families

Adolescents who become homeless with their

families become homeless because of situations that

l& dlScussed below, definitions used for ‘‘mnaway’ and ‘‘homeless’ adolescents vary. Generally, hopelessness denotes a long-term situation,

while ‘ ‘runaway’ is used to characterize those adolescents who have left home overnight without permission. In fact, the population is a dynamic one.

In addition, both runaway and homeless populations include adolescents who have been asked or ordered to leave home and have nowhere else to live

(so-called “throwaway” or “thrownaways.’

-II-663-
II-664 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Photo credit: Office of Technology Assessment

The decreasing availability of safe, affordable,

accessible low-income housing in this country is

believed to have contributed substantially to the

increase in the numbers of homeless families.

affect their family as a whole. Various events can

precipitate hopelessness for families, just as they

can for individuals or couples.

Broad social and economic developments leading

to hopelessness include inflation and unemployment coupled with reductions in funding of social

and human service programs (59). Furthermore, the

availability of low-income housing has generally

decreased as a consequence of factors such as

gentrification of inner cities (77).2 The specific

incidents precipitating hopelessness for a family are

as varied as eviction from housing, estrangement

from family members, criminal victimization, illness, loss of employment, and disaster (e.g., fire).

Once an adolescent’s family becomes homeless,

shelter rules and restrictions may result in the

adolescent’s separation from his or her family, Some

communities lack family shelters, and as a result,

families may have to separate in order to receive

shelter. Another problem that arises is that some

shelters do not allow adolescent males to enter with

their mothers (15,66).

Young adolescents whose families are homeless

may sometimes be placed in foster care.3 In some

cases, the placement of a child from a homeless

family in foster care is the parent’s choice, and in

others it is the result of the intervention of child

welfare authorities. A parent may choose to place

children in foster care temporarily, believing that the

children will be better provided for in foster care

while the parent gets back on his or her feet.

Guidelines recently developed by the National

Association of Public Child Welfare Administrators

discourage child welfare intervention in cases where,

in the absence of other apparent abuse or neglect,

parents are unable to support their children adequately despite the use of all available resources,

such as in the case of hopelessness (76). The States

of California, Texas, and Maryland all prohibit child

welfare intervention on the basis of hopelessness

alone (76). Still, children in some States may be

removed from families that are homeless on the

grounds of abuse or neglect—because being unable

to provide a home may be perceived to be evidence

of neglect. In New Jersey in 1986, 18 percent of the

children in foster care (ages not specified) were in

foster homes because their families could not find a

place to live (24). Hopelessness was the primary or

secondary reason for foster care placement for 40

percent of the children in foster care in New Jersey.

The removal of children from the custody of their

parent or parents may result in the loss of eligibility

for welfare benefits under Aid to Families With

Dependent Children (AFDC),4 further reducing the

parents’ ability to secure housing. Furthermore, the

parents may not be allowed to regain custody of the

children until they demonstrate that they have

obtained adequate housing. Thus, it may be extremely difficult for a parent to regain custody of a

child who has been placed in foster care, even in

cases where there has been no evidence of parental

abuse or neglect. Visits to see children also become

difficult for parents who are moving from shelter to

shelter, and the reduced contact between parents and

children may further erode family relationships (76).

Wentrzficarion refers to the “back to the city” movement by middle- and upper-class suburbanites that began in the 1970s. This has resulted in the

conversion of many low-income dwellings to more expensive housing (e.g., condominiums) no longer affordable to their former tenants. A pticukwly

harmful cost of this movement for the poor has been the dramatic decrease in single-room occupancy hotel rooms; nearly half of the Nation’s total stock

has disappeared since the early 1970s (27).

JFor more ~omation about foster ewe, see ch. 3, “Parents and Families’ Influence on Adolescent Health, ’ in MS vOluIne.

4~e -cpm~w is a Pmwa es@blished under tie s~i~ Seeurity Act that provides cash welfare payments to fties witi dependent c~ldren

who have been deprived of parental support or care as a result of the deaa incapacitation, unemploymen~ or continued absence of a parent and who

meet income and resouree criteria specified by the State. It is administered by the Family Support Administration of DHHS.
Chapter 14—Homelessness: Prevention and Services . II-665

Recently, Title V, Subtitle B, Section 553 (Assistance To Promote Family Unification) of the CranstonGonzalez National Affordable Housing Act of 1990

(Public Law 101-625) authorized an additional $35

million for each of fiscal years 1991 and 1992 to

provide housing assistance for certain families in

order to avert childrens’ hopelessness and subsequent placement in foster care. The families affected

by this provision of Public Law 101-625 would be

those: 1) who are eligible for assistance under

Section 8 of the United States Housing Act of 1937

and 2) whom the public child welfare agency for a

jurisdiction has certified is a family for whom the

lack of adequate housing is a primary factor in the

imminent placement of the familys child or children

in out-of-home care or the delayed discharge of a

child or children to the family from out-of-home

care. Allocations from the fund are to be made on the

basis of a jurisdiction’s demonstrated need.

Hopelessness for Adolescents on Their Own

Definitions used for ‘runaway’ and ‘‘homeless’

adolescents vary. The National Network of Runaway and Youth Services differentiates among the

following categories: 1) runaways, young people

who are away from home at least overnight without

the permission of a parent or caretaker; 2) homeless

youth, youth who have no parental, substitute foster,

or institutional home and who in some cases may

have left (or been urged to leave) with the full

knowledge or approval of a legal guardian; and 3)

street kids, long-term runaway or homeless youth

who have become adept at fending for themselves

‘‘on the street, ’ usually by illegal activities (41).5

Homeless adolescents and street kids who have

been forced out of their homes when they are no

longer wanted by their families are sometimes called

“throwaways,” “thrownaways,” or “pushouts.” A

recent report by the U.S. Department of Justice

differentiated between: 1) runaways, children who

leave home without permission and stay away

overnight; and 2) thrownaways, children who have

been told to leave the household, children who have

been abandoned or deserted, and children who run

away and whose caretaker does not allow them to

return, makes no effort to recover them, or does not

care whether they return (74).

In fact, the population of homeless and runaway

adolescents is a dynamic one, with at least some

homeless adolescents having histories of being

runaways and at least some runaway adolescents

being just a step away from being more permanently

homeless themselves, As a practical matter, therefore, the distinctions between homeless adolescents

on their own and runaway adolescents are sometimes arbitrary. Furthermore, both groups are served

through the same service system—namely, runaway

and homeless youth centers, many of which are

funded in part by the Federal Government.6 Much of

the information in this chapter on homeless adolescents on their own has been gathered from adolescents using runaway and homeless youth centers.

Unless otherwise specified, when data on homeless

adolescents are reported, this chapter does not make

distinctions between adolescents who might be

identified as runaways and those who are truly

homeless and living on their own.

Adolescents become runaways or homeless on

their own for many reasons. Very few report leaving

home to have fun or to travel (33,71). Adolescents

frequently run away from dysfunctional and abusive

families (43,54,57,58,72,74).7 Evidence suggests

that the majority of these homeless adolescents have

histories of being physically or sexually abused

(31,33,42,57). Not surprisingly, conflict with family

members is often cited as a primary reason for

leaving home (2,66,72). Nearly two-thirds of the

young people seen at federally funded runaway and

homeless youth shelters cite a conflict with parents

as their main reason for leaving home (30,66). For

some homosexual or bisexual adolescents, family

conflicts over their sexual orientation precipitate

their running away (33,56). High rates of parental

alcohol abuse have also been reported for families of

homeless adolescents on their own, contributing to

SA1~ough [hc (cm ‘‘youth’ is commonly used when discussing adolescent hopelessness, OTA prefers the term ‘‘adolescent. The term Youth

implies a broader undefined agc range than the term adolescent and may include children younger than adolescents ages 10 through 18, as well as young

adults. In this chapter, OTA uses the term adolescent except in those cases where youth is part of the actual name of a piece of legislation (e.g., Homeless

and Runaway Youth Act), the actual name of a service organization or provider (e.g., homeless and runaway youth centers), or part of a definition

provided by an organization or in legislation to describe a particular population (e.g., the definition of homeless youth provided by the National Network

of Runaway and Youth Services).

bFeder~ly funded runaway and homeless youth centers are locally controlled facilities that receive Federal funds under the Fede~ R~way ~d

Homeless Act to provide emergency shelter and other services to runaway or otherwise homeless youth.

TFor fufier discussion of dysfunctional f~illch st?e ch. 3, ‘‘Parents and Families’ Influence on Adolescent Healttq ” in this volume,

-~ft: !} It, ‘f I -!< (/[ i
II-666 . Adolescent Health—Volume //: Background and the Effectiveness of Selected Prevention and Treatment Services

family violence and conflict (47,51,57). Most runaways and homeless adolescents on their own come

from single-parent or ‘reconstituted’ families (43).8

A study of 536 homeless and runaway adolescents in

New Jersey found that only 14 percent had left

homes where both their biological parents resided

(58).

In a sample of 118 adolescents entering runaway

shelters during a 2-week period in New York City,

Shaffer and Caton reported that unaccompanied

homeless adolescents tend to have parents who are

not homeless (57). It will be interesting to see if the

number of unaccompanied homeless adolescents

with homeless parents increases as the number of

homeless families in general rises.

Adolescents leaving foster care or institutional

settings (e.g., State psychiatric hospitals or juvenile

justice facilities) may become homeless if proper

discharge planning, including followup, is not performed, or if adolescents are placed in out-of-home

settings that are inappropriate to their needs (1,39,

59,76). Adolescents leaving foster care or mental

health institutions may have no place to live after

they are no longer eligible for these residentially

based services (15,39,59). About 10 percent of

adolescents receiving ongoing services from runaway and homeless youth centers had spent most of

the time during the previous year in an institutional

setting (72).

In their study of adolescents entering runaway

shelters in New York City, Shaffer and Caton found

that half of 118 young people interviewed in shelters

serving runaway and homeless adolescents had

spent some time in foster care; a fifth had most

recently lived in an institutional setting (57). Those

with a history of foster care placement had more

transient residential histories in general than adolescents who had not been in the foster care system.

In a study of 93 homeless adolescents in various

settings in the Hollywood, California area (e.g.,

shelters, soup kitchens, and informal congregate

sites such as street corners), Robertson found that

substantial percentages of homeless adolescents had

been in various institutional settings previously—

including foster care (40.9 percent), group homes

(38.2 percent), and juvenile detention or jail (55.9

percent) (47). About a third of these adolescents,

Robertson found, had gone to a shelter or the streets

after their most recent separation from an institutional setting. Many of these adolescents (all of

whom were ages 12 to 17) had simply runaway from

their last placement; others had been discharged to

the custody of their parents, but returned to the

streets after a fight or by mutual agreement (48).

Another recent study of young adults who had

been out of foster care for at least 2 years also

reported that one-third had spent their first night

after discharge on the streets; 29 percent had

experienced periods of hopelessness since leaving

the system at age 18 (76).

Service Needs of Homeless Adolescents

Homeless adolescents have a wide range of

service needs. The problems and service needs of

homeless adolescents living with their families

differ in some ways from the problems and needs of

adolescents homeless on their own.

Homeless Adolescents in Families

How Many of the Homeless Are Families With

Children?—Most of what is known about homeless

adolescents in families has come from surveys of

families in shelters. Virtually nothing is known

about homeless families who survive living in

vacant buildings, their cars, or temporarily ‘doubled

up’ with friends or relatives.9 Cities surveyed by the

U.S. Conference of Mayors in 1987 reported that an

average of one-third of their homeless populations

were families with children. Some cities surveyed

(e.g., New York) reported that homeless families

with children made up nearly two-thirds of their

homeless population (63). The vast majority (over

70 percent) of the cities surveyed reported that

homeless families were the largest group for whom

emergency shelter and other needed services were

most lacking.

There is a broad consensus that the numbers of

homeless families are growing, and that children

(including adolescents) may be the fastest growing

group of homeless people. The U.S. Conference of

Mayors, in its 1986 survey of 25 cities, reported that

the most significant change in the homeless population during 1986 was the growing number of

a’ ‘R&OnstitUted” f~les we ~icwy those in which a child lives with two addts who tiction as the child’s parents, o~y one Of Wimn is a

biological parent (e.g., stepfamilles).

%e U.S. General Accounting Office estimated that 186,000 children and adolescents lived in “shared housing” at any given time during 1987 (65).
Chapter 14—Hopelessness: Prevention and Services ● II-667

families with children; 80 percent of the cities

surveyed reported an increase in the number of

homeless families ‘with children (62). The 1987

survey of cities by the U.S. Conference of Mayors

reported that the numbers of homeless families and

children were continuing to increase (64). On

average, the number of homeless families with

children had increased by one-third during the

previous year (Charleston, South Carolina, reported

an increase of 144 percent). It must be noted,

however, that these figures do not reflect actual

counts by the U.S. Bureau of the Census. During the

1990 census, new efforts were made to include

homeless persons in the census count by surveying

shelters and observing individuals in places where

homeless people tend to congregate (e.g., under

bridges, in parks). The findings based on this

one-night count may provide some important information on the numbers of homeless families (and

adolescents). Given the many methodological problems involved in counting homeless persons and the

many “hidden” homeless who may not be observed

by census interviewers, however, it is unlikely that

the 1990 effort will produce a truly accurate

assessment of the numbers of homeless families

with adolescents.10

How Many Homeless Families Include Adolescents?—Data on the numbers of homeless adolescents ages 10 to 18 who are living with their families

are not available. Estimates of the numbers of

homeless children in families vary. Available literature, which is based exclusively on studies of

families staying in shelters, suggests that homeless

families typically consist of women on their own

(usually single) with their young children-usually

under the age of 5 (7,8,9,10,25,37,63). To OTA’s

knowledge, there are no studies that look exclusively

at adolescents living with their families in shelters.

There are studies that include adolescents ages 10 to

18, but these studies do not examine adolescents

separately. The story of one adolescent who lived

with his family in a homeless shelter is recounted in

box 14-A.

A 1989 U.S. General Accounting Office (GAO)

report estimated that, on any given night, there are

68,000 children and adolescents age 16 and under

who are members of homeless families (65). Of

those 68,000, an estimated 12 percent (8,160 adolescents) are ages 13 through 16 and an estimated 36

percent (24,480 children and adolescents) are ages 6

through 12.

Other studies, although using somewhat different

age breakdowns, have found results roughly consistent with the GAO study. Two studies reporting age

breakdowns of children living with their families in

shelters found that fewer than 10 percent of one

study sample were ages 12 to 16 (8), and that 26.6

percent of another sample of sheltered children were

ages 11 to 17 (37). A study of homeless adolescents

using meal programs in Alameda County, California

found that 17 percent of children in recently

homeless families were ages 13 to 17 (50). Differences in the percentages of children who are

adolescents in any given shelter probably depend on

a number of factors, including shelter regulations

that restrict the sheltering of older children and the

composition of the local homeless population.

Service Needs of Homeless Adolescents in

Families—The limited research that has been conducted on children (including adolescents) who are

homeless in families indicates that these children

experience a broad range of problems, including

physical and mental health problems and school

problems (3,39,41a). Some of these problems and

the service needs of these children are discussed

below.l1

Physical Health-studies indicate that homeless

children are at higher risk for virtually all medical

disorders experienced by children in general (37,39,

41a,77). They are particularly vulnerable to ailments

that result from environmental exposure and unsanitary living conditions, including problems such as

upper respiratory and ear infections, gastrointestinal

problems, lice infestations, burns and trauma (37,41a,

77). They also experience high rates of dental

problems. 12 Data from the 19 Health Care for the

Homeless projects funded by the Robert Wood

10~ tie stew~ B. Mc~ey HOmele~~ Assist~~ Amendments Act of 1~ (fiblic J.AW lt)l-645, sec. 402), Congress requested the U.S.

Government Accounting Office to study the methodology and procedures used by the Bureau of the Census in their count of homeless people.

1 ]Here ~d ~ the rema~dmof the dls,cussion that follows, the term ‘ ‘children’ is used to refer to children up to the age of 18 UIlle,S5 Ot.helWiSe specfled.

Data sources genemlly do not break out adolescents ages 10 to 18; consequently, it is often not possible to describe theti needs specifkally.

IZFor a gener~ dismssion of dental problems experienced by IOW-inCOme adolescents) ‘= Ch” 8* ‘‘Dental and Oral Health Problems: Prevention and

Services, ‘‘ in this volume.
II-668 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 14-A—A 13-Year-Old's Recollection of Life in a Homeless Shelter

My mother and my four brothers and sisters and I spent 21/2 years in the shelter. We moved there when I was

11 because my mother wanted to keep the family together, and not send us all to separate foster homes. Our old

one room house that we were renting was condemned. It shouldn’t have been lived in or rented; it had a cracked

window that kept it cold during the winter. My little brother caught pneumonia and was in the hospital for 2 months

and almost died. Our social worker said that we must move out and go to a shelter, or she would put us all in a foster

home--my mother did not want to separate us, so we decided to move to a shelter.

Life in the shelter was very hard to get used to. When we first got there, we had to stand in line outside in the

cold to eat. We couldn’t have visitors; not even relatives could come to the room to see us. There were times when

there were mice and rats in our room. Sometimes we didn’t have any heat and in the summer you couldn’t open

the windows to get air when the air conditioners broke down. I had to getup really early, because I had to take three

buses so I could get to school. At school some of the kids would make fun of me about living in the shelter, but

I would just ignore them. The food at the shelter tasted like plastic or paper cardboard. We saw the cooks stealing

food that we were supposed to eat. People were getting sick from the food that we got at the cafeteria. There were

no doctors to look after those who were sick. People were breaking into rooms when no one was in them. There

were security guards there, but they were often as afraid as we were. One security guard shot himself. Drugs started

to take over some of the people, and they would blame their children outside why they were doing drugs. I once

saw some people come and throw a man off a balcony, because he owed them money. There was a lot of shooting

and even children dying. One man who was shooting someone at the shelter almost hit a baby.

Soon after all of this stuff we got a doctor to come and be on the property, we got new guards to work there,

and even the food got better. They made it so that the people ate food by sections so there wouldn’t be too long of

a line to stand in. People started to come and go when they wanted so that they didn’t feel like prisoners. We could

even have visitors. My mother got a chance to get a trade as a carpenter. She and some other parents started a

children’s watch so that all of the children would be in their rooms at a certain time. The best part of the shelter was

that there were always kids to play with. Only families were allowed to stay at the shelter. A photographer came

to the shelter to teach photography and my mom said it would be a good idea to go, even though I didn’t really want

to. Now I take lots of pictures, and some have even been published in Life Magazine and The Washington Post.

There were people who only stayed in the shelter for a little while, but some stay forever. Luckily we finally

got out and now we live in our own home and we are doing very well. Thanks to the shelter we had some place to

go and we were all able to stay together as a family.

Johnson Foundation and the Pew Memorial Trust

(39) indicate that children who are homeless experience chronic health problems at about twice the rate

reported in the National Ambulatory Medical Care

Survey13 for children in general (77). Inadequate

facilities for daily hygiene increase risk of disease

and make it nearly impossible to follow prescribed

medical regimens. Living in close quarters, particularly in communal shelters, can increase the risk of

disease transmission (26).

Children who are homeless have been found to

experience nutritional deficits, such as iron deficiencies (39), and visual problems (4la).14 Shelters and

other emergency food assistance facilities report that

they are often unable to provide nutritionally balanced meals to residents and that they view lack of

food and poor nutrition as serious problems for

homeless families (63).

Mental Health—Information about the mental

health of older children in shelters with their families

is extremely limited. However, in studies of the

children of homeless families in Boston, Massachusetts, researchers found that children had serious

developmental and emotional problems (7,8,9,10).

These studies assessed school-aged children living

in shelters in Boston--of whom about one-third

were ages 12 to 16 and two-thirds were ages 6 to

1 l-on the Children’s Depression Inventory and the

Children’s Manifest Anxiety Scale and found that

they manifested high degrees of distress. Despite

13~e N~ti~~ ~b~at~~ M~&~ Cme Smey 15 ~ ongo~g s~ey conducted by D~S of ~btiatory visits to of%ce-based physicians. S= ch.

6, “Chronic Physical Illnesses: Prevention and Services, “ in this volume, for additional information about the suwey.

IAFor a gene~ discussion of the nutritional problems of adolescents, see ch. 7, “Nutrition and Fitness Problems: Prevention and Services, ” in this

volume.
Chapter 14—Hopelessness: Prevention and Services . II-669

their methodological limitations, the studies in

Boston do substantiate the generally high levels of

distress that children living in shelters can experience (9). Many of the difficulties experienced by the

Boston children (e.g., poverty, residential instability), however, predated their current episode of

hopelessness, indicating that the lives of these

children may have been disrupted for some time (9).

In contrast, a Philadelphia study of 43 shelter

children ages 6 to 12 found that only 9 percent had

scores in “the clinical range” on an index of

emotional and behavioral problems; another 7 children ages 6 to 12 (16 percent) in this study had scores

near the clinical range (41a). These findings could

have been a result of having parents rather than

children or professionals assess the children state

of psychological health (41a). In general, the researchers in this study seemed surprised at parents’

favorable ratings of their children’s health. When the

researchers used projective measures of emotional

status, such as making three wishes and house-treeperson drawings, the 6- to 12-year-olds showed “a

strong tendency to wish for major changes in their

life situation, indicating an intense awareness of

their plight as homeless poor people” (41a). In

contrast, younger children seemed less aware of

their and their families’ plight (41a).

The experience of hopelessness puts families as

a whole under high levels of stress, and children in

families that are homeless may be at greater risk of

child abuse and neglect than similar domicile d

children. In one Boston court, homeless children

account for one-third of the abuse or neglect cases

(22).

Access to Health Care---Children who are homeless are frequently without adequate or any health

15 A Washington State study insurance coverage.

found that 35 percent of a sample of homeless

children had no insurance coverage; 40 percent were

covered by Medicaid. One-third of the homeless

chilrden in this study did not have a usual site of

health care (e.g., public clinic, hospital clinic, or

emergency room), and over half (58.9 percent) did

not have a usual health provider (e.g., doctor, nurse,

or nurse practitioner). Lack of money or insurance

coverage of dental care frequently prevented families from seeking this care when it was needed for

children. Rates of emergency room use by children

who are homeless have been reported to be much

higher than for children in general, either because

care for homeless children is not sought until

problems become acute or because such children

have no regular health provider (37,41a).l6

Education—The U.S. Department of Education,

in a recent report to Congress on school-aged

homeless children and adolescents, estimated that

there are 272,773 school-aged homeless children

throughout the United States (70).17 Estimates were

made using a variety of methods, including actual

l-day counts, data based on estimation, and partial

data where information was not available for all

parts of a State. One State, Hawaii, did not provide

data for the report. Because of these methodological

concerns, caution is advised when interpreting the

data. 18

About three-quarters (about 72 percent) of schoolaged homeless children and adolescents are estimated by the U.S. Department of Education to be

attending school; more than one-quarter (about 28

percent) of school-aged homeless children and

adolescents are not thought to be attending school.19

The U.S. Department of Education reports that about

47 percent of homeless school-aged children and

adolescents who are attending school are in grades

7 through 12 (26 percent in grades 10 through 12 and

IsFor a general discussion of heal~ insu~ce coverage among adolescents, see ch. 16, “Financial Access to H@th Services, ’ in VOI. III.

16 For a discussion of issues pertaining to the delivery of care to adolescents, see ch. 1S, “Major IS5ue5 pe rtaining to the Delivery of Primary and

Comprehensive Health Services to Adolescents, ” in Vol. III.

ITEst~ate~ ~clude fiwe~ for tie Vu@n Isl~ds, Amefic~ Samoa, and pu~o Rico. ~ese territories account for ml estimated 3,~ homeless

school-aged children and adolescents.

18Th1s study was submitted t. Conuess in response t. section 724(b)(2) of tie Stewm B.Mcwey Homelms Assistance Act (Public hW 100-77).

Recent amendments to the act (the Stewart B. McKimey Homeless Assistance Amendments Act of 1990-Public Law 101-645) require an additional

study by the U.S. Department of Education to “determine the best means of identifying, locating, and counting homeless children and youth”. . .“to

create as accurate an account as possible of the number, location, and living circumstances of such children and youth that are attending school regularly,

part-time, or not at all, and reasons for the non-attendance of such children and youth. ’

l~ata were not provided t. (he U,S, Dep~ent of Education by Alab~, tile Dis~ct of Columbia, ~uisi~, Mississippi, New York, or tie Vhgln

Islands.
11-670. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

21 percent in grades 7 through 9), and about 49

percent in kindergarten through grade 6 (70).20

New York City data reveal that about two-thirds

(64 percent) of homeless junior-high-school-aged

adolescents and half of homeless high-school-aged

adolescents in the city attend school (44,45).

The National Coalition for the Homeless estimates that 40 percent of homeless school-aged

children do not attend school (40).

Bassuk and her colleagues report that by the time

they reach the shelter, children have frequently

already experienced problems in school (9,10). For

example, 43 percent of homeless school-aged children in a Boston study were found to have repeated

a grade by the time they were surveyed in the shelter.

Not surprisingly, the study of 6- to 12-year-old

children in Philadelphia shelters found that the

children tended to have low scores on standardized

tests of expressive vocabulary and word decoding

(41a).

Homeless children face a number of barriers to

continuing their schooling (45). Because shelters

rarely have day-care facilities, older children will

often stay out of school to care for younger children

while parents are out job hunting or looking for

housing (1 1). Similarly, school-aged parents maybe

prevented from attending school (70). Even if they

had been attending school regularly prior to entering

the shelter, adolescents are frequently unable to

continue to attend their ‘‘home’ school, as the

shelter is rarely in the same area. Until Federal laws

were changed recently with the Stewart B. McKinney Act (discussed below), homeless children were

often refused enrollment in schools because they

lacked a permanent address (23); even with the

change in law, resistance from school personnel

continues in some areas (55).

Lack of appropriate documents, such as birth

certificates and immunization records, may also

make it difficult for homeless families to register

children for school (63,70). Families moving from

place to place may find it particularly difficult to

keep important personal records securely with them.

Without transportation, they find it extremely difficult to file requests for copies of birth certificates

personally, and by the time copies have come

Photo credit: Office of Technology Assessment

Recent changes in Federal law prohibiting exclusion of

children from school because they have no permanent

address, and special schools and programs for homeless

children in difficulty in school, are ways in which

policy makers and educators are addressing

the educational needs of homeless children

in families.

through mail requests, families may have relocated.

Significant delays can also be experienced when

records are transferred from schools where children

were previously enrolled (70). If children are living

separately from their parents (e.g., with friends or

family), the unavailability of a legal guardian can

prevent school registration (40).21

Even when they are enrolled in school, homeless

children face barriers to school attendance. Attendance at a child’s “old” school may require long

daily trips on public transportation; and money is not

always available to pay for transportation (40,70).

Many homeless children find that they must face

ridicule from their classmates when it is discovered

that they are homeless (23,55). Another problem is

that homeless shelters are often lacking in the

privacy and quiet needed for children to complete

their homework (40). Educators who work with

homeless children indicate that it often takes special

effort to keep homeless children in school, even

knocking on shelter doors every day to ensure

attendance (55).

One response to this problem has been to create

special schools for homeless children where they

will not be ostracized and educators understand their

needs (23). Special schools for homeless children

2oData on grade level were not available for 4 percent of children and adolescents.

zlT1fle ~ of the 1ggo ~en~ents to the Mc~ey Act (fiblic ~w 101.645) ad&es~s the~ barriers to school enrolhnent (discussed bdow).
Chapter 14—Hopelessness: Prevention and Services . II-671

have been created in Tacoma, Washington; Santa

Clara, California; and Salt Lake City, Utah (23).

Homeless children and adolescents often have

special educational needs that include remediation

in basic skills, support services such as counselors

and social workers, after-school programs to address

basic needs including food and shelter, and sensitivity and awareness training for school personnel (70).

Homeless Adolescents on Their Own

Recent concern about homeless children has

focused primarily on the needs of children who are

part of homeless families. As noted earlier, however,

many, if not most, homeless adolescents are living

on their own. In many ways, the problems of

homeless adolescents on their own raise more

difficult policy issues.

How Many Adolescents Are Homeless on Their

Own? —Estimates of the number of unaccompanied

homeless adolescents ages 10 to 18 vary. Among the

cities surveyed by the U.S. Conference of Mayors in

1987, 12 cities reported on numbers of unaccompanied homeless adolescents. These cities reported that

unaccompanied adolescents (ages not specified)

represented 4 percent of their homeless population

(64). Nine of twelve cities reporting on the numbers

of unaccompanied homeless adolescents reported

that homeless adolescents were a group that was

increasing in size.

Title V of the Stewart B. McKinney Homeless

Assistance Act of 1987 provided funding for the

Primary Health Care and Substance Abuse Program

(the Health Care for the Homeless Program) by

adding a new Section 340 to the Public Health

Service Act (34). The federally funded Health Care

for the Homeless Program provides direct health

care services to homeless persons and is administered by the Bureau of Health Care Delivery and

Assistance within DHHS. In 1988, during the first

year of operation of the program, 1.8 percent of the

contacts were with runaway or homeless adolescents

(ages not specified) (34).

DHHS, in the 1984 annual report on runaway

youth centers, estimated that about one-third (or

100,000) of the young people receiving services

under the Runaway and Homeless Youth Act

(discussed below) were homeless (71). DHHS further estimated in 1984 that there are more than a

Photo reedit: Sasha Bruce Youthworks, Inc.

In many ways, the problems of homeless adolescents on

their own raise more difficult policy issues than do the

problems of homeless children with their families.

million runaway and homeless adolescents ages 10

to 17 each year (72). Because of the lack of more

recent national data, these estimates, based upon a

1976 National Statistical Survey of Runaway Youth

mandated by Congress in the original Runaway

Youth Act (Public Law 93-4 15), continue to be used

(72).

In a 1990 study sponsored by the Office of

Juvenile Justice and Delinquency Prevention of the

U.S. Department of Justice** to determine the

numbers of children who are missing each year,

researchers used a variety of methods to develop

estimates-including a national telephone survey of

over 10,000 randomly selected households to develop estimates of the numbers of children who had

run away, been thrown away, been abducted, been

lost, or were otherwise missing; a survey of juvenile

facilities (e.g., group foster homes, juvenile correctional facilities, mental health facilities, and drug

abuse rehabilitation facilities) to determine the

number of runaways from these facilities; an interview study with children who had run away and

returned home; and a study of a national sample of

agencies having contact with children to determine

the numbers of children known to these agencies

who had been abandoned or thrown away.

According to the U.S. Department of Justice

study:

. There are approximately 450,700 children and

adolescents who run away in the United States

22~s S@dy ~U ~mdated by he l$)&$ ~SSi~g ~l&en’S Assis~ce Act (fiblic bw 9W.43, WC. 404 (b)(q)) (75).
II-672 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

●

●

each year; and about 133,500 of them are

without a place to sleep during some night

while they are away from home (75).

There are approximately 127,100 “thrownaway” children and adolescents in the United

States each year; and about 59,200 of them are

without a familiar and secure place to stay at

some point during their thrownaway experience (75).

About 45,900 children and adolescents in the

United States in 1988 qualified as both runaways and thrownaways (75).23

All of these estimates include high proportions of

adolescents. The U.S. Department of Justice study

found that nearly all of the estimated 112,600

‘‘thrownaways’ who were identified through the

household survey were ages 13 to 17; about onequarter of the estimated 14,500 “abandoned” children identified through a community survey of

child-serving agencies were ages 11 to 17; and 98

percent of the estimated 446,700 ‘‘runaways” identi.tied through the household study were ages 11 to

17 (75). The researchers consider these estimates of

the numbers of throwaway and abandoned adolescents and children to be conservative because they

rely on interviews with caretakers (who might be

more likely than their children to report an incident

as running away rather than being thrown away) and

because estimates of the numbers of abandoned

children relied on limited data from providers (75).

The U.S. Department of Justice study, on the basis

of the household survey only—i.e., excluding estimates of the numbers of abandoned children and

adolescents and the numbers of runaways from

juvenile facilities24--estimated that 513,400 children and adolescents become runaways or thrownaways in the United States each year (75).25 One

cannot determine from the data how many of these

513,400 children and adolescents could be classified

as homeless during their runaway or thrownaway

experience. The data clearly indicate, though, that

tens of thousands of adolescents in the United States

each year have the experience of being without a

familiar and secure place to sleep.

In fiscal year 1987, 10.1 percent of the 56,000

adolescents who received shelter or counseling

through federally funded runaway and homeless

youth centers were classified as homeless (72). That

year, however, only about half of the adolescents

who received such services at these centers were

reunited with their families, a fact which suggests

that the percentage of adolescents who are homeless

may be much higher. Of the adolescents receiving

services, 35.2 percent were placed in alternative

living arrangements, 9.2 percent had no planned

destination, and 5.4 percent returned to the streets. In

general, younger and runaway adolescents tended to

return home; older and homeless adolescents tended

to pursue alternate arrangements. GAO estimates

that 70,000 unaccompanied young people may have

been served by federally funded and other runaway

shelters in 1987; there may be another 64,000 to

208,000 homeless adolescents who are not seen in

shelters (65).

A study of adolescents using shelters in Los

Angeles County reported that 35 percent had no

home to which they could return; another quarter

were chronic runaways who were unlikely to be

returned home (35). Two-thirds of the adolescents

seen by outreach agencies (e.g., drop-in centers or

street workers) were truly homeless; most were

staying on the street.

There is little information available about homeless adolescents on their own who do not use

available shelter and runaway services (i.e., adolescents who stay, for example, in cars, abandoned

buildings, parks, or all-night restaurants).26 Homeless adolescents living on their own who do use the

runaway and homeless youth shelter system, however, tend to be non-Hispanic white (although blacks

represent a disproportionate share), ages 16 or 17

(generally older than homeless adolescents with

their families), and are more likely to be male than

~sIndividu~s could qti~ aS bo~ for example, if they had had more than one incident of leaving home, or if, after running away, they had become

thrownaways when their caretaker refused to allow their return home.

24~e au~ors of tie s~dy caution ag~t simply add~g toge~er estimates of tie numbers of ~erent types Of ‘ ‘Inking’ Children (e.g., IUIlaWayS

with thrownaways) because of the potential for overlap between categories, and because it may not make conceptual sense to combine categories (75).

~Bwause of tie ~@ proportion of adolescents identifi~ as ~ways or @wnaways h tie household swey, one would expect a very high

proportion of these 513,000 runaways/thrownaways to be adolescent.

26~e propo~on of umccomp~ed homeless adolescen~ who use shelter services is unknown. One study, wtich sa.mPkd homeless adolescents from

a variety of sites other than shelters in Hollywood, Californi& found that only 40 percent reported that they had stayed in a shelter during the previous

month (52).
Chapter 14—Homelessness: Prevention and Services ● II-673

female (55 percent of homeless adolescents using

runaway and homeless youth shelters are male) (66).

The ethnic mix of adolescents who use the runaway

and homeless youth shelter system, however, tends

to vary depending on the greater community. In their

sample of adolescents entering runaway shelters

during a 2-week period in New York City, for

example, Shaffer and Caton reported that about half

were black and more than one-third were Hispanic

(57). The numbers of male adolescents from Central

America who have entered the country illegally and

are now homeless may be increasing (43).

According to data collected from runaway and

homeless youth centers, most homeless adolescents

using runaway and homeless youth centers are from

the local area (49,66,72). DHHS reported in 1987

that nearly nine-tenths (87.4 percent) of adolescents

receiving services from federally funded runaway

and homeless youth centers had last lived within 50

miles of the runaway shelter; more than half (52.2

percent) of the adolescents receiving such services

had last lived within 10 miles of the shelter (66,72).

Some geographic areas, such as Los Angeles and

San Francisco, report relatively higher proportions

of homeless adolescents coming from other areas

(33,60). Of the adolescents using federally funded

runaway and homeless youth shelters, about half

have run away previously (72),

Service Needs of Homeless Adolescents on

Their Own-Adolescents who are homeless and on

their own are at greater risk than those in the general

population for a number of health problems, including physical and mental health problems, substance

abuse, pregnancy, sexually transmitted diseases, and

physical and sexual abuse.

Physical Health—Few specifics are known about

the physical health status and health care needs of

unaccompanied homeless adolescents (4). Existing

data suggest that many of the problems they

experience are similar to those experienced by

homeless children in families. For example, even

when homeless adolescents find it relatively easy to

find food (either through soup kitchens and shelters,

or by purchasing food), their diets are often nutritionally deficient (42), and their poor diets may

exacerbate medical problems (21).

In addition, the American Medical Association

Council on Scientific Affairs notes that living on the

streets makes it particularly difficult for homeless

adolescents to perform routine tasks associated with

personal hygiene (4). Thus, it is nearly impossible to

follow treatment protocols such as keeping a wound

clean. Resistance to disease is lower under the

stressful conditions of living on the streets, so the

chances of contracting infectious diseases are increased (57). Two-thirds of homeless adolescents in

one study reported recent health problems (no

further information available) (47). More than half

had received medical treatment during the past year;

about a fifth said that their health had become worse

since becoming homeless.

Homeless adolescents ages 13 to 19 who were

seen by 17 of the 19 Health Care for the Homeless

projects funded by the Robert Wood Johnson

Foundation and the Pew Memorial Trust suffered

higher rates of nearly all acute disorders (e.g., upper

respiratory infections, genitourinary problems, minor

skin problems) and trauma as compared to adolescents included in the National Ambulatory Medical

Care Survey (78). Homeless adolescents in this

clinical sample also experienced chronic disorders

(e.g., eye disorders such as poor vision, gastrointestinal disorders, ear problems such as otitis media

(middle-ear infections) or impaired hearing, and

dental problems) at nearly twice the rate of similarly

aged adolescents in the National Ambulatory Medical Care Survey study. Nutritional disorders were

also more common among the homeless adolescents

(78).

Homeless adolescents on their own, as well as

those with their families, face a number of barriers

to receiving appropriate services. Older adolescents,

in particular, may fall ‘‘between the cracks’ as they

fall outside of the jurisdiction of programs designed

to serve children but do not yet have the full rights

of adults. Such adolescents may not be eligible to

receive public assistance (welfare) if they have not

been legally emancipated through the court, may be

excluded from shelters serving families or single

adults, and may have difficulty gaining access to

medical services without parental consent (4,5,59).27

‘7Forageneral discussion of how parental consent requirements may affect adolescents’ access to health care, see ch. 17, ‘Consent ~d Confidcnti~ity

in Adolescent Health Care Decisionmaking, ’ in Vol. II].
II-674 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Most homeless adolescents have no medical

insurance coverage (46).28 Often, adolescents believe that without money, they are ineligible to

receive services such as medical care (4,5). Hospitals, including emergency rooms, are frequently the

most common source of regular care. Greater use of

hospital v. ambulatory care results in costly utilization patterns (46).

Mental Health-Homeless adolescents on their

own frequently experience higher rates of mental

health problems than adolescents in the general

population. 29 There are anecdotal reports that the

population of young people on the street is becoming

younger, and more disturbed and dysfunctional (54).

Researchers report that homeless adolescents

experience high rates of depression and are likely to

have a history of suicide attempts. One study found

that 83.6 percent of homeless and runaway adolescents were diagnosed as depressed through an

interview by an examining physician (v. 24 percent

of a sample of nonrunaway adolescents who also

attended the same clinic), and 18.2 percent of

homeless and runaway adolescents revealed a history of attempting suicide (as compared to 4 percent

of nonrunaway adolescents) (79). Another study

found that at least a third of the homeless adolescent

females and 15 percent of the homeless adolescent

males had previously attempted suicide (57). Another third of the homeless males and females had

thought about attempting suicide. Other researchers

report that nearly half of homeless adolescents had

histories of suicide attempts, with 29 percent having

attempted suicide in the previous year (38,53). Data

from DHHS on adolescents served by federally

funded runaway and homeless youth centers suggest

that as many as 61 percent of these adolescents are

depressed and that about 11 percent maybe suicidal

(72).

Almost a quarter of a sample of homeless

adolescents in the Hollywood, California area had

received inpatient mental health treatment at some

time, although few had received any type of mental

health treatment during the year prior to their being

surveyed (38,47,53). Rates of mental disorders listed

in the third edition of the American Psychiatric

Association’s Diagnostic and Statistical Manual of

Mental Disorders (DSM-III) were found to be at

least three times higher than those of a nonhomeless

group of comparison adolescents (as assessed by

items from the Diagnostic Interview Schedule and

the Diagnostic Interview for Children and Adolescents, both of which are based on DSM-III). In

addition to high levels of self-reported depression

symptoms, a sizable portion (29 percent) reported

four or more symptoms on a psychotic symptom

index, further emphasizing the need that many of

these adolescents have for mental health evaluation

and possible treatment (38).

Adolescents in their sample of homeless and

runaway adolescents in New York, Shaffer and

Caton found, had a psychiatric profile similar to

adolescents attending a psychiatric clinic (57). In

addition, 38 percent of the adolescents Shaffer and

Caton surveyed reported that they needed help for

emotional problems; one-fifth had previously received psychiatric treatment. Shaffer and Caton

concluded that much of the current psychiatric

disturbance was present before the current runaway

or homeless episode.

Substance Abuse—Various studies have reported

high rates of substance abuse among homeless

adolescents. 30

Yates et al. found, for example, that 83.6 percent

of the 110 homeless and runaway adolescents and

young adults31 using an outpatient medical clinic in

Hollywood, California reported that they used drugs

or alcohol (as compared to 67.0 percent of the 665

nonrunaway clients seen at the clinic) (79). These

researchers also found that 34.5 percent of the

homeless and runaway adolescents using the clinic

had used intravenous drugs (as compared to 3.7

percent of their nonrunaway peers) (79).

A survey of adolescents and young adults ages 10

to 24 visiting an outpatient medical clinic in Los

2$For ~ ~ener~ di~cu~~ion of ~olescen~’ problems ~~ resWct to heal~ fiur~ce, see ch. 16, “Financial Wess to H(@th Service&” iKI VO1. ~.

z~or ~ ~ener~ ~scu~~ion of ment~ he~~ problems among adol~cents, see ch. 11, “Mental Health Problems: Prevention and Semices, ” in this

volume.

%or a general discussion of substance abuse among adolescents, see ch. 12, “Alcohol, Tobacco, and Drug Abuse: Prevention and Services,” in this

volume.

slF@two percent of tie runaway clients were ages 10 to 17 (as were 34 perCent of the no~ way clients), 40 percent of the runaways were ages

18 to 21 (as were 57 percent of the nonrunaways), and 8 percent of the runaways were ages 22 to 24 or of an unknown age (as were 9 percent of the

nonrunaways).
Chapter 14—Hopelessness: Prevention and Services . II-675

Angeles found that an estimated half of the homeless

and runaway adolescents seen were involved in drug

abuse (54).

Shaffer and Caton reported that 70 percent of the

homeless and runaway adolescents entering runaway shelters in New York City used drugs (57).

Robertson found that more than one-third of the

93 homeless adolescents interviewed in a study in

the Hollywood, California area met DSM-III diagnostic criteria for drug abuse (47). This drug abuse

rate among homeless adolescents (1 in 3) was five

times greater than the rate reported for adolescents

who were not homeless (47). About one-quarter of

the homeless adolescents surveyed by Robertson

reported having used drugs (e.g., heroin, cocaine)

intravenously at least once (47). Robertson and her

colleagues also found that more than one-third (38

percent) of the 93 homeless adolescents they interviewed in the Hollywood, California, area met the

DSM-III criteria for alcohol abuse on dependence in

the previous year and that nearly half (48 percent) of

the 93 had an elevated lifetime prevalence of alcohol

dependence or abuse (47,51,52). Robertson and her

colleagues found that overall, 7.5 percent of the 93

homeless adolescents (13 percent of those diagnosed

as alcohol abusers and 2 percent of the nonabusers)

had ever received alcohol inpatient treatment. Only

18 percent of the homeless adolescent alcohol

abusers had received treatment of any type in the

previous year. The fact that so few received treatment was probably due in part to the fact that

relatively few of the adolescents perceived their

alcohol use to be a problem. Homeless adolescents

with alcohol abuse problems were more likely to be

male, white, and older than other homeless adolescents (mean age = 16.1 years; range: ages 13 to 17)

(47,52). These adolescents also had more chronic

histories of hopelessness, were less likely to utilize

shelters, and experienced greater difficulty in meeting other subsistence needs (e.g., food and clothing).

These adolescents were more likely to have left

home because of physical or sexual abuse, to have

had a more chronic and extensive history of institutional contact, to have more mental health problems,

and to abuse drugs.

Sexual and Reproductive Health-- Several studies have found that most homeless and runaway

adolescents have higher rates of sexual experience

than other adolescents.

Yates et al. reported that nearly all of the 110

10- to 24-year-old runaway adolescents seen at an

outpatient medical clinic in Hollywood, California

(46.9 percent were ages 15 to 17, and 41.6 percent

were ages 18 to 21) had had sexual intercourse (79).

These investigators found that more than one-half

(57.3 percent) of the runaway street adolescents and

young adults in their Los Angeles study had had

sexual intercourse before the age of 15 (as compared

to 31.0 percent of the nonrunaways) and that almost

20 percent of the runaway street adolescents and

young adults in their study had had sexual intercourse before age 10 (as compared to 2.1 percent of

the nonrunaways) (79).

Roberston similarly found that nearly all (92.3

percent) of the 93 homeless adolescents she surveyed in various settings in the Hollywood, California area reported being sexually active (mean age =

16.1 years) (47). Forty percent of the homeless

adolescents Robertson surveyed reported being sexually active by age 13 (47).

Furthermore, Shaffer and Caton, in their study of

118 adolescents entering runaway shelters during a

2-week period in New York City, found that

three-quarters of adolescents under the age of 18

reported that they had engaged in sexual intercourse

(57).

Even though most homeless adolescents are

sexually active, few of them report consistent use of

contraceptives (46,57). Homeless adolescents who

engage in unprotected sexual intercourse are at

increased risk of pregnancy and sexually transmitted

diseases (STDS).32 Various studies have reported

high rates of pregnancy for homeless female adolescents. 33 In their sample of adolescents entering

runaway shelters during a 2-week period in New

York City, for example, Shaffer and Caton found

that one-third of the homeless female adolescents

they interviewed (mean age = 15.7 years old) had

been pregnant (57). Almost half (44.4 percent) of the

homeless female adolescents surveyed by Robertson

in the Hollywood, California area had been pregnant

X?Fora ~ener~ discussion of adolescent pre~cy, see ch. 10~ ‘‘Pregnancy and Parenting: Prevention and Services, ’ in this volume. The risk of STDS

among adolescents is discussed in ch. 9, ‘‘AIDS and Other Sexually Transmitted Diseases: Prevention and Services, ” in this volume.

JJFor a gcncml discussion of pregnancy rates among adolescents, see ch. lo, “Pregnancy and Parenting: Prevention and Services, ” in this volume.
II-676 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

(47). National data indicate that about 40 percent of

all young black women and a fifth of young white

women have been pregnant before the age of

18--older than the adolescent females in these

samples (29).

Of homeless females ages 13 to 15 seen by Health

Care for the Homeless projects funded by the Robert

Wood Johnson Foundation and the Pew Memorial

Trust, 14 percent were pregnant at or after their first

contact with the project, as were 31 percent of

females ages 16 to 19 (data are not reported on

lifetime pregnancies) (78). The pregnancy rate

among these homeless females was more than 10

times the pregnancy rate reported for females ages

13 to 15 in the National Ambulatory Medical Care

Survey; in fact, it was at least 3 times the pregnancy

rate reported for females ages 16 to 19 in that survey.

Homeless and runaway adolescents participate in

street prostitution (often for ‘ ‘survival, ’ i.e., in

exchange for food, shelter, or money with which to

purchase food or shelter) at relatively high rates.

Nearly 30 percent of homeless adolescents (31

percent of females; 28 percent of males) surveyed by

Robertson in the Hollywood, California area reported that they engaged in prostitution; they were

more likely to engage in prostitution during periods

of hopelessness than when they were housed (46).

Similarly, 35 percent of those seen at the Larkin

Street Youth Center in San Francisco reported that

they had engaged in prostitution, primarily for

economic reasons (33).

Yates et al. reported that 26 percent of runaway

street adolescents seen at an outpatient medical

clinic in Hollywood, California engaged in prostitution (as compared to only 0.2 percent of nonrunaway

adolescents seen at the same clinic) (79).

Lower rates of prostitution among homeless

adolescents are reported for clients of The Bridge, a

multiservice agency in Boston, Massachusetts. There,

less than 20 percent of homeless adolescents are

reported to have resorted to prostitution (43),

Particularly in some areas, such as San Francisco

and Los Angeles, relatively high numbers of homeless adolescents are reported to be homosexual

(32,80). A Seattle survey found that 40 percent of a

sample of street adolescents identified themselves as

gay, lesbian, or bisexual (56). A fifth of males using

a New York City shelter reported that they were gay

(61). Frequently, these adolescents have been rejected by their families because of their sexual

orientation. Once on the streets, they are particularly

vulnerable to violence and victimization (1,80).

Because they are more frequently involved in

sexual activity (including both homosexual and

heterosexual prostitution) and intravenous drug use,

homeless adolescents are at higher risk for infection

with human immunodeficiency virus (HIV), the

virus that causes AIDS (16,28,80). An ongoing

study at Covenant House shelter in New York City,

in which clients receive a health assessment upon

admission to the facility, indicates that 6 to 7 percent

of adolescents (ages 15 to 20) screened tested

positive for AIDS antibodies (61).

Runaway and homeless youth centers in all 10

Federal regions report that one of their primary

health concerns is the prevention of STDs and care

for victims of STDs and AIDS among runaway and

homeless youth (72). DHHS, with the involvement

of its National Institute on Drug Abuse, has begun to

provide AIDS prevention training to staffs of

federally funded runaway and homeless youth centers (30).

Physical and Sexual Abuse—Researchers report

that large numbers of homeless adolescents were

subjected to physical or sexual abuse prior to

becoming homeless (6,21,31,36,47,58).

More than 60 percent of a sample of 75 homeless

adolescents surveyed in San Francisco, reported that

they had been sexually abused before leaving home

(28). A study of 187 Canadian adolescents and

young adults ages 16 to 21 who were receiving

services at a shelter for runaway and homeless youth

revealed that 81 percent experienced severe physical

abuse at home (6). This abuse was most frequently

perpetrated by a parent.

In the fiscal year 1984 annual report on federally

funded runaway and homeless youth centers, DHHS

reported that for about one-third of young female

adolescents and one-fifth of young male adolescents

using centers, physical or sexual abuse by family

members or others was a problem that led to their

running away (71).

Over one-third (37.2 percent) of the sample of 93

homeless adolescents surveyed by Robertson in the

Hollywood, California area reported that they had

left home at least once because of physical abuse;

10.7 percent reported that they had left home
Chapter 14—Hopelessness: Prevention and Services . //-677

because of sexual abuse (47). A fifth of the homeless

adolescents in this sample had been removed from

their homes at some time because of abuse or

neglect—an observation that corroborates the belief

that many of these homeless adolescents had, in fact,

come from abusive households,

In a New Jersey sample of 536 adolescents using

runaway and homeless youth center services (of

whom 60 percent were considered to actually be

homeless), almost half reported physical or emotional abuse, and over 10 percent reported sexual

abuse at home (58).

Sexual and physical victimization continue to be

a fact of life for many adolescents living on the street

(79). Yates et al. reported that 3.6 percent of the 110

runaway and homeless adolescents seen at an

outpatient medical clinic in Hollywood, California

(as compared to 1.4 percent of the 655 nonrunaway

adolescents seen at the clinic) were treated for

trauma (79). They also reported that 1.8 percent of

the runaway and homeless adolescents seen at this

clinic were treated for rape (as compared to 0.5

percent of nonrunaway adolescents seen at the

clinic) (79).

Robertson found that 42 percent of the 92

homeless adolescents in her study in the Hollywood,

California area reported physical abuse, and 13

percent reported sexual abuse in the past year (46),

The fact that the number of homeless adolescents

reporting sexual abuse in Robertson’s study (13

percent) is low in comparison to the number

reporting that they engaged in prostitution (29.7

percent) suggests that the homeless adolescents

Robertson surveyed did not perceive the exchange of

sexual favors for food, shelter, or protection (survival sex) as constituting sexual abuse. Consequently, the self-reports of sexual abuse among these

adolescents may be low.

A survey of young people using Los Angeles

County shelters found that about half of them had a

history of abuse and neglect (35).

Education-—A recent GAO study found that 37

percent of adolescents receiving shelter services at

federally funded runaway and homeless youth centers between October 1985 and June 1988 were not

attending school (66). Half of those age 16 or older

had either dropped out of school, been expelled, or

been suspended.

Several researchers have reported that most homeless adolescents have poor histories of school

adjustment (42). Shaffer and Caton, for example,

reported in their study of 118 adolescents entering

runaway shelters during a 2-week period in New

York City, found that three-quarters of the males and

one-half of the females they interviewed had been

expelled from school at some time, most for fighting

or drug use (57). About half of the adolescents they

interviewed had repeated a grade (57). Data from

DHHS on runaway and homeless adolescents using

federally funded runaway and homeless youth centers indicate that more than one-fourth of these

adolescents had problems with school attendance,

about a quarter had poor grades, and almost 10

percent had difficulties with teachers (72).

Staying in school after leaving home can be very

difficult for runaway and homeless adolescents.

Adolescents on their own face significant problems

(e.g., finding places to study, obtainin g appropriate

records, need for day-care facilities if they are young

parents) similar to those described for homeless

adolescents staying with their families in shelters.

They face additional problems if they do not have a

guardian who can enroll them in a school. If they

wish to enroll in a new school district, for example,

it may be particularly difficult for them to obtain

appropriate records and signatures if they are estranged from their guardian(s) (40). A survey of

young people in Los Angeles County reported the

need for services to help homeless adolescents return

to school, including the need for testing to determine

any need for special services (35).

Illegal Activity/Juvenile Justice System Involvement—As noted above, some homeless and runaway

adolescents use illegal drugs, engage in prostitution,

or participate in other types of illegal activities that

may bring them into contact with the juvenile justice

system.34

Adolescent males, in particular, are reported to

have experienced contact with the justice system

(72). For nearly a quarter (23.7 percent) of adolescent males receiving ongoing services from runaway

and homeless youth centers in fiscal year 1987,

34 For ~ discu~slon of ~&r ~ffen~e~ t~t my b~ng ~dolescen~ into contact wi~ me juvenile justice system, see ch. 13, ‘‘Delinquency: ~eventiOn

and Scrviccs, ’ In this volume. As noted in that chapter, running away itself may bring adolescents into contact with this system.
II-678 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

being “in trouble with the justice system” was cited

as a problem that had contributed to their leaving

their last residence (as compared to 9.7 percent of the

adolescent females). Over 10 percent (1 1.8 percent)

of males and less than 5 percent (3.8 percent) of

females receiving services from the centers cited

“being in trouble with the juvenile justice system”

or law enforcement as being their primary reason for

seeking services at the center. Furthermore, 1.9

percent of the adolescents served by the runaway and

homeless youth centers (2.6 percent of males; 1.4

percent of females) were expected to reside in

correctional institutions after receiving services at

the centers.

Many of the adolescents in Robertson’s sample of

93 homeless adolescents in the Hollywood, California area reported that they obtained income from

illegal activities such as panhandling, prostitution,

and drug dealing (46). Some of these activities were

adaptive behaviors in which homeless adolescents

engaged to provide for basic needs (e.g., breaking

and entering to get a place to stay). Many adolescents in this study reported that they only engaged in

these behaviors when they were homeless or that

they engaged in these behaviors more frequently

when they were homeless.

Robertson found that homeless adolescents who

abused alcohol were more likely than other homeless adolescents to engage in illegal and problem

behaviors (46). They were almost twice as likely to

have sold drugs (half of those doing so to support

their own drug habit), and more likely to trade sex

for drugs or money.

More than one-third (37 percent) of the males and

almost a fifth (19 percent) of the females surveyed

by Shaffer and Caton in their study of adolescents

entering runaway shelters during a 2-week period in

New York City reported that they had been charged

with an offense (e.g., assault or robbery) at some

time (57). A minority (22 percent of males; 10

percent of females) had been in a detention center

previously; 12 percent of the males had been in a

work camp or prison. About a quarter of the males

(28 percent) and 12 percent of the females reported

that they had stolen something in the previous 3

months. Males were significantly more likely than

females to have been charged with an offense, gone

to court, and to have been convicted or incarcerated.

Training in Independent Living—In addition to

needing physical and mental health services, homeless adolescents often have a need for training in

independent living skills, including vocational training (19).

In 1985, the Hollywood Homeless Youth Project

in Hollywood, California, reported that 86 percent of

the adolescents requesting services wanted job

training and placement, half wanted help in finding

shelter, and half requested school services (54).

Shaffer and Caton also reported that adolescents

most wanted help in finding a job (57). Another half

wanted counseling for problems with thoughts and

feelings. Other homeless adolescents have reported

that a primary goal was to find their own apartment

(19). This goal can be particularly difficult to

achieve because unemancipated minors cannot legally enter into a contract such as a lease (49).

Major Federal Policies and Programs

Pertaining to Hopelessness

Primary responsibility for addressing the needs of

the homeless has traditionally been held by various

private charities, religious groups, and nonprofit

agencies. Through missions, private shelters, clothing closets and the like, the private sector has

responded to meet the most basic needs of society’s

poorest individuals. While few deny that the Federal

Government must make some response, there is

controversy as to whether the Federal Government

should take a primary role in responding to the

problem. Some believe that alleviating the homelessness crisis requires solutions that have to be

implemented at the national level. Others believe

that discretion for programming should be retained

at the State or community level, with private and

civic groups working together to solve what are

essentially local problems.

The primary mechanism for providing direct

services to homeless families is through temporary

shelters. Although shelters for the homeless increasingly serve as sites for the provision of services

beyond simple shelter (e.g., mental health services,

health care services), they generally do not fully

address the multiplicity of needs of sheltered families and individuals. Shelters where homeless families with adolescents stay are often squalid and

dangerous. Privacy is sometimes totally lacking, and

families may be housed barracks style with dozens

of other families (20). Welfare hotels, where families are housed together in one room, sometimes for

a year or longer, are frequently in the worst parts of
Chapter 14—Hopelessness: Prevention and Services . ii-679

Photo credit: Office of Technology Assessment

Traditionally, the private sector has taken primary

responsibility in addressing the needs of the homeless

through private charities, religious groups, and nonprofit

agencies. Whether the Federal Government should

assume a primary role in providing for the homeless,

including adolescents, is a controversial topic.

the cities, expose children to the dangers of substance abuse and crime, and may contain such

environmental risks as lead-based paint and exposed

wiring. Shelters and hotels rarely have a place where

adolescents may play, either inside or outdoors.

Cooking and refrigeration facilities are often lacking. Families may resort to prohibited hotplates for

cooking; perishable items may be kept in coolers or

toilet tanks (1 1,25).

A number of existing Federal programs seek to

address the emergency needs of poor people, including the homeless. Until budgets were severely cut

during the 1980s, the Federal Government took a

rather active role in developing a national stock of

low-income housing. Traditional welfare programs

such as AFDC provide some income security for

needy children and their parent(s). Medical care is

available for low-income persons through the Medicaid program and federally funded community health

centers.35 Nutritional assistance is available through

enrollment in the Food Stamp Program, the Temporary Emergency Food Assistance program, and

participation in the Supplemental Food Program for

Women, Infants, and Children. 36 A variety of

Federal block grant funds may be used to fund

services or fund programs that are utilized by the

homeless (e.g., the alcohol, drug abuse, and mental

health services block grant; maternal and child

health block grants; community development block

grant funding; and the social services block grant) .37

As the need for emergency housing has become

more acute, many States have taken advantage of the

‘‘emergency assistance’ and ‘special needs’ funds

available under the AFDC program to help families

at risk of becoming homeless (69,69a). This program, in which States may voluntarily participate,

allows for the limited use of Federal matching funds

to secure temporary shelter and other emergency

assistance for needy families with children who are

at risk of becoming homeless. Though the funds are

designed to provide critical aid to at-risk families,

however, they are now being used in some areas to

shelter families for extended periods of time in

‘‘welfare hotels, Because of Federal restrictions on

the use of the funds, they may not be used for

permanent housing even when this housing would

be far less costly. In 1990, the Cranston-Gonzalez

National Affordable Housing Act (Public Law

101-625) addressed this problem by authorizing the

use of grants to help eligible families make the

transition to permanent housing (see below).

In addition to Federal programs intended to

address the needs of poor people in general, there are

a number of Federal programs designed to address

the needs of homeless people specifically. Several of

these are discussed below. The majority of these

programs focus on the emergency needs of the

homeless population as a whole rather than the

specific needs of homeless adolescents.

Emergency Aid to the Homeless and the

McKinney Homeless Assistance Act

Congress has a relatively short history of dealing

directly with the problem of hopelessness. For the

most part, the legislative response has focused on the

homeless population in general and has not specifically targeted the needs of homeless adolescents.

Initially, because hopelessness was thought to be a

ssFor ~fomatlon on tie Mcd]caid program, see ch. 16, ‘‘Financial Access to Health Care, ‘‘ in Vol. III. Federally funded community health centers

are discussed in ch. 18, ‘‘Issues in the Delivery of Services to Selected Groups of Adolescents, ’ in Vol. III.

J~For i~omation on tie Food Stamp fio=m and tic Supplemental Food ~ogram for Women, I~ants, and Children, see ch. 7, ‘ ‘Nutrition and Fitness

Problerm: Prevention and Semices, ” in this volume.

sTScvcral block ~ant programs are discussed in ch. 19, ‘The Role of Federal Agencies in Adolescent Health, ” in Vol. III.
11-680. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

temporary crisis, legislative efforts were of a shortterm or emergency nature (69).

In 1983, Congress appropriated $100 million for

the Emergency Food and Shelter Program to be

funded through the Federal Emergency Management Agency (Public Law 98-8). This legislation

allowed locally created boards consisting of representatives of charitable organizations and community leaders to distribute funds to local groups

providing emergency services to the needy, including the homeless. It also appropriated $125 million

for the Temporary Emergency Food Assistance

Program, which provided for the distribution of

surplus food commodities to the needy through the

U.S. Department of Agriculture. Subsequent legislation, including legislation in 1987, extended funding

for the Emergency Food and Shelter Program and

the Temporary Emergency Food Assistance Program (Public Law 98-92, Public Law 99-198, Public

Law 100-77).

During the 100th Congress, 1987 through 1988,

the problem of hopelessness was elevated to a

higher priority on the legislative agenda. In 1987,

Congress passed a supplemental appropriations act

providing $50 million in emergency relief funds for

the homeless (Public Law 100-6). Then Congress

began work on a comprehensive homeless aid

package, the Stewart B. McKinney Homeless Assistance Act, which was signed into law in July 1987

(Public Law 100-77). The 1987 McKinney Homeless Assistance Act authorized funds for a comprehensive range of health, mental health, transitional

housing, emergency food and shelter, education,

substance abuse, and social services for homeless

people. One section of the act (section 613) added a

new section (512(c)) to the Public Health Service

Act, which authorized funds for a new program of

demonstration projects for alcohol and other drug

treatment for homeless individuals. Companion

legislation passed by Congress provided $355 million for funding McKinney Act programs in fiscal

year 1987 appropriations (Public Law 100-71); $358

million was appropriated for fiscal year 1988 (Public

Law 100-202).

The 1987 McKinney Homeless Assistance Act

contains a number of provisions pertaining to

housing, including a provision that authorizes funding for emergency shelter and supportive housing

demonstration projects (including special funding of

at least $20 million for projects serving homeless

families with children); and a provision that authorizes the conversion of unused government buildings

into homeless shelters. A number of programs under

the U.S. Department of Agriculture were authorized

by the 1987 McKinney Act, including outreach

programs to inform homeless persons about food

stamps, expedited service for homeless persons

applying for food stamps, and extended funding for

the Temporary Emergency Food Assistance Program. In addition, the legislation established a

3-year Interagency Council on the Homeless at the

Federal level.

To ensure access to public education for homeless

children, the 1987 McKinney Homeless Assistance

Act provided for grants for each State to establish an

Office of Coordinator of Education for Homeless

Children and Youth. All States but one, plus the

District of Columbia, the Virgin Islands, American

Samoa, and Puerto Rico, received fiscal year 1988

funds under the program (69).38 The Office of

Coordinator of Education for Homeless Children

and Youth in each State is responsible for the

following:

●

●

●

●

The

gathering data on the extent of child and

adolescent hopelessness in the State,

determin ing what problems homeless children

and adolescents have in gaining access to

public schools,

identifyng special educational needs of homeless children and adolescents, and

developing State plans for providing educational services to all homeless children and

adolescents in the State.

McKinney Act also provided grants for programs that ‘‘successfully’ address the needs of

homeless elementary and secondary students, and

authorized up to $50,000 for demonstration grants to

study the underlying causes of adolescent homelessness.

In 1988, Congress reauthorized and expanded the

McKinney Act (Public Law 100-628). The 1988 law

included provisions requiring DHHS to recommend

legislative and regulatory changes designed to

eliminate the use of emergency assistance funds to

pay for sheltering families in welfare hotels and

authorized funding for at least two (but not more

~~Haw~ did not apply for fiscal year 1988 funds, but did apply for fiscal year 1989 funds under tie pro-.
Chapter 14—Hopelessness: Prevention and Services . II-681

than three) demonstration projects designed to

reduce the number of homeless families in welfare

hotels. Funded demonstration projects would be

required to make transition facilities available,

reducing permanently the number of rooms used to

house families in welfare hotels by the number of

units made available in transition facilities. In 1988,

Congress appropriated a total of $78 million for

McKinney Act service programs through the U.S.

Departments of Labor, Health and Human Services,

and Education and Related Agencies Appropriations

Act (Public Law 100-436); it appropriated $285

million for Federal Emergency Management Agency

and U.S. Department of Housing and Urban Development programs authorized by the McKinney Act

(Public Law 100-404).

In 1989, Congress appropriated $151.6 million for

McKinney Act service programs through the U.S.

Departments of Labor, Health and Human Services,

Education, and related agencies (Public Law 101-

166). It appropriated $414.5 million for Federal

Emergency Management Agency and U.S. Department of Housing and Urban Development programs

authorized by the McKinney Act (Public Law

101-144). In 1990, an additional $3.2 million was

appropriated for health services for the homeless

(Public Law 101-302).

Congress reauthorized and further expanded the

McKinney Act provisions in the Stewart B. McKinney Homeless Assistance Act Amendments of 1990

(Public Law 101-645). These amendments provided

grants for demonstration programs to enhance comprehensive primary health services for homeless

adolescents and their families through various mechanisms. Title V of the amendments provides for

comprehensive primary health services for homeless

children that may be delivered by some providers

without Medicaid status. Title VII provides for

grants to establish Family Support Centers, which

would serve to enhance the physical, social, and

educational development of children, including

nutritional services, screening and referral, drop-out

prevention services, job training services, and for

parents’ supportive services. Title VI of the amendments expands the educational components of the

1988 amendments, stressing the importance of

coordination between the various State and local

agencies that come in contact with homeless children (e.g., departments of education and social

services, shelters, and youth centers), and the

removal of school enrollment barriers (e.g., immunization, residency, school documents, and guardianship issues).

In December 1988, with the addition of new

McKinney funds, the National Institute of Mental

Health within DHHS announced that it would make

available grant funds for research and research

demonstrations on homeless severely mentally ill

adults and homeless families with children who

were at risk of severe emotional disturbance (74). In

fiscal year 1989, the National Institute of Mental

Health made available approximately $2.5 million

to support new research grants, and up to $2 million

in additional funds were available to support new

research demonstration grants to evaluate promising

new programs for the homeless in actual service

settings. Although homeless adolescents were identified as a possible focus for these grants in the

December 1988 program announcement, no grants

targeted toward adolescents were awarded in the

first cycle of funding.

In January 1990, the National Institute on Alcohol

Abuse and Alcoholism, in consultation with the

National Institute on Drug Abuse, announced that it

would be implementing a provision of the McKinney Homeless Assistance Act of 1988 by making

available cooperative agreement awards for research

demonstration projects for alcohol and/or other drug

treatment of homeless people (73a). It urged applicants to give special attention to the inclusion of

minorities and women in the research application

and encouraged the submission of applications that

addressed the special needs of homeless subpopulations such as women with children, adolescents,

young adult males, chronic public inebriates, and

individuals with alcohol and/or other drug problems

concomitant with a mental illness.

Cranston-Gonzalez National Affordable

Housing Act

In November 1990, Congress passed for the

Cranston-Gonzalez National Affordable Housing

Act (Public Law 101-625). One of the provisions of

the act makes funds available for implementing an

approved housing policy strategy at the State and

local levels. The act could benefit adolescents who

are homeless with their families by providing further

funding for low-income housing projects, providing

additional support for first-time home buyers, and in

other ways. The act specifically makes low-income

housing available ‘‘to families identified as having
II-682 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

a lack of adequate housing that is a factor in the

imminent placement of a child in foster care or in

preventing the discharge of a child from foster care

and reunification with his or her family. ”

The act also includes grants (given a 50-percent

State or community funding match) for public

housing youth sports programs which utilize community centers, parks or playgrounds, and provides

for the salaries and expenses for staff. The maximum

Federal grant amount annually for each housing

project is $125,000.

Runaway and Homeless Youth Act

In 1974, Congress passed and appropriated funds

for the Runaway Youth Act as Title III of the

Juvenile Justice and Delinquency Prevention Act of

1974 (Public Law 93-415). The Runaway Youth Act

has since been reauthorized several times (Public

Law 95-1 15; Public Law 96-509; Public Law

98-473; Public Law 100-690). The Runaway Youth

Act authorized grants to community-based agencies

to develop or support programs addressing the needs

of runaway adolescents (ages not specified; however, in fiscal year 1987, 93.4 percent of the

individuals receiving ongoing services at federally

funded centers were ages 12 to 17 (72)). In 1977,

Congress extended Title III of the Juvenile Justice

and Delinquency Prevention Act of 1974 to serve

homeless as well as runaway adolescents. Congress

took this action in response to pleas from service

providers and advocates that many of the “runaway’ young people served by the programs could

not be reunited with their families, and so were

actually homeless (68).

Programs under the Runaway and Homeless

Youth Act are administered by the Administration

for Children, Youth, and Families within the Office

of Human Development Services of DHHS. In April

1991, the Secretary of Health and Human Services

announced a reorganization of some DHHS programs for children and families (70a). As announced, the reorganization would combine all

programs currently in the Family Support Administration and the Office of Human Development

Services, and the maternal and child health block

grant program in the Health Resources and Services

Administration of the Public Health Service, into a

new “Administration for Children and Families”

(70a). In general, programs funded through the

Runaway and Homeless Youth Act are intended to

meet short-term emergency needs. The four general

purposes of programs described in the act are as

follows:

●

●

●

●

to alleviate the problems of runaway and

homeless youth;

to reunite children with their families and to

encourage the resolution of intrafamily problems through counseling and other services;

to strengthen family relationships and encourage stable living conditions for children; and

to help youth decide on a future course of

action.

Runaway and homeless youth centers funded

under the Runaway and Homeless Youth Act

provide emergency shelter for up to 15 days, with the

goal of reuniting adolescents with their families. The

centers also provide services that include individual

and family counseling, outreach, and referrals and

aftercare assistance in areas such as health, employment, and education (66,71).

During fiscal year 1987, Runaway and Homeless

Youth Act funds were used to make awards to 307

runaway and homeless youth centers, an increase

from the 286 centers funded the year before (71).

Funds were transferred from the Administration for

Native Americans for funding of an additional four

centers in fiscal year 1987 to serve Native American

adolescents. In fiscal year 1989, financial support

was provided to 343 grantees (30). Many of these

grantees actually operate more than one service site;

the actual number of service sites may be almost

double the number of grantees. The Runaway and

Homeless Youth Act also provides for limited

funding of demonstration projects, including options such as transitional living programs for homeless and runaway adolescents.

During fiscal year 1987, federally funded runaway and homeless youth centers provided services

to an estimated 340,000 adolescents, 56,000 of

whom were provided shelter, ongoing counseling, or

other services (72). Although the mandate of the

Runaway and Homeless Youth Act now includes the

provision of services to adolescents who are homeless, homeless adolescents frequently require more

intensive services than those that can be provided

through the centers. Homeless adolescents can

rarely secure a positive living arrangement after only

15 days at a runaway shelter because, for example,

family reunification is not always a viable option. A

Los Angeles study found that only 19 percent of
Chapter 14—Hopelessness: Prevention and Services . //-683

adolescents seen in shelters were good candidates

for immediate family reunification (35).

Federal Runaway and Homeless Youth Act funds

provide only a portion of the funds used by runaway

and homeless youth centers. Such centers also

receive funds from a number of other sources,

including State and local governments, local United

Ways, religious groups, foundations, corporations,

and other private sources (41). Many also rely

heavily on the use of volunteers. A 1985 survey of

210 agencies serving runaway and homeless adolescents found that 75 percent received some funding

from Runaway and Homeless Youth Act funds,

which covered about a third of their budgets.

Shelters relied on an average of five public and

private funding sources in addition to these funds

(see box 14-B).

In addition to supporting runaway and homeless

youth centers, the Runaway and Homeless Youth

Act supports a National Runaway Switchboard. This

switchboard, which provides counseling and referral

services to adolescents and their parents, handles

some 250,000 calls per year, 90 percent of them from

young people (about 20 percent of these callers used

the service to contact their families) (72). Since

fiscal year 1985, the National Runaway Switchboard

has also served as the Adolescent Suicide Hotline; it

gets about 2,500 suicide-related calls per month.39

In 1988, the Runaway and Homeless Youth Act

(H.R. 1801) was incorporated into the Anti-Drug

Abuse Act of 1988 (H.R, 5210) and reauthorized

during the 100th Congress (Public Law 100-690).

Congress appropriated $26.9 million for the Runaway and Homeless Youth Act for 1989 (Public Law

100-690); it appropriated $28.8 million for 1990

(Public Law 101-204). In addition to continuing

authorization for funding of shelter programs and

runaway hot lines, the law reauthorizing Runaway

and Homeless Youth Act programs authorized anew

transitional living program for homeless adolescents

and young adults ages 16 to 21, provided other

runaway programs are fully funded. Transitional

living programs are structured programs that provide

shelter while helping young people develop the

skills they need to live on their own. Transitional

living programs would provide a variety of services,

including counseling in interpersonal and life skills.

No more than 20 young people would be served at

Photo credit Sasha Bruce Youthworks

Transitional living programs are structured programs that

provide shelter to young people while helping them

develop the skills they need to live on their own.

one time by each program, and shelter and services

would not be provided for more than 18 months, It

was not until 1990 that a total of $19.8 million was

appropriated for transitional living program grants

to be made in fiscal years 1990 and 1991 (41).

Evaluation of funded programs was to begin late in

1991, and grantees are required to submit annual

reports to DHHS on their activities and achievements (42 U.S.C. 5714-2). The Young Americans

Act of 1990 (Public Law 101-501) also allows for,

but does not require, grants to be made for transitional living services to young individuals who are

homeless, with no age restriction specified.

Barriers to Care Under the Runaway and

Homeless Youth Act

Organizations that provide services to homeless

and runaway adolescents face a number of barriers

to providing effective services (35,41) and shelter

providers report that they cannot always provide

services for all adolescents in need. A survey of

shelter agencies in Los Angeles County found, for

example, that providers turn away six young people

for every five they serve. Los Angeles County has

only 112 shelter beds, despite a homeless and

runaway adolescent population that may be as great

as 10,000 at any one time (35).

Staff turnover in shelters is reported to be high, in

part because of the low salary base. While shelter

providers function to link adolescents with other

community services, they report a lack of a contin-

~~For ~ dl~cu~~lon of ~ulcide hOt ]ine~, see Ch, 11, ‘‘Ment~ H~~ ~ob]ems: ~evention ~d Swices, ” in thk VOIUme.
II-684 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Box 14-B—Bridge Over Troubled Waters: An Agency Serving Runaways and Homeless Street Youth

Bridge Over Troubled Waters is a multiservice agency in Boston, Massachusetts, that is designed to meet the

shelter and service needs of runaways and homeless street youth. It currently serves some 4,000 young people ages

13 to 25—most of them are ages 16 to 21--each year (14). As noted further below, Bridge receives funds from a

combination of public and private sources.

Programs and Services

When it was founded in 1970, Bridge consisted of three programs:

● a streetworker outreach program,

● medical van services, and

. counseling (14).

Over the years, Bridge programs have been expanded to include:

●

●

●

●

●

a free dental clinic,

a runaway program,

an education/pre-employment program,

a Family Life Center for pregnant and parenting young women, and

the Bridge Houses and several other residential programs that offer housing options for targeted groups of

homeless adolescents (e.g., single parents, long-term street youth with substance abuse problems, and high

school-aged runaways).

All Bridge services are provided without cost to recipients.

Outreach—Bridge uses streetworkers to make informal contact with homeless and runaway young people and

to inform them of the services available through Bridge (14). The goal of the outreach program is to establish a

trusting relationship with homeless and runaway young people, so that those in need of service will eventually feel

safe and comfortable asking for the services they need. Bridge streetworkers conduct outreach on weekday

afternoons and evenings in a range of areas where young people are known to gather. In 1989, streetworkers

contacted over 3,000 homeless and runaway young people.

Medical and Dental Services-Bridge provides free medical services through its free medical van and

in-house clinic (14). The Bridge medical van is staffed by volunteer physicians and nurses. Each weeknight, the van

makes stops at places where young people gather and provides onsite medical care. The in-house clinic operates

1 day per week and is staffed by a nurse practitioner. In 1989, approximately 2,000 individuals received medcal

services through the free medical van, and the nurse practitioner at the in-house clinic saw 187 patients.

Since 1972, Bridge has provided free dental services at the dental clinic located at the agency’s downtown

facility (14). Complete treatment and restorative services are provided by a pool of volunteer dentists, hygienists,

and dental assistants. In 1989, 482 young people received services at the dental clinic.

Counseling—Bridge provides a range of counseling services to its clients (14). On the basis of the results of

an intake assessment to determine their service needs, clients are assigned to a long-term counselor. The counselor

then works with the client to identify issues of concern and to develop a treatment plan to address those issues.

Treatment plans are reviewed frequently by the client and his or her counselor, and are updated at least every 6

months. In 1989, 2,158 clients received services through the counseling program.

Runaway Program—Through its runaway program, Bridge provides crisis services to adolescents underage

18 who have left home and are on the streets with no place to go (14). The runaway program provides food, clothing,

and shelter in the home of an emergency shelter care volunteer. Efforts are made through the program to reunite

runaway adolescents with their parents; where family reunification is not appropriate (e.g., where there is a risk of

physical or sexual abuse, or there is severe family dysfunction), however, efforts are made to find alternative

housing, sometimes in the Bridge Houses (see below) operated by Bridge. Each year, runaway program services

are provided to over 400 adolescents.

Education/Pre-Employment Services--Through the Education/Pre-Employment Program, Bridge staff

provide tutoring for young people working toward completing the general educational development (GED) program

(14). A job developer works with these students, as well as other interested clients, to develop job readiness and

interviewing skills. The Bridge Family Life Center provides support to pregnant and parenting young women,

including providing instruction in prenatal care, child development, and health and nutrition (14). Individual
Chapter 14—Hopelessness: Prevention and Services ● II-685

counseling is also provided, along with life skills education. Child care is available to enable mothers to attend GED

classes.

Residential Programs—Bridge has several residential programs (14). The two Bridge Houses provide shelter

to a total of 32 residents for a period of 6 to 8 months. The Bridge Houses target different groups of homeless:

adolescents and young adults reside in one Bridge House, and single parents and their children reside in another

(12). Residents participate in programs focusing on education and building independent living skills; they are

required to participate in weekly group counseling, individual counseling, and daily cooking and cleaning (14).

They must attend high school or a GED program and hold a job. Residents are also required to pay rent based on

their income. Staff, who are responsible for supervising residents’ activities, coordinating job development and

recreational activities, and providing counseling on house-related issues, are on duty 24 hours per day. Six Bridge

transitional apartments provide housing for 15 graduates of Bridge Houses, along with an additional year of informal

supervision and support services (14). Bridge staff provide support to aid residents in their final transition to

independent living.

Funding

Program expenses for Bridge in 1989 were $1,481,214. Residential programs accounted for the largest portion

of expenses (42 percent). Runaway, counseling, and streetwork outreach accounted for the next largest portion (31

percent) (13). In 1988, program expenses exceeded revenue by nearly $60,000. In 1989, however, increases in

funding, primarily from grants and contracts from foundations and additional funding from United Way, allowed

Bridge to show a surplus of revenue.

Bridge receives funding from a combination of sources (13). Funding for 1990 was from the following sources:

. 40 percent from public grants and contracts (13 percent of total funding is from Federal sources, 23 percent

from the State, and 5 percent from the city);

. 22 percent in the form of grants and contributions from foundations,

. 25 percent from United Way,

. 7 percent from individual contributions, and

. 5 percent from other sources such as local charities.

Federal funding for Bridge comes through the the Runaway and Homeless Youth Act administered by the U.S.

Department of Health and Human Services, and includes discretionary funding for a 3-year demonstration grant to

Bridge for the single-parent house and the transitional apartments.

uum of needed services. In particular, they report a served during the study period, drug or alcohol

lack of drug detoxification and inpatient drug abuse

treatment facilities, and of acute mental health beds

and programs to provide followup services after

discharge from inpatient care. Service providers also

cite the lack of transitional living programs to help

adolescents learn important skills for living on their

own (e. g., managing finances, problemsolving, and

employment and training) (35,41).

Shelter staff are supposed to develop plans for

living arrangements and other needs of clients

served by runaway and homeless youth centers.

According to a study by GAO, however, no aftercare

plans are made for almost half of homeless adolescents using the shelters. Furthermore, the plans that

are made may be insufficient to fully address the

needs of the homeless adolescent (66). For example,

although drug or alcohol abuse problems were

reported for over a fifth of homeless adolescents

treatment was planned for only 4 percent,

Effectiveness of Runaway and Homeless

Youth Services

In part because of the barriers to service discussed

above, shelters have shown mixed success in placing

homeless adolescents in more stable living situations. A recent GAO study reported that about

one-third of the homeless adolescents (as compared

to 58 percent of runaway adolescents) using federally funded runaway and homeless youth shelters

between October 1985 and June 1988 planned to live

with a parent or other relative upon leaving the

shelter (66). Approximately 20 percent of the

homeless adolescents using these shelters expected

to enter foster or group homes, and 6 percent

expected to enter independent living. On the other

hand, 14 percent expected to live with friends or on

the street, 6 percent expected to live in another
II-686 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

HOUSE ORGANIZATION AND MAINTENANCE POLICIES

We have established the following policies in order to maintain the house, get meals prepared,

and meet individual needs for privacy, order, and time.

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

11)

12)

13)

14)

Residents will assist with daily house chores as assigned, and on Saturdays all

residents will assist in major house-cleaning chores . Daily chores must be don e

before you leave in the morning or by 9:30 a.m. There will be no use o f

telephones or radios until completion of chores .

Residents are expected to maintain their bedrooms. They are to be cleaned in th e

morning before leaving the house or by 9:30 a.m. All clothing and shoes must be

in closets or drawers and off the floor. The bedrooms are to be kept neat.

Residents are responsible for their own personal hygiene and laundry (clothing ,

sheets, towels, etc. )

No pets are allowed in the house, nor are they permitted to be kept at the house.

Items of value (wallets, money, IDs, etc.) are to be locked in the office.

Stepping Stone will not accept liability/responsibility for residents’ personal

belongs. Loss and/or damage to personal property is assumed by the resident.

Residents are required to sit down at the diner table for the evening meal and

also participate in evening group sessions.

Visiting hours for guests: Monday through Friday - 2:00 p.m. to 5:00 p.m.

Saturday and Sunday - 12:00 noon to 6:00 p.m.

Parents and family members may visit at any reasonable time with prior counselor

and youth notification.

The “Emergency Only - Do Not Disturb” sign on the office door means do not knock

or open the door unless what you need absolutely cannot wait. Please be

thoughtful when sessions are going on.

Every resident except the assigned cook must help clean up the dining room and

kitchen after the evening meal.

Dishes and utensils must be washed by hand and then placed in the dishwasher or

in the drainer no matter what time of the day. Do not leave them in the sink or

elsewhere. This may result in entertainment ban.

No sleeping allowed during the day. The TV is not to be on during the day.

After group sessions or dinner the TV may be on with the OK from the staff.

The radio must be kept at a level that does not interfere with the telephones or

people’s conversations. Do not blast the radio please. Violations will result

in entertainment ban.

Evaluations must be completed before 7:00 p.m. It is your responsibility to ask

staff to do it with you.

Washers and dryers are not to be used between 10:00 p.m. and 8:00 a.m.

AGREEMENT: I have read and understand these policies. I voluntarily will participate in the

Stepping Stone program and agree to abide by the above policies while at the house.

Resident ● Witness

6/87

Date Courtesy ot Stepping Stone

House rules such as these of a California transitional Iiving program help homeless adolescents develop the skills

they need to live on their own.
Chapter 14—Hopelessness: Prevention and Services . //-687

runaway shelter, and 14 percent did not know where

they would go. At least some of these adolescents

probably chose to remain on the streets either

because the alternatives they were offered (e.g,

returning to live with an abusive parent or entering

foster care environments) were not desirable to or

appropriate for them; because desired alternatives

(e.g., independent living) were not available to them;

or because, given the lack of appropriate alternatives, they did not wish to leave the relative freedom

of the streets and a supportive ‘‘community’ of

friends.

In one New Jersey study, one-third of adolescents

receiving shelter services were able to return to their

families after receiving services; another third went

to foster care or a group home (58).

However, other studies have reported more positive results or effects of shelters. According to a

report of the Los Angeles Task Force on Runaway

and Homeless Adolescents, 70 percent of adolescents in Los Angeles County who received shelter

services from October 1986 to September 1987

either returned to their families or went to other

appropriate alternatives (e.g., foster care or independent living). Six months later, almost all of these

adolescents (94 percent) were reported to have

remained off the street (35).

A September 1983 report by GAO that assessed

the role of runaway and homeless youth centers in

reuniting families and resolving family conflicts,

indicated that the great majority of adolescents who

used their services (93 percent) and their parents (98

percent) believed that the services provided by the

center had been helpful in resolving their family

problems (64a).

Thus, while runaway and homeless youth shelter

programs have proven to be extremely helpful to

some adolescents, there are other adolescents for

whom shelter services may not be adequate. The

number of these adolescents is not known, but they

seem likely to be those who are the most deeply

troubled and for whom being reunited with a family

is not a feasible option.

Missing Children’s Assistance Act

In 1984, Congress passed the Missing Children’s

Assistance Act as Title IV of the Juvenile Justice and

Delinquency Prevention Act (Public Law 98-473).

The Missing Children’s Assistance Act, which is

administered by the Office of Juvenile Justice and

Delinquency Prevention within the U.S. Department

of Justice, authorizes Federal support for various

activities designed to address issues related to the

problem of missing children.

Programs funded under the Missing Children’s

Assistance Act include a national toll-free telephone

line for reporting information on missing children, a

national resource center and clearinghouse, and

funding of various research projects on and programs for missing and exploited children. These

programs are focused primarily toward missing

children-i. e., children whose whereabouts are unknown to their legal custodian in circumstances that

indicate that the child was removed without the

consent of their legal guardian-or children at high

risk of being abused or sexually exploited.

Although homeless children per se are not the

primary focus of the Missing Children’s Assistance

Act, such children may be included as a focus for

services if they fall under the definition of missing

children as included in the Missing Children’s

Assistance Act. The interpretation of what constitutes risk of abuse remains ambiguous under the act

(75). The mere fact that a minor is living on the street

is not enough to warrant an expectation that he or she

has a strong likelihood of being abused or sexually

exploited. Furthermore, the need for actual evidence

of such abuse increases as the child becomes older

(67).

In 1987, the U.S. Department of Justice funded a

study under the Missing Children’s Assistance Act

to develop reliable and valid national estimates of

the numbers of missing children over the course of

a year and to establish profiles of missing children.

Runaways and thrownaways are included in the

study, as are family-abducted children and non-familyabducted children (75).

Anti-Drug Abuse Act of 1988

The Anti-Drug Abuse Act of 1988 (public Law

100-690) authorized $15 million for drug abuse

treatment and prevention programs for homeless and

runaway adolescents (ages not specified)--including peer counseling programs; individual, family,
II-688 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

and group counseling; and community education

activities. 40 This funding is available only when

appropriations for the Runaway and Homeless

Youth Act (see above) exceed the amount appropriated for the previous year.

Funding first became available in fiscal year

1989. Grants were awarded by the Administration of

Children, Youth, and Families in DHHS to 104

organizations and agencies to address drug abuse

problems among homeless and runaway adolescents

(30).

Collaborative Efforts Among Federal Agencies

The Administration for Children, Youth, and

Families, the agency in DHHS’s Office of Human

Development Services that administers the Runaway and Homeless Youth Act, has entered into

collaborative arrangements with other Federal agencies to improve services to homeless adolescents. In

fiscal year 1988, the Administration for Children,

Youth, and Families signed a memorandum of

understanding with the Public Health Service to

facilitate the development of relationships between

federally funded Health Care for the Homeless

projects and runaway and homeless youth centers.

The memorandum of understanding also includes a

pilot program that enables medical students to

volunteer their services in homeless and runaway

youth centers.

The Administration for Children, Youth, and

Families has also worked with the National Institute

on Drug Abuse to develop an AIDS prevention

curriculum for shelter staff. Training programs for

shelter staff have now been initiated (30).

Conclusions and Policy Implications

DHHS estimated in 1984 (on the basis of data

from a 1976 survey mandated by Congress) that

there are as many as 1 million homeless and runaway

adolescents ages 10 through 17 each year, and this

estimate continues to be used.

Information about the causes and consequences of

adolescent hopelessness is limited.41 Some homeless adolescents are homeless because their families

are homeless; others are homeless. on their own.

Adolescents who are homeless with their families

are likely to be homeless because of lack of available

housing, limited economic resources, family crises

(e.g., divorce or separation of parents or of an

adolescent and his or her partner, loss of family

source of income, eviction). Adolescents who are

homeless on their own are more likely to be

homeless because they have left dysfunctional

families in which there are high levels of conflict,

because they have been abused, because they

themselves are suffering from mental disorders or

other problems, or because they have left foster care

or institutional settings (e.g., juvenile justice facilities or mental health institutions) without arrangements for stable housing.

Whether in families or on their own, homeless

adolescents experience a broad range of physical,

mental, and school problems. Homeless adolescents

on their own have high rates of substance abuse,

sexual activity (including prostitution), and delinquency. Sometimes these activities are used as

survival strategies (e.g., exchange of sexual favors

for food or a place to stay). There is anecdotal

evidence that the population of young people on the

street is becoming younger and more dysfunctional.

Little is known about the health, education, or

other needs of homeless adolescents who do not use

the existing runaway and homeless youth shelter

system. Most of the research that has been done to

date has relied heavily on adolescents sampled from

shelters in urban areas and does not follow adolescents over time. As a consequence, very little is

known about homeless adolescents who do not

utilize shelter services (or even what proportion do

use services) or about the characteristics and service

needs of homeless adolescents in nonurban areas.

There is strong evidence, however, that homeless

adolescents are at high risk for physical health

problems (including pregnancy and sexually transmitted diseases), mental health problems, and substance abuse. They are also at high risk for social

problems such as dropping out of school, lack of

employment skills, and criminal and delinquent

behavior.

40For ~ ~eneral discussion of Federal pOlicie5 Pertaining to substance abuse among adolescents, see ch. 12, “Alcohol, Tobacco, and Drug Abuse:

Prevention and Services, ’ in this volume.

41DHHS, ~ rquired by tie Stew@ B. McKfiey Homeless Assistance Act (~bfic ~WJ IM-77), tid~ a study of the underlying CaUSt?S Of yOUth

hopelessness in 1988, and the results are expected in late 1991 (43a).
Chapter 14—Hopelessness: Prevention and Services . II-689

The approaches for preventing hopelessness

among adolescents vary, depending in part on

whether adolescents are living with their families or

are in foster care or institutions. Clearly, one

possible strategy for preventing hopelessness among

adolescents living with their families would be to

increase the Nation’s supply of safe, affordable,

accessible low-income housing. An additional strategy would be to support prevention, early identification, and supportive interventions to help resolve

problems in dysfunctional families that contribute to

adolescents’ leaving home (e. g., parental substance

abuse, physical or sexual abuse of a child, and family

conflicts related to an adolescent’s homosexuality).

Adolescents living in foster care, group homes, or

institutions such as State psychiatric hospitals or

juvenile justice facilities are particularly important

subjects for hopelessness prevention programs.

Unless they receive adequate preparation for independent living and developmentally appropriate

supportive services, adolescents who leave these

settings are at high risk of becoming homeless. The

Federal Government provides grants to States to

develop model ‘‘independent living’ programs to

facilitate adolescents’ transition to independent

living after leaving the foster care system (76). Even

adolescents who participate in independent living

programs, however, may need various types of

social, economic, and emotional support before they

can become independent (76).

Many adolescents who become homeless, whether

with their families or on their own, have physical,

mental health, or social problems prior to becoming

homeless. Once they become homeless, these problems may worsen and their need for services is likely

to increase. Studies indicate that homeless adolescents are at extremely high risk for a multiplicity of

physical health problems (e.g., nutritional deficiencies, sexually transmitted diseases, problems related

to physical or sexual abuse), mental health problems

(e.g., depression, substance abuse), and school

problems (e.g., dropout). Because these problems

cut across traditional agency boundaries, homeless

adolescents are likely to be best served by a system

that offers a continuum of coordinated and comprehensive services.

Comprehensive, developmentally appropriate services for homeless adolescents are practically nonexistent in this country. Even safe shelter is not always

available. At the Federal level, the needs of homeless adolescents have been addressed most directly

through the limited funding of the Runaway and

Homeless Youth Act, which helps fund runaway and

homeless youth centers. These centers provide 15

days of emergency shelter to homeless and runaway

adolescents and aim to reunite the adolescents with

their families. Unfortunately, the number of beds

available is far outstripped by the number of

adolescents in need. Furthermore, for adolescents

who have run away from or been thrown out of

abusive or severely dysfunctional families, the goal

of family reunification may not be appropriate; these

adolescents need far more than 15 days of emergency shelter.

In addition to needing emergency shelter, many

adolescents who are homeless, whether with their

families or on their own, need safe permanent

housing and a variety of health, educational, and

social support services. In most communities, services for homeless adolescents are fragmented and

inadequate. Thus, for example, few communities

have a full range of mental health and substance

abuse programs to serve homeless adolescents, and

the lack of residential substance abuse treatment

programs for homeless adolescents, particularly

those without health insurance, has been frequently

noted (41,60).42 Another point that should be made

is that many adolescents who are homeless on their

own face legal barriers to obtainin g housing or other

services. If they have not been emancipated, they

may not be able to sign a lease, obtain Federal

income support and health insurance benefits, obtain

medical care, or enroll in school without permission

of a guardian.

43 Policies that would enable homeless

adolescents to more easily obtain the services they

need would reduce their risk for further problems

(e.g., by increasing the chances that they may finish

school, by ensuring that they get appropriate health

care, by allowing them to secure safe housing).

As a group, homeless adolescents are in need of

targeted education and employment training programs that offer a range of options, including

flexible day labor and part-time work. As noted

‘$ZMo~t homele~~ ~dole~cen@have n. heal~ ~swmce. TIM effectiveness of substance abuse treatment foradolesmnts is discuss~ m Ch 12> ‘Mcoholt

Tobacco, and Drug Abuse: Prevention and Services, ’ in this volume.

~Jhgal ~mmclpation is discussed in ch. 17, “Consent and Confidentiality in Adolescent Health Care Decisionrnaking, ” in Vol. III.
11-690. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

earlier, Congress recently changed the McKinney

Homeless Assistance Act to require States to ensure

access to public education for homeless adolescents.

The responses of States to this requirement should

be carefully monitored. Working adolescents who

have not completed high school may need alternative school programs in order to complete school;

other adolescents who have experienced disruptions

in their education while homeless may need special

“catch-up” programs. Because they are likely to

have few marketable skills, particularly if they have

not completed high school, homeless adolescents

may also need employment preparation and training.

Addressing the problems of homeless adolescents

demands responses at the Federal, State, and local

levels, and involvement of both the public and

private sectors. Specific policy options related to the

problems of runaway and homeless adolescents are

listed in Volume I.

Chapter 14 References

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6.

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APPENDIX
Appendix A

GLOSSARY OF ABBREVIATIONS AND TERMS

Abbreviations

—Alcoholics Anonymous

AAP —American Academy of Pediatrics

AAPT —Adolescent Alcohol Prevention Trial

ACS —American Cancer Society

ACYF —Administration on Children, Youth and

Families (DHHS)

ADAMHA —Alcohol, Drug Abuse, and Mental Health

ADHD

ADM

AFDC

AFL

AIDS

ALERT

AODA

APA

APHA

ASAM

ASHA

ATV

AYI

BHCDA

BIA

BMCH

BMI

BSST

CASSP

CATOR

CBO

c c c

CDC

CFR

CHC

CMHC

CPS

CPSC

CRS

Administration (PHS)

—attention deficit hyperactivity disorder

—alcohol, drug abuse, and mental health

(block grant)

—Aid to Families With Dependent Children

(program)

—Adolescent Family Life (program under

Title XX of the Public Health Service Act)

—acquired immunodeficiency syndrome

—Adolescent Experiences in Resistance

Training (program)

—American Medical Association

—alcoholism and/or drug abuse (counselor)

—American Psychiatric Association

—American Public Health Association

—American Society of Addiction Medicine

—American School Health Association

—all-terrain vehicle

—Alaska Youth Initiative

—Bureau of Health Care Delivery and

Assistance (HRSA)

—Bureau of Indian Affairs (U.S. Department

of the Interior)

—Bureau of Maternal and Child Health

(HRSA)

-body mass index

—behavioral social skills training

-Child and Adolescent Service System

Program (NIMH)

-Chemical Abuse Treatment Outcome

Research (network)

-Congressional Budget Office (U.S.

Congress)

-Civilian Conservation Corps

-Centers for Disease Control (PHS)

-Code of Federal Regulations

-Community health center

---community mental heaIth center

-children’s protective services

-Consumer Safety Product Commission

---Congressional Research Service (Library

of Congress)

CSFII

CVC

CWLA

DARE

DARP

DAWN

DDI

DHEW

DHHS

DHKS

DIEC

DMCH

DMFS

DMFT

DOE

DOT

DSM-111

-Continuing Surveys of Food Intakes by

Individuals (USDA)

--Civilian Volunteer Corps (New York City)

-Child Welfare League of America

—Drug Abuse Resistance Education (project)

—Drug Abuse Reporting Program

—Drug Abuse Warning Network (NIDA)

--dideoxyinosine

—U.S. Department of Health, Education, and

Welfare (now DHHS)

—U.S. Department of Health and Human

Services

—Diet and Health Knowledge Survey (USDA)

—Division of Injury Epidemiology and

Control (Centers for Disease Control)

—Department of Maternal and Child Health

—Decayed, Missing, or Filled Surfaces (of

permanent teeth)

—Decayed, Missing, or Filled (permanent)

Teeth

—U.S. Department of Energy

—U.S. Department of Transportation

—Diagnostic and Statistical Manual of

Mental Disorders, 3rd ed.

DSM-III-R —Diagnostic and Statistical Manual of

Mental Disorders, 3rd cd., revised

EPSDT —Early and Periodic Screening, Diagnosis,

and Treatment program (Medicaid)

ER --emergency room

FACES —Family Cohesion and Flexibility Scale

FBI —Federal Bureau of Investigation (U.S.

Department of Justice)

FDA —Food and Drug Administration (PHS)

FR —Federal Register

GAO -General Accounting Office (U.S.

Congress)

GED -tests of general educational development

GMENAC --Graduate Medical Education National

Advisory Committee

HDL —high-density lipoprotein

Hispanic —Hispanic Health and Nutrition

Examination Survey (NCHS)

-human immunodeficiency virus (AIDS virus)

HNIS —Human Nutrition Information Service (USDA)

HPV —human papillomavirus

HRSA —Health Resources and Services

Administration (PHS)

HSV —herpes simplex virus

ICD-9-CM —International Classification of Diseases,

9th revision, Clinical Modification

-II-695-
II-696 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention anti Treatment Services

ICPS —Interpersonal Cognitive Problem-Solving

(program)

—I Have a Dream (program)

—investigational new drug

IOM —Institute of Medicine (NAS)

IQ —intelligence quotient

ISA-SPS —Improving-Social-Awareness/SocialProblem-Solving (program)

I v —intravenous

JOBS —Job Opportunities and Basic Skills

(program)

LDL —low-density lipoprotein

LSC —Life Skills Counseling (program)

LSD —lysergic acid diethylamide

LST —Life Skills Training (program)

MCT —minimum competency test

—Massachusetts Institute of Technology

MMPI —Minnesota Multi-Phasic Personality

Inventory

MSA —Metropolitan Statistical Area

NAATP —National Association of Addiction

Treatment Providers

NACHO —National Association of County Health

Officials

NAMCS —National Ambulatory Medical Care Survey

(NCHS)

NAPPH —National Association of Private Psychiatric

Hospitals

NAS —National Academy of Sciences

NASHS —National Adolescent Student Health

Survey

NCCAN —National Center on Child Abuse and

Neglect (OHDS)

NCEMCH —National Center for Education in Maternal

and Child Health (Georgetown University)

NCHS —National Center for Health Statistics (CDC)

NCI —National Cancer Institute (NIH)

NCYFS —National Children and Youth Fitness Study

NDATUS —National Drug and Alcoholism Treatment

Unit Survey (ADAMHA)

NEISS —National Electronic Injury Surveillance

System (CPSC)

NFCS —Nationwide Food Consumption Survey

(USDA)

NHANES —National Health and Nutrition Examination

Survey (NCHS)

NHDs —National Hospital Discharge Survey (NCHS)

NHES —National Health Examination Survey (NCHS)

N-HIS —National Health Interview Survey (NCHS)

NHLBI —National Heart, Lung, and Blood Institute

(NIH)

NHTSA —National Highway Transportation Safety

Administration (U.S. Department of

Transportation)

—National Institute on Alcohol Abuse and

Alcoholism (ADAMHA)

NICHD —National Institute of Child Health and

Human Development (NIH)

NICHY —National Information Center for Children

and Youth With Handicaps

NIDA —National Institute on Drug Abuse

(ADAMHA)

NIDR —National Institute of Dental Research (NIH)

—National Institute of Education

—National Institutes of Health (PHS)

—National Institute of Mental Health

(ADAMHA)

NLSY —National Longitudinal Survey of Labor

Market Experience-Youth Cohort (U.S.

Department of Labor)

NMCES —National Medical Care Expenditure Survey

(Agency for Health Care Policy and

Research, PHS)

NMCUES —National Medical Care Utilization and

Expenditure Survey (NCHS)

—National Mental Health Association

NSFG —National Survey of Family Growth (NCHS)

OB-GYN -obstetrics-gynecology

ODPHP

OHDS

OHI-S

OJJDP

ONCDP

OSAP

OSERS

OTA

OTI

PCP

PDAY

PHS

PID

PRIDE

PSI

RCT

RDAs

RTC

RTI

SEER

SES

SLHC

-Office of Disease Prevention and Health

Promotion (DHHS)

-Office of Human Development Services

(DHHS)

-Simplified Oral Hygiene Index

-Office of Juvenile Justice and Delinquency

Prevention (U.S. Department of Justice)

-Office of National Drug Control Programs

(Executive Office of the President)

-Office for Substance Abuse Prevention

(ADAMHA)

-Office of Special Education and

Rehabilitative Services (U.S. Department

of Education)

-Office of Technology Assessment (U.S.

Congress)

-Office for Treatment Improvement

(ADAMHA)

—phencyclidine

—Pathological Determinants of

Atherosclerosis in Youth

—Public Health Service (DHHS)

—pelvic inflammatory disease

—Parents’ Resource Institute for Drug

Education

—Postponing Sexual Involvement (program)

—randomized clinical trial

—recommended dietary allowance

—residential treatment center

—Research Triangle Institute

-Surveillance, Epidemiology, and End

Results Program (NCI)

—socioeconomic status

—school-linked health center
Appendix A—Glossary of Abbreviations and Terms . II-697

SMART

SPRANS

STAR

STD

STEP

SYETP

TAP P

THC

TOP

TOPS

TPI

-Self Management and Resistance Training

(program)

—special projects of regional and national

significance (under Title V of the Social

Security Act)

-Students Taught Awareness and Resistance

(program)

—sexually transmitted disease

-Summer Training and Education Program

-Summer Youth Employment and Training

Program (U.S. Department of Labor)

—Teenage Pregnancy and Planning Program

-tetrahydrocannabinol

—Teen Outreach Program

—Treatment Outcome Prospective Study

(Research Triangle Institute)

—Treatment Priority Index (for oral

malocclusion)

Terms

Abortion: Termination of pregnancy. In this Report, the

term is generally used to refer to induced abortion

rather than spontaneous fetal loss. In the United States,

the methods most commonly used to terminate pregnancies are surgical (e.g., vacuum curettage, dilation

and curettage, dilation and evacuation, hysterotomy,

and hysterectomy). A nonsurgical medical method of

abortion used in France-the administration of the

compound RU-486 and prostaglandins--is not available in the United States,

Abortion rate: The number of abortions in a given

population per some population base during a given

time period (e. g., 43 abortions per 1,000 females ages

15 to 19 in a given year).

Abstinence from sexual activity: Refraining from sexual

intercourse, one approach to the prevention of sexually

transmitted disease (STD), AIDS, and pregnancy.

Compare contraception.

Abuse: See alcohol abuse, emotional abuse, physical

abuse, psychoactive substance abuse, sexual abuse.

Academic tracking: The separation of students into

groups by achievement levels.

Access: Potential and actual entry of a population into the

health care delivery system.

Accidental injury: An injury that is not self-inflicted or

caused by maltreatment or other violence.

Acne: Common acne (acne vulgaris) is a chronic inflammatory disease of the pilosebaceous apparatus, with

lesions occurring most frequently on the face, chest,

and back. The cause is unknown, but it has been

suggested that many factors, including certain foods,

stress, hereditary factors, hormones, drugs, and bacteria play an etiologic role.

Acquired immunodeficiency syndrome (AIDS): See

AIDS .

.)07 ‘) it, :+1 .!:i (/1, .{

USDA

VISTA

VLDL

WHO

WIC

YMCA

YNH-SPS

You

YRBSS

YWCA

—U.S. Department of Agriculture

—Volunteers in Service to America

(ACTION)

—very low density lipoprotein

—World Health Organization

-Special Supplemental Food Program for

Women, Infants, and Children (U.S.

Department of Agriculture)

—Young Men’s Christian Association

—Yale-New Haven/Social-Problem-Solving

(project)

—Youth Opportunity Unlimited (program)

—Youth Risk Behavioral Surveillance

System (CDC)

—Young Women’s Christian Association

Activity limitation: Each person identified as having a

chronic condition by the National Health Interview

Survey conducted by DHHS is classified according to

the extent to which his or her activities are limited

because of the conditions as follows: 1) persons unable

to carry on their major activity (for children 5 to 17, a

person’s major activity refers to school attendance; for

individuals age 18 and over, it usually refers to a job,

housework, or school attendance); 2) persons limited

in the amount or kind of major activity performed; 3)

persons not limited in major activity but otherwise

limited; and 4) persons not limited in activity. See also

disability.

Acute condition: Generally, an injury, an illness, or an

impairment of limited duration. For purposes of the

National Health Interview Survey conducted by DHHS,

an acute condition is a physical or mental condition

that has lasted less than 3 months, is not a condition

that normally lasts more than 3 months (e.g., diabetes,

arthritis), and is of sufficient consequence to have

involved either at least one doctor visit or at least 1 day

of restricted activity. Acute conditions experienced by

U.S. adolescents include injuries, illnesses ranging

from respiratory conditions such as colds and influenza, intestinal viruses, dermatitis, ear infections,

dental problems, and some acute psychiatric conditions. Compare chronic condition.

Acute illness (physical, mental): For purposes of this

Report, an acute illness is a disease or disorder (as

opposed to an injury) of limited duration. The distinction between physical and mental illnesses is whether

the illness is of the body or of the mind. This

distinction is somewhat arbitrary, however, because

some mental illnesses have a physiological base. See

also acute condition.

Addiction model: A model of treatment for alcohol and

drug abuse based on the philosophy that once a person
II-698 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

has become a problem user of alcohol or drugs, he or

she will always be a problem user and should avoid any

use of alcohol and drugs for life.

Adjudicated: Passed on judicially, settled, or decreed, or

convicted and sentenced. An adjudicated case is one in

which the court has entered a judgment.

Adjustment disorder: A mental disorder defined in

DSM-III-R as a maladaptive reaction to an identifiable

psychosocial stressor or stressors that occurs within 3

months after the onset of the stressor and has persisted

for no longer than 6 months. Adjustment disorder

develops in reaction to a stressful event or series of

events (e.g., discordant family relationships, parental

divorce or death, illness, moving to a new place) and

impairs ability to function in school or on the job,

because the individual cannot cope with problems in

an appropriate way and may become emotionally

incapacitated by stress.

Adolescence: Definitions of adolescence vary, and many

observers agree that a definition based on age alone is

not sufficient. Adolescence typically takes place during the second decade of life, and is initiated by

puberty, although physical and other changes occur

(i.e., in height, weight, head size, facial structure, facial

expression, and cognitive abilities). As used by OTA,

adolescence most often refers to the period of life from

ages 10 through 18.

Adolescent delinquency: Offenses committed by adolescents that would be considered violations of criminal

law if committed by adults (ranging from minor ones

such as disorderly conduct to serious ones such as

aggravated assault) and offenses committed by adolescents that are considered offenses only because they

are committed by a minor (i.e., “status offenses” such

as running away from home, truancy).

Adolescent health: Narrow definitions of adolescent

health might be the absence of physical disease and

disability and the absence of engagement in healthcompromising behaviors that lead to the so-called new

morbidities (e.g., outcomes of sex, drug use, and

violence). A broader definition would also include

positive components of health (e.g., social competence); and health and well-being from the perspective

of adolescents themselves (e.g., perceived quality of

life). A fully realized view of adolescent health would

also consider the impact of social (e.g., families,

schools, communities, policies) and physical (e.g.,

fluoridation, automobile and highway design and

construction) influences on health and would be

sensitive to developmental changes that occur during

adolescence. See also health.

Adrenal glands: Endocrine glands situated near the

kidney that produce steroids like sex hormones,

hormones related to metabolic functions, and adrenaline.

Adrenarche: Maturation of the adrenal glands, usually

beginning between ages 6 and 8.

Advocacy (for adolescents): Refers to support, coordination, and linkage to experts, individuals, groups, and

institutions who may help adolescents. It may be

provided by parents or others known to an adolescents.

Affective disorder: Any disorder relating to, arising

from, or influencing feelings or emotions, characterized by alterations in mood. See mood disorders,

anxiety disorders, depression.

Aftercare: A variety of services designed to render

assistance to an individual recovering from substance

abuse following discharge from a hospital or formal

treatment program, including such things as peer

support and counseling, crisis services, job referral,

and drop-in centers.

Aggravated assault: See assault.

AIDS (acquired immunodeficiency syndrome): A disease characterized by a deficiency of the immune

system caused by human immunodeficiency virus

(HIV). The primary defect in AIDS is an acquired,

persistent, quantitative functional depression within

the T4 subset of lymphocytes. This depression often

leads to infections caused by micro-organisms that

usually do not produce infections in individuals with

normal immunity. HIV infection can be transmitted

from one infected individual to another by means that

include the sharing of a contaminated intravenous

needle and engaging in unprotected sexual intercourse

(i.e., intercourse without the use of condoms) with an

infected person.

Aid to Families With Dependent Children (AFDC)

program: A program, established by the Social Security Act of 1935, providing cash payments to needy

children (and their caretakers) who lack support

because at least one parentis dead, disabled, continually absent from the home, or unemployed. Eligible

families must meet income and resource criteria

specified by the State. See Family Support Act of 1988.

Alcohol (ethyl): One of the most commonly used of all

psychoactive substances, alcohol is a transparent,

colorless liquid, obtained by fermentation of carbohydrates with yeast. It is contained in beer, wine, and

various other beverages (e.g., gin, whiskey).

Alcohol abuse: A form of psychoactive substance abuse

that involves the substance ethyl alcohol.

Alcohol dependence: A form of psychoactive substance

dependence that involves the substance ethyl alcohol.

Alcohol, Drug Abuse, and Mental Health (ADM)

Block Grant Program: The major Federal program

providing funds to States for outpatient alcohol, drug

abuse, and mental health treatment programs. (Funds

are not allowed to be used for inpatient services.)

States receive a share of the ADM block grant

appropriation through a formula based in part on the

size of the State population (Subpart 1, part B of Title
Appendix A—Glossary of Abbreviations and Terms . II-699

XIX of the Public Health Service Act). The ADM

Block Grant Program is administered by the Office of

Treatment Improvement in the Alcohol, Drug Abuse,

and Mental Health Administration in DHHS.

Ambulatory care: Medical services provided to patients

who are not inpatients of hospitals. It includes

outpatient hospital care.

Amenorrhea: Absence of menstrual bleeding.

American Indian or Alaska Native: A person having

origins in any of the original peoples of North

American and maintaining cultural identification

through tribal affiliation or community recognition,

Compare black, white, Hispanic, and Asian or Pacific

Islander.

Amphetamines: A group of three closely related compounds, all of which are potent central nervous system

and behavioral stimulants: 1) amphetamine, 2) methamphetamine, and 3) dextroamphetamine. Amphetamines are used medically to treat hyperactivity in

children, mild brain dysfunction in children, narcolepsy (recurrent, uncontrollable, brief episodes of

sleep), or mild depression.

Analgesics: Pain killers.

Androgens (also called androgenic hormones): Male

sex hormones such as testosterone, which is responsible for inducing and maintaining secondary male sex

characteristics.

Anemia: A condition that exists when the level of

hemoglobin in a person’s blood drops to an abnormally

low level (e.g., below 11 grams per deciliter of whole

blood).

Anorexia nervosa: See eating disorders.

Antisocial behaviors by children: Also known as

conduct problems in the criminology literature, these

are hostile or harmful behaviors that deviate from the

social norm (e. g., aggression, stealing, lying, acting

fighting).

Anxiety disorders: A set of disorders defined in DSM-IIIR as disorders in which excessive apprehension,

tension, or uneasiness that stems from the anticipation

of internal or external danger is the primary symptom.

This anxiety is manifested by physiological changes

such as sweating, tremor, and rapid pulse. Separation

anxiety disorder involves irrational fears or panic

about being separated from those to whom one is

attached, usually the parent(s), While separation anxiety disorder is more common among children, it may

continue into adolescence.

Appetitive effects (of drugs): Usually pleasurable sensations or feelings, such as euphoria, which may instill

a craving (or appetite) for continued use of a substance

in order to prolong or re-create the desired effects.

Appropriation (by Congress): An act of Congress that

authorizes one or more Federal agencies to incur

obligations and make payments from the general fund

or various special finds of the U.S. Treasury. Appropriations do not represent funds available in the

Treasury but are limitations on the amounts that

agencies may obligate during the time period set in the

law. Compare authorization.

Arrest rate: The number of arrests made in a given

population per some population base during a given

time period (e.g., 5 arrests per 100,000 population).

The arrest rate is analogous to an incidence rate for an

offense.

Arson: See serious property offenses.

Asian or Pacific Islander: A person having origins in

any of the original peoples of the Far East, Southeast

Asia, the Indian subcontinent, or the Pacific Islands.

The area includes China, India, Japan, Korea, the

Philippine Islands, and Samoa. Compare black, white,

Hispanic, and American Indian or Alaska Native.

Assault: The unlawful intentional inflicting, or attempted

inflicting, of injury upon the person of another. Simple

assault is the unlawful intentional inflicting of less

than serious bodily injury without a deadly or dangerous weapon or an attempt or threat to inflict bodily

injury without a deadly or dangerous weapon. Aggravated assault is the unlawful intentional inflicting of

serious bodily injury or death by means of a deadly or

dangerous weapon with or without actual infliction of

injury.

Assertiveness training: Counseling for the purpose of

improving interpersonal communications skills. Some

programs focus on helping people to identify their own

values; others communicate particular values and help

people learn to live by them.

Asthma: Constriction of the bronchial tubes, producing

wheezing and difficulty breathing, in response to

irritation, allergy, or other stimuli.

Asymptomatic: Without symptoms.

Atherosclerotic cardiovascular disease: Heart disease

related to a disorder of the arterial walls that includes

degenerative changes, deposition of lipid, proliferation

of smooth muscle cells, fibrosis, and calcification of

the arterial walls.

Attention deficit hyperactivity disorder (ADHD): A

mental disorder defined in DSM-III-R as a disturbance

lasting at least 6 months that is characterized by

developmentally inappropriate degrees of inattention,

impulsiveness, and hyperactivity. The diagnosis is

made when at least 8 of 14 specified criteria are met

(e.g., often fidgets with hands or feet or feels restless,

often talks excessively, often does not seem to be

listening to what is being said). Onset of the disorder,

which is more common in males than females, is

typically before the age of 4 but must occur before age

7. Central nervous system abnormalities are thought

to be predisposing factors. Some impairment in

schoolwork or cooperating in group social activities is

common.
11-700. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Authoritative parenting: Parenting style that includes

embracing traditional values, guiding children’s activities firmly and consistently, stating values clearly,

responding to children emotionally, providing a stimulating environment for children, and maintaining an

appropriate ratio of children’s autonomy to parental

control at all times.

Authorization (by Congress): Substantive legislation

that creates or continues a Federal agency or program

for an indefinite or specified period of time. It may

prescribe funding methods, allow a particular type of

expenditure, or limit the level of budget authority.

Compare appropriation.

AZT: See zidovudine.

Bacterium (pl., bacteria): Any of a group of one-celled

micro-organisms having round, rodlike, spiral, or

filamentous bodies that are enclosed by a cell wall or

membrane and lack fully differentiated nuclei. Bacteria may exist as free-living organisms in soil, water,

organic matter, or in the bodies of plants and animals,

Some, but not all, bacteria can cause disease.

Barbiturates: A group of sedative-hypnotic compounds

that are capable of producing all degrees of behavioral

depression, ranging from mild sedation, through anesthesia, to coma and death. Barbiturates have traditionally been subclassified into compounds of varying

durations of action. Many of the behavioral effects of

the barbiturates are quite similar to those observed

during alcohol-induced inebriation.

Bed-disability day: As defined by the National Health

Interview Survey conducted by DHHS, any day on

which person stays in bed for more than half of the

daylight hours (or normal waking hours) because of an

illness or an injury. All hospital days are bed-disability

days. See also restricted-activity day.

Behavioral problems: Behavior that disturbs or harms

the adolescent or others. Includes the mental health

problems termed disruptive behavior disorders (e.g.,

attention deficit disorder, conduct disorder). See

problem behaviors. Compare physical problems and

mood disorders.

Bipolar or manic-depressive disorder: A mental disorder defined in DSM-III-R involving extreme swings in

mood between severe depression and intense elation.

During the manic phase, hyperactivity and a decreased

need for sleep are common, as are an inflated sense of

self-esteem and a lack of recognition that the behavior

is not normal. These manic periods alternate with

periods of depression, sometimes immediately following each other and sometimes with a period of normal

moods between the manic and depressive phases.

Birth rate: A measure derived by dividing the number of

live births in a population in a given period by the

resident population at the middle of that period. It is

expressed as the number of live births per 1,000

population. The rate may be restricted to births among

women of a specific age, race, marital status, or other

characteristic (e.g., 65 births per 1,000 females ages 15

to 19), or it may be related to the births among the

entire population.

Black: A person having origins in any of the black racial

groups in Africa. Normally excludes persons of

Hispanic origin except for tabulations produced by the

Bureau of the Census, which are noted accordingly.

Compare white, Hispanic, Asian or Pacific Islander,

American Indian or Alaska Native.

Block grants: Sums of Federal funds allotted to State

agencies (e.g., education, health) which may be passed

on to local agencies. States determine the mix of

services provided and the population served and are

accountable to the Federal Government only to the

extent that funds are spent in accordance with program

requirements. Sometimes, however, set-asides are

required for specific population groups. See also

names of specific block grant programs: Alcohol, Drug

Abuse, and Mental Health (ADM) Block Grant Program, Community Development Block Grant Program,

Maternal and Child Health (MCH) Services Block

Grant Program, Social Service Block Grant Program.

Body mass index (BMI): Weight in kilograms divided

by height in meters squared [m2

]. This is a measure

used in determining obesity or overweight.

Bulimia nervosa: See eating disorders.

Burglary: See serious property offenses.

Calculus: A hard deposit of calcium phosphate and

carbonate with organic matter on the surfaces of the

teeth.

Cancer: A tumor with the potential for invading neighboring tissue and/or metastasizing to distant sites, or

one that has already done so. Cancers are categorized

into major classes by their cell types. A carcinoma is

a cancer of the epithelia, including the external

epithelia (mainly skin and linings of the gastrointestinal tract, lungs, and cervix) and the internal epithelia

that line various glands (e.g., breast, pancreas, thyroid). A sarcoma is a tumor made up of a substance

like the embryonic connective tissue; sarcomas are

often highly malignant. See also leukemia.

Cannabis: The dried flower of the hemp plant, Cannabis

sativa, that contains the psychoactive substance tetrahydrocannabinol (THC), which is the active ingredient in

rnarijuana and hashish.

Career criminals: High rate and or long duration

offenders who contribute most to total crime rates.

Central cities: The largest cities, with 50,000 or more

inhabitants, in a Metropolitan Statistical Area (MSA).

A smaller city within an MSA may qualify if it has at

least 25,000 inhabitants or has a population of

one-third or more of that of the largest city and a

minimum population of 25,000. An exception occurs

where two cities have contiguous boundaries and

constitute, for economic and social purposes, a single
Appencfix A--Glossary of Abbreviations and Terms . II-701

community of at least 50,000, the smaller of which

must have a population of at least 15,000.

Cerebral palsy: The popular term for a necrologic defect,

typically present from infancy or childhood, that

causes a major, but typically nonprogressive, disturbance of motor function. The term covers several

diseases of widely differing etiologic and anatomic

types,

Cervicitis: Inflammation of the cervix uteri (the neck of

the uterus).

Chancre: 1) The usually painless primary lesion of

syphilis, occurring at the site of entry of the infection,

typically presenting as a small red papule or crusted

erosion that breaks down to become round or oval,

indurated, and slightly elevated with an eroded surface

that exudes a serous fluid and gives rise to a nontender,

firm regional lymphadenopathy (bubo); 2) any of

various primary cutaneous lesions that are seen at the

site of inoculation of infection in such diseases as

herpes and tuberculosis.

Chancroid: A sexually transmitted disease (STD) caused

by the bacterial agent Haemophilus ducreyi and

characterized by a painful primary ulcer at the site of

inoculation, usually on the external genitals. Potential

complications include secondary infections, fisfulae,

and paraphimosis or phimosis.

Chapter 1 programs: Chapter 1, Title I of the Elementary and Secondary Education Act, provides

Federal assistance for State and local educational

programs for disadvantaged U.S. pupils from prekindergarten through secondary school.

Child and Adolescent Service System Program (CASSP):

A small program, administered by the National Institute of Mental Health in DHHS, that was created by

Congress in 1984 to promote greater coordination

among public and private agencies providing services

to children and adolescents with mental health problems.

Children’s protective services: See protective services.

Child welfare services: See social services.

Child welfare system: See social services.

Chlamydial infection: Any sexually transmitted disease

(STD) that is characterized by infection with the

bacterial agent Chlamydia trachomatis. Such infection, which may be asymptomatic or accompanied by

symptoms such as dysuria (difficult urination), penile

or vaginal discharge, and urinary frequency, can

potentially lead to complications that include urethral

stricture, urethritis, salpingitis, epididymitis, infertility, and adverse obstetrical outcomes. Methods of

prevention include the avoidance of multiple sexual

partners. Treatment is with antibiotics. Chlamydia is

the most common type of sexually transmitted disease

among U.S. adolescents.

Cholesterol: A white, waxy, fat-like substance present in

all of the body’s tissues and in the bloodstream,

essential to life. The cholesterol that comes from food

(dietary cholesterol) is not an essential nutrient diet

because sufficient amounts of cholesterol are produced

in the body. Just how cholesterol is distributed through

the body is not entirely clear, but, in simple terms,

low-density lipoproteins (LDL) (the so-called “bad”

cholesterol) appear to bring cholesterol into the

system, and highdensity lipoproteins (HDL) (the

so-called ‘‘good’ cholesterol) appear to carry cholesterol away from the system through the liver. Levels of

cholesterol in the bloodstream can be affected by diet,

and by genetic disorders, and diabetes and other

metabolic diseases, Hypercholesterolemia (elevation

of the blood cholesterol level) is thought to result by

causing atherosclerotic cardiovascular disease.

Chronic condition: Generally, an illness, an injury, or an

impairment that is lingering and lasting. For purposes

of the National Health Interview Survey conducted by

DHHS, a chronic condition is any physical or mental

condition that either has lasted 3 months or more or is

one of certain conditions that normally has a duration

of more than 3 months (e.g., diabetes, arthritis).

Compare acute condition.

Chronic illness (physical, mental): For purposes of this

Report, a chronic illness is a disease or disorder (as

opposed to an injury) that persists over an extended

period of time. The distinction between physical and

mental illnesses is somewhat arbitrary, however,

because some mental illnesses have a physiological

base. See also chronic condition. Compare acute

illness.

Civilian noninstitutionalized population: The civilian

population not residing in institutions. Institutions

include correctional institutions, detention homes, and

training schools for juvenile offenders, homes for

dependent and neglected children, homes and schools

for the mentally or physically handicapped, and homes

for unwed mothers. This population is the denominator

in rates calculated for the National Ambulatory Medical Care Survey, the National Health and Nutrition

Examination Survey, and the National Health Interview Survey.

Cocaine: A psychoactive substance derived from coca

leaves. Several types of coca preparations are used for

their psychoactive properties: coca leaves (chewed),

coca paste (smoked), cocaine hydrochloride powder

(inhaled or injected), and cocaine alkaloid—

“freebase” or “crack” (smoked).

Cocaine abuse: A form of psychoactive substance abuse

that involves the substance cocaine.

Cocaine dependence: A form of psychoactive substance

dependence that involves the substance cocaine.

Cognitive-behavioral skills training programs: Prevention and/or health promotion interventions that are

based on the idea that problem behavior and emotional

distress sometime result from an inability to develop
II-702 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

and maintain positive social relationships due to

deficits in social skills. Interpersonal cognitive problemsolving programs focus on processes such as

interpreting social cues and others’ intentions, generating alternative solutions, and means-ends thinking.

Behavioral social skills training interventions focus on

teaching specific behaviors such as entering a peer

group, accepting criticism, giving compliments and

resisting peer pressure. Many programs incorporate

aspects of both types of training, often as a part of a

school curriculum and done in small groups of

students.

Comer’s School Development Program: An educational intervention, developed by Yale child psychiatrist James Comer, that seeks to overcome “the

sociocultural misalignment between home and

school’ that Comer believes underlies the academic

and disciplinary problems of many school serving

low-income black and ethnic minority students.

Community Development Block Grant Program: A

Federal program of block grants to States and local

communities established by Title I of the Housing and

Community Development Act of 1974, as amended.

The program provides Federal financial assistance to

State and local governments to be used to fund a wide

range of activities designed to further one of three

national objectives: 1) benefit low- and moderateincome persons, 2) prevent or eliminate slums and

blight, or 3) address an urgent community development problem that threatens the safety and health of the

community. The 1974 act, as amended, identifies 19

categories of activities that may receive funding,

including housing rehabilitation, historic preservation,

economic development, public works, relocation assistance, public services, energy conservation, and

property acquisition and demolition. Public works,

housing rehabilitation, and economic development are

the activities most often funded.

Community health center (CHC): An organization that

provides primary health care and other health-related

services to individuals in the local community. As of

1989, there were about 1,200 community health

centers providing services at more than 2,000 sites

throughout the country. Roughly half of these centers

were receiving Federal grants under Section 330 of the

Public Health Service Act, which authorizes grants to

public and private nonprofit organizations that provide

primary health care to populations or areas that are

‘‘medically underserved.

Community mental health centers (CMHCs): Local

organizations that provide outpatient mental health

services for people of all ages who have mental and

emotional problems. There is no agreement about

which organizations should be counted as CMHCs.

Since 1981, with the advent of the Federal Alcohol,

Drug Abuse, and Mental Health (ADM) Block Grant

Program, the changes in the definition of CMHCs, and

the discontinuation of CMHC monitoring by the

National Institute of Mental Health in DHHS, organizations formerly classified as CMHCs have been

reclassified as other types of organizations (e.g.,

multiservice mental health organizations, freestanding psychiatric outpatient clinics). Currently, CMHCs

are funded in various ways, including fees, third-party

payment, and State and local government contracts.

Some CMHCs receive Federal ADM block grant

funds.

Comorbidity: The occurrence of a health condition along

with another health condition.

Comparison group: In evaluation research, a group that

does not receive the “experimental” intervention or

program, but receives no or a different intervention.

Comprehensive services for adolescents: The elements

of comprehensive health and related services for

adolescents are not entirely agreed upon. They include,

at a minimum, care for acute physical illnesses, general

medical examinations in preparation for involvement

in athletics, mental health counseling, laboratory tests,

reproductive health care, family counseling, prescriptions, advocacy, and coordination of care; the more

comprehensive may include educational services,

vocational services, legal assistance, recreational opportunities, and child care services and parenting

education for adolescent parents.

Condition: As defined for purposes of the National

Health Interview Survey conducted by DHHS, a

departure from a state of physical or mental well-being.

A health condition maybe an injury, an illness, or an

impairment. See also acute condition, chronic condition.

Condom: A sheath commonly made of rubber worn over

the penis for the purpose of preventing pregnancy or

preventing the transmission of human immunodeficiency virus (HIV) or particular types of sexually

transmitted diseases (STDs).

Conduct disorder: A mental disorder defined in DSM-III

R as a disturbance lasting at least 6 months in which a

young person persistently violates the basic rights of

others and violates major age-appropriate societal

norms or rules. The diagnosis is made when at least 3

of 13 specified criteria are met (e.g., stealing, running

away, frequent lying, deliberate fire-setting, frequent

truancy, breaking into someone else’s property, deliberately destroying property, being physically cruel to

animals, using a weapon in more than one fight). Onset

is usually prepubertal. Predisposing factors thought to

be antecedent are attention deficit hyperactivity disorder (ADHD), parental rejection, early institutional

living, frequent shifting of parental figures, absence of

a father or presence of a father with alcohol dependence, large family size, and association with a delinquent subgroup. Complications include school suspen-
Appendix A—Glossary of Abbreviations and Terms . II-703

sion, legal difficulties, psychoactive substance use

disorders, high rates of injury from fights, unwanted

pregnancy, and suicidal behavior. Compare delinquent

acts by adolescents.

Condyloma acuminatum: A sexually transmitted disease (STD) characterized by warty lesions on the

mucous membrane or skin of the external genitals or

in the perianal region and caused by human papillomaVirus (HPV).

Continuing Survey of Food Intakes by Individuals

(CSFII): A household survey, conducted by the Food

and Nutrition Service of the U.S. Department of

Agriculture since 1985, that is designed to measure

levels and changes in the food and nutrient content and

nutritional adequacy of U.S. diets on a continuing

basis.

Contraception: In this Report, the use of methods other

than abstinence from sexual activity to prevent pregnancy. See contraceptives or contraceptive methods.

Contraceptives or contraceptive methods: Methods of

preventing pregnancy other than abstinence from

sexual activity. Such methods include periodic abstinence (rhythm method); control of ejaculation (coitus

interruptus); the use of spermicidal chemicals in jellies

or creams; mechanical barriers (e. g., condoms, caps, or

diaphragms); prevention of implantation (e.g., intrauterine device); the use of synthetic hormones to

control the female reproductive cycle; and sterilization

of the male or female partner. Various methods vary in

terms of their effectiveness in preventing pregnancy,

their side effects, and their noncontraceptive benefits

such as protection from sexually transmitted diseases

(STDS). See also condoms, diaphragm, oral contraceptives, and spermicides.

Control group: In a randomized clinical trial or other

experimental design, the group receiving no treatment

or some treatment with which the group receiving

experimental treatment is compared. The control

treatment is generally a standard treatment, a placebo,

or no treatment. Compare experimental group.

Cooperative learning interventions: interventions in

schools that involve putting students together in

groups where they need to work together to create a

final product. Cooperative learning enables heterogeneous groups of students to work across ability levels;

encourages students to participate actively as teachers

and as learners with their peers; and facilitates empathy

across and within racial, ethnic and ability groups; and

shifts the questions of absolute authority away from

teachers.

Correlation coefficient: Percentage of interdependence

between two variables. When a change in one variable

is accompanied by a change in the second variable in

the same direction, the correlation is positive; if the

second variable changes, but in direction opposite to

that of the first, the correlation is negative.

Covariation: The tendency of health problems to occur

in the same individual at approximately the same time.

The problems may have a single common cause, or one

problem may be the cause of another,

Crack cocaine: See cocaine.

Crimes: Infractions of the law by adults.

Crisis intervention: Therapeutic techniques for individuals who are experiencing a crisis.

Cross-sectional studies: Studies involving samples representative of the entire population. In criminology

research, studies that compare individuals involved in

offending behavior with those who do not commit

offenses at one point in time.

Cystic fibrosis: An autosomal recessive disorder caused

by the production of a unique glycoprotein that results

in abnormal mucous secretions. It is one of the most

common genetic diseases in caucasian children, and is

most often seen in children and young adults. It is

usually fatal before age 20. Death is due to excess

mucus in the lungs and to pancreatic insufficiency.

Day treatment: See partial hospitalization/duy treatment.

Death rate: See mortality rate,

Decisionmaking skills: Skills relevant to the ability to

make rational, health-promoting decisions about one’s

life. Often a part of life skills training interventions.

Delinquent acts by adolescents: Two broad categories of

acts committed by adolescents: 1) acts that would be

considered crimes if committed by an adult (ranging

from minor offenses such as disorderly conduct to

serious offenses such as aggravated assault); and 2)

status offenses, which are considered offenses only

when committed by minors (e.g., running away from

home, truancy). See also minor offenses, serious

property offenses, serious violent offenses. Compare

conduct disorder.

Delinquent adolescent: An adolescent who has either

violated Federal, State, municipal, or local criminal

laws or has committed status offenses (e.g., running

away from home, truancy).

Demand reduction substance use prevention strategies: Strategies related to the prevention of drug use

and abuse that involve changing behavior through

education (of individuals or of society as a whole),

through providing alternatives to alcohol and other

drug use, and through community action to change the

social or physical environment that supports the

undesirable behavior. Compare supply reduction substance use prevention strategies.

Demographic factors: Age, gender, race, ethnicity,

geographic location and socioeconomic status are

typically defined as demographic factors.

Dental and oral health: The term dental means of or

relating to the teeth or dentistry (the health profession

that cares for teeth); and the term oral means of or

relating to all aspects of the oral cavity (e. g., the gums
II-704 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

and the tongue). Thus, dental and oral health refers to

the health of these structures.

Dental caries: The localized, progressive decay of a

tooth, starting on the surface, and if untreated, extending to the inner tooth chamber and resulting in

infection.

Dental sealants: Thin coatings of plastic material placed

on the occlusal (chewing) surfaces of posterior teeth to

prevent the accumulation of food debris and bacteria in

the pits and fissures of these teeth and subsequent

dental decay.

Depression: A psychiatric syndrome defined in DSM-IIIR that involves dejected mood and often poor sleep and

weight loss. Depression may have genetic and biochemical components. Antidepressant drugs seem to

act by affecting neurotransmitters in the brain. See also

bipolar disorder, dysthymia.

Designer drugs: Structural analogs of substances scheduled under the Controlled Substances Act that are

prepared to mimic the psychoactive effects of controlled drugs. Because the analogs are not structurally

identical to their parent compound, their manufacture

and distribution is not a violation of the Controlled

Substances Act.

Detoxification: The recovery, or the process of bringing

about the recovery, of a patient from a state of

dependence on alcohol or other drug, Medical detoxification is the use of medication under the supervision

of medical personnel to systematically reduce or

eliminate the effects of alcohol in the body in a hospital

or other 24-hour facility. Social detoxification is to

systematically reduce or eliminate the effects of

alcohol in the body on a drug-free basis, in a

specialized nonmedical facility by trained medical

personnel with physician services available when

required. Drug detoxification is the period of planned

withdrawal from drug dependency supported by the

use of a prescribed medication (e.g., methadone).

Development: A process of growth and differentiation by

successive changes. In humans, includes physiological

development; cognitive development (increasing ability to think critically and engage in higher order

reasoning); ego development (qualitatively different

psychosocial stages, including internalization of the

rules of social intercourse, increasing cognitive complexity and tolerance of ambiguity, and growing

objectivity); and moral development (changes in the

ability to recognize and reason about moral dilemmas

and to make choices based on moral principles and

reasoning).

Developmental disabilities: Most broadly, any disability

that interferes with normal human development. As

defined by the Developmental Disabilities Assistance

and Bill of Rights Act, the definition is based on

functional limitations rather than specific disorders.

These limitations must be manifest before age 22; be

attributable to a mental or physical impairment; and

result in substantial limitations in three or more major

life activities, such as self-care, learning, receptive, and

expressive language, and mobility. See also developmental disorders.

Developmental disorders: A group of mental disorders

defined in DSM-III-R as disorders in which the

predominant disturbance is in the acquisition of

cognitive, language, motor, or social skills. The course

of developmental disorders tends to be chronic, with

some signs of the disorder persisting in a stable form

(without periods of remission or exacerbation into

adult life).

Developmentally appropriate: Health promotion, prevention, and treatment services and environments

designed so that they fit the emotional, behavioral/

experiential, and intellectual levels of the individual

who is to benefit from the service. Because of the

asynchronous development within even individual

adolescents (as well as individuals in other age

categories), designing programs so that they are

developmentally appropriate is a distinct challenge.

Diabetes (diabetes mellitus): A chronic metabolic disorder characterized by an inappropriate elevation of

blood glucose level, and impaired fat and protein

metabolism, for which a relative or absolute lack of

insulin is responsible. It occurs in two forms: insulindependent diabetes mellitus (type I) for which the peak

age of onset is age 14, and non-insulin-dependent

diabetes (type II) for which the peak age of onset is age

50 to 60. Both types are associated with disease of

small and large blood vessels.

Diagnosable mental disorders: Disorders included in

the American Psychiatric Association’s Diagnostic

and Statistical Manual of Mental Disorders, 3rd cd.,

revised (DSM-III-R) or in the International Classification of Diseases, 9th revision, Clinical Modification

(ICD-9-CM).

Diagnostic and Statistical Manual of Mental Disorders, 3rd cd., revised: See DSM-III-R.

Diaphragm: A prescription contraceptive method that

involves the insertion of a dome-shaped rubber cap

with a flexible rim into the vagina prior to intercourse.

Spermicidal cream or jelly is placed in the dome before

insertion. The diaphragm and spermicide combination

probably provides some protection against sexually

transmitted disease (STD), including pelvic inflammatory disease (PID).

Dideoxyonosine (DDI): A drug used for some patients

with human immunodeficiency virus (HIV) infection or

AIDS. Also called didanosine.

Diet and Health Knowledge Survey (DHKS): A survey

begun by the U.S. Department of Agriculture in 1989

as a followup to the Continuing Survey of Food Intaks

by Individuals (CSFII). DHKS targets food managers

participating in CSFII and seeks to link individuals’
Appendix A—Glossary of Abbreviations and Terms . II-705

knowledge and attitudes about diet and health to their

actual behavior.

Disability: A term used to denote the presence of one or

more functional limitations. As defined by DHHS’

National Center for Health Statistics, a disability is a

temporary or long-term reduction of a person’s activity

as a result of an acute or chronic condition. Disabilities

may be caused by illnesses, injuries, or impairments.

They are measured by the number of days that a

person’s activity has been reduced or by a person’s

degree of ability to carry on the major activity for

his/her age group (for children 5 to 17, major activity

refers to school attendance). Compare handicap and

impairment.

Discretionary time: That portion of time during which

individuals are not engaged in mandatory or maintenance activities (e. g., school, work, sleeping, eating).

Disease: Any deviation from or interruption of the normal

structure of function of any part, organ, or system (or

combination thereof) of the body that is manifested by

a characteristic set of symptoms and signs and whose

etiology, pathology, and prognosis may be known or

unknown. Compare injury. See conditions.

Disruptive behavior disorders: The three primary behavior disorders in DSM-III-R that are of concern

during adolescence are attention deficit hyperactivity

disorder (ADHD), oppositional defiant disorder, and

conduct disorder.

Diversion programs (for adolescent juvenile offenders): Programs that seek to limit juvenile offenders

involvement with the juvenile justice system b y

diverting such offenders from the courts and juvenile

justice facilities to other social control institutions

(e.g., the family, schools, social service programs).

DMFS index: An index used to measure the average

number per person in a specified population of

Decayed permanent tooth surfaces, Missing permanent

teeth, and Filled (or restored) Surfaces of permanent

teeth. It is a somewhat more sensitive measure of

dental caries than the DMFT index.

DMFT index: An index used to measure the average

number per person in a specified population of

Decayed permanent teeth, Missing permanent teeth,

and Filled permanent Teeth.

Down syndrome: A congenital syndrome characterized

by moderate to severe mental retardation, congenital

onset of growth failure, facial abnormalities including

slanted eyes, congenital heart disease, and acute

leukemia. It is caused by an extra chromosome and is

associated with advanced maternal age at conception.

Dropout rate: School dropout rates can be defined in

several ways. In this Report, the dropout rate used is

the status dropout rate, or the proportion of a

particular group of individuals (usually an age cohort)

who are not enrolled in school and have not finished

high school at a particular point in time. Other types of

dropout rates include the event dropout rate (the share

of students who leave school without completing high

school in a single year) and the cohort dropout rate

(the proportion of a group of students that drop out

over time).

Drug: Strictly speaking, a drug is any chemical or

biological substance other than food that may be used

to affect the structure or function of the body. In this

Report, however, the term drug generally refers to

psychoactive substances with the potential for dependence or abuse. Sometimes the term is used more

narrowly in this Report to refer to illicit drugs (i. e.,

drugs other than alcohol or tobacco, which are legally

available to adults).

Drug abuse: See psychoactive substance abuse. In the

Drug Abuse Warning Network (DAWN) of the National Institute on Drug Abuse, drug abuse is defined

as “the nonmedical use of a substance for. . psychic

effect, dependence, or suicide attempt/gesture.

Drug abuse violations: As defined in the Federal Bureau

of Investigation’s Uniform Crime Reports, State and

local offenses related to the unlawful possession, sale,

use, growing, and manufacture of narcotic drugs.

Drug Abuse Warning Network (DAWN): A system that

collects data on emergency room visits and deaths

related to drug use from a sample of hospital emergency rooms and medical examiner facilities that

report data for each “drug abuse” patient or death

encountered by medical examiners. The DAWN system is designed primarily as an early warning system

to monitor drug abuse patterns and health hazards

associated with drug use and to detect new abuse

entities and new combinations. The system is maintained by the National Institute on Drug Abuse in

DHHS.

Drug demand reduction: See demand reduction substance use prevention strategies.

Drug dependence: See psychoactive substance dependence.

Drug supply reduction: See supply reduction substance

use prevention strategies.

DSM-III-R (Diagnostic and Statistical Manual of

Mental Disorders, 3rd cd., revised): A manual

compiled by the American Psychiatric Association

that includes a system for classifying mental disorders

of children, adolescents, and adults.

Dysfunctional families: Families that lack cohesion and

mutual support within a framework of affection that

respects individual differences and the need for

personal expression of autonomy. Such families may

either stifle individuality or use inappropriate means of

expressing such individuality (conflict and confrontation).

Dysmenorrhea: Painful menstruation. Essential (or

primary) dysmenorrhea is painful menstruation for

which there is no demonstrable cause. Other types of
11-706. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

dysmenorrhea are caused by spasmodic uterine contractions, psychic disturbances, pelvic lesions, or other

problems.

Dysthymia or depressive neurosis: A chronic mood

disorder defined in DSM-III-R as a disorder in which

an individual is depressed during at least a 2-year

period the majority of the time. Associated symptoms

are poor appetite or overeating, insomnia or hypersomnia, fatigue, low self-esteem, and feelings of hopelessness.

Early adolescence: A period encompassing the profound

physical and social changes that occur with puberty, as

maturation begins and social interactions become

increasingly focused on sex (e.g., on members of the

opposite sex). Typically takes place from ages 10

through 14. Compare middle adolescence, late adolescence, younger adolescents, older adolescents.

Eating disorders: A set of mental disorders defined in

DSM-III-R as being characterized by gross disturbances in eating behavior. Eating disorders in adolescence primarily include anorexia nervosa and bulimia

nervosa. Anorexia nervosa is defined by DSM-III-R

as a disorder whose essential features are refusal to

maintain body weight over a minimal normal weight

for age and height, intense fear of gaining weight or

becoming fat, even though underweight, a distorted

body image, and amenorrhea (in females). Bulimia

nervosa is defined by DSM-III-R as a disorder whose

essential features are recurrent episodes of binge

eating; a feeling of lack of control over eating behavior

during the eating binges; self-induced vomiting, use of

laxatives or diuretics, strict dieting or fasting, or

vigorous exercise to prevent weight gain; and persistent overconcern with body shape and weight. Death is

less likely for bulimics than for anorexics, but physical

health problems are common for both groups.

Ectopic pregnancy: A pregnancy that is located away

from normal position.

Education for All Handicapped Children Act (Public

Law 94-142): A Federal law that mandates that all

physically and mentally handicapped children be

provided a free, appropriate education and the “related

services’ necessary to obtain an education. The

Federal Government provides a small amount of grant

money to States to help them implement this law.

Educational neglect: As defined by DHHS’s National

Center on Child Abuse and Neglect, educational

neglect can take several forms: permitted chronic

truancy, failure to enroll a school-aged child in school,

causing the child to miss school for nonlegitimate

reasons, and inattention to special educational need

(e.g., refusal to allow or failure to obtain recommended

remedial educational services).

Elementary school: A school classified as elementary by

State and local practice and composed of any span of

grades not above grade 8. A preschool or kindergarten

school is included under this heading only if it is an

integral part of an elementary school or a regularly

established school system.

Emancipated minor: A minor who has been legally

freed from the control and authority of his or her

parents.

Emotional abuse: As defined by DHHS’s National

Center on Child Abuse and Neglect, emotional abuse

takes three different forms: close confinement, such as

tying or binding, or other tortuous restriction of

movement; verbal or emotional assault (e.g., habitual

patterns of belittling, denigrating, or scapegoating);

and other overtly punitive, exploitative, or abusive

treatment other than those specified under other forms

of abuse (e.g., deliberate withholding of food).

Emotional neglect: As defined by DHHS’s National

Center on Child Abuse and Neglect, emotional neglect

can take several forms: inadequate nurturance and

affection; chronic or extreme spouse abuse in the

child’s presence; encouragement or permitting of drug

or alcohol use by the child; permitting other maladaptive behavior; refusal of recommended, needed and

available psychological care; delay in psychological

care; and other emotional neglect (e.g., other inattention to the child’s developmental/emotional needs not

classifiable under any of the above forms of emotional

neglect, such as inappropriate application of expectations or restrictions).

Emotional problems: The mental health problems exhibited in the form of emotional distress (e.g., anxiety

and other mood disorders); may include subjective

distress. Compare behavioral problems, physical problems.

Endometriosis: The presence of functional endometrial

glands or stroma or both outside the uterus, in sites

including the ovaries, broad ligaments, rectovaginal

septum, and umbilicus. The endometrial glands respond to hormonal stimuli, resulting in menstrual

bleeding and cystic blood accumulations in these sites.

Painful menses and pelvic pain are the main symptoms.

Epididymitis: Inflammation of the epididymis, the elongated cordlike structure along the posterior border of

the testis, whose elongated coiled duct provides for the

storage, transit, and maturation of spermatozoa.

Estrogen: Steroid hormones synthesized and secreted by

the ovarian follicle, the fetoplacental unit, the testis, or

the adrenal cortex. The biologic properties include

induction of estrus (the period of receptivity to mating

that occurs prior to ovulation), growth and maturation

of the female secondary sex characters, and preparation of the womb for a fertilized ovum. Estrogens are

widely used as components of oral contraceptives.

Ethnicity: A term used to indicate national origin (e.g.,

Hispanic, Asian). Most ethnic-specific census and

health status information is available only for individuals of Hispanic origin. Compare race.
Appendix A—Glossary of Abbreviations and Terms . II-707

Experimental design: Strictly speaking, a research

design in which research participants are randomly

assigned to one or more experimental groups or one or

more control or comparison groups, Compare quasiexperimental design.

Experimental group: In a randomized clinical trial, the

group receiving the treatment being evaluated for

safety and efficacy. The experimental treatment may

be a new technology, an existing technology applied to

a new problem, or an accepted treatment about whose

safety or efficacy there is doubt. Compare control

group.

Extracurricular activities: Activities that are not part of

the required school curriculum and that take place

outside of the regular course of study. Examples are

school-sponsored varsity athletics, drama, and debate

clubs.

Family: As defined by the U.S. Department of Commerce, Bureau of the Census, a group of two persons

or more, one of whom is the householder, related by

birth, marriage, or adoption and residing together. Also

see family household, household.

Family communication programs: Programs that seek

to prevent or delay early sexual activity among young

adolescents by improving parent-child communication.

Family counseling: Counseling proivided to an entire

family rather than solely to an individual.

Family household: As defined by the U.S. Department of

Commerce, Bureau of the Census, a household maintained by a family; in addition, any unrelated persons

who may be residing there are included in the count of

household members.

Family income: For purposes of the National Health

Interview Survey and National Health and Nutrition

Examination Survey, all people within a household

related to each other by blood, marriage, or adoption

constitute a family.

Family life education: Ideally, a curriculum, program, or

framework for helping young people make responsible

choices and decisions by providing accurate and

age-appropriate information about human sexuality,

and by exploring the attitudes, behaviors, and value

systems that shape the development of healthy sexuality. May include teaching of skills in communication,

responsible decisionmaking, and assertiveness. See

life skills training. Family life education is the more

current and encompassing term for programs formerly,

and now sometimes, known as sex education.

Family planning programs authorized by Title X of

the Public Health Service Act: Title X, established by

the Family Planning Services and Population Research

Act of 1970, funds public or private nonprofit entities

that operate voluntary family planning projects; funds

training for personnel to improve the delivery of

family planning services; promotes service delivery

improvement through research; and develops and

disseminates information on family planning. Contraceptives may be distributed without parental consent

or notification, but the use of Title X funds for abortion

as a method of family planning has been prohibited by

statute and regulations. Low-income individuals are

targeted as a priority group for receiving services.

Although projects funded by Title X do not focus

exclusively on adolescents, they are required to offer

a broad range of family planning services to all who

want them, including adolescents.

Family planning services: A range of services intended

to help individuals plan when to have children, which

typically include birth control information and counseling, provision of contraceptives, pregnancy testing

and counseling, gynecological examinations, and referrals for related services. Such services are available

through a variety of public and health providers that

include Title X family planning clinics as well as more

general health services settings.

Family Support Act of 1988 (Public Law 100-485): A

major welfare reform bill that made changes in the Aid

to Families With Dependent Children (AFDC) income

support program and required States to implement by

October 1, 1990, a Job Opportunity and Basic Skills

(JOBS) Program. This act also required that, beginning October 1, 1990, all States provide AFDC and

Medicaid coverage to families whose principal wageearner is unemployed. Coverage under this provision

is limited, however, to 6 months out of any 12-month

period.

Family support interventions: A broad array of social

support services provided to families, including day

care, medical care, counseling, family needs assessment, and referrals to other social service agencies.

Federally funded runaway and homeless youth centers: Locally controlled facilities that receive Federal

funds under the Federal Runaway and Homeless

Youth Act (Title III of the Juvenile Justice and

Delinquency Prevention Act) administered by the

Administration for Children, Youth, and Families

within the Office of Human Development Services of

DHHS as well as other funds. In fiscal year 1987, there

were 307 federally funded runaway and homeless

youth centers throughout the country. Federally funded

runaway and homeless youth centers provide emergency shelter (for up to 15 days), counseling, and other

services to runaway or otherwise homeless youth.

Federal poverty level: The official U.S. Government

definition of poverty based on cash income levels for

families of different sizes. Responsibility for changing

poverty concepts and definitions rests with the Office

of Management and Budget.

Financial access (to health services): In this Report,

used to refer to aspects of access that have to do with
11-708. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

health insurance coverage and ability to pay for

services. Compare legal access.

Firearm: A weapon from which a shot is discharged by

gunpowder. The term firearm is usually used only of

small arms. The term firearms includes guns (defined

as portable firearms).

First-listed diagnosis: In the National Hospital Discharge Survey conducted by DHHS, this is the

diagnosis listed first on the face sheet of a patient’s

medical record,

Fistulae: Abnormal passages leading from an abscess or

hollow organ to the body surface or from one hollow

organ to another and permitting passage of fluids or

secretions.

Fluoridation: The addition of a minute quantity of a

fluoride (usually one part per million of fluoride ion)

to drinkln‘ g water supplies in order to protect growing

children against dental caries. Fluoride can also be

applied topically (in toothpaste and rinses).

Food Stamp Program: A program of food assistance to

low-income individuals that is administered by the

U.S. Department of Agriculture’s Food and Nutrition

Service. Adolescents ages 15 to 17 make up an

estimated 34 percent of the participants in the Food

Stamp Program.

Forcible rape: See serious violent offenses.

Foster care: In its broadest sense, the placement of

children in foster family homes, group homes, group

child care facilities and residential treatment centers

by the child welfare system. Most children in foster

care are placed in foster family homes, that is, with a

foster parent or parents and the parents’ own or other

foster children. Children and adolescents placed in

foster care have been removed from their homes

because of abuse, neglect, or abandonment, and they

have either been adjudicated “dependent” by the

courts or voluntarily placed in foster care by their

families, Compare therapeutic foster care.

Freestanding psychiatric outpatient clinic: An administratively distinct organization that is not part of

another organization (e.g., a hospital) that has as a

primary purpose the provision of only ambulatory

mental health services on either a regular or emergency

basis. The medical responsibility for all patients/

clients and/or direction of the mental health program

is generally assumed by a psychiatrist.

Freestanding psychiatric partial care organization:

An administratively distinct organization that is not

part of another psychiatric organization (e.g., a hospital). It is comprised of programs for ambulatory

patients who generally require more time (3 or more

hours) than that provided through an outpatient visit,

but who require less than 24-hour care. Compare

partial hospitalization/day treatment.

General educational development (GED) program:

Academic instruction to prepare persons to take the

high school equivalency examination.

General hospital with separate psychiatric organization: A non-Federal hospital that routinely admits

patients to a separate psychiatric service (e.g., inpatient, outpatient, or partial hospitalization), for the

express purpose of diagnosing and treating psychiatric

illness. A separate psychiatric unit is an organizational

or administrative entity within a general hospital that

provides one or more treatments or other clinical

services for patients with a known or suspected

psychiatric diagnosis.

Genital herpes: See herpes genitalis.

Glucose: A sugar found in certain foodstuffs (especially

fruits) and in the normal blood of humans and other

animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living

organisms, its utilization being controlled by insulin.

Gonadarche: Maturation of the reproductive organs.

Gonadotropin: Hormones that act upon the gonads.

Gonorrhea: A sexually transmitted disease (STD) characterized by infection with the bacterial agent Neisseria gonorrhoeae. Gonorrhea, which may be asymptomatic or accompanied by vaginal/penile discharge,

abdominal pain, or other symptoms, can potentially

lead to complications that include disseminated gonococcal infection (e.g., septicemia), pelvic inflammatory disease (PID), epididymitis, and infertility or

sterility. Spermicides and condoms offer some protection from this disease. Treatment is with antibiotics.

Gonorrhea is the second most common type of

sexually transmitted disease among U.S. adolescents.

Hallucinogens (psychedelics): A group of heterogeneous compounds that affect a person’s perceptions,

sensations, thinking, self-awareness, and emotions.

Some hallucinogens come from natural sources (e.g.,

mescaline from peyote); others (e.g., LSD) are manufactured. Some surveys (including the NIDA Household Survey on Drug Abuse) consider phencylidine

(PCP) a hallucinogen because it has some of the same

effects.

Handicap: As defined by OTA in 1982, the inability to

perform one or more life functions (e.g., eating,

conversing, working, attending school) at a “typical”

level, caused by the interaction of an individual’s

disability with the physical and social environments in

which that person is functioning or expected to

function. Handicaps include physiological impairments such as deafness, blindness, and orthopedic

impairment; chronic health impairments such as heart

conditions, leukemia, and epilepsy; emotional disturbance; mental retardation; learning disability; and

speech impairment. Compare disability and impairment.

Hashish: A resin obtained from the Indian hemp (marijuana) plant, Cannabis sativa, ingested for its intoxi-
Appendix A—Glossary of Abbreviations and Terms . 11-709

eating qualities. Hashish has a higher concentration of

THC (tetrahydrocannabinol) than marijuana.

Head of household: See householder.

Health: Most broadly, a state of optimal physical, mental,

and social well-being, and not merely the absence of

disease and infirmity. See adolescent health.

Health outcome: A measure of the effectiveness of

preventive or treatment health services, typically in

terms of patient health status, but sometimes in terms

of patient satisfaction. Attributing changes in outcomes to health services requires distinguishing the

effects of the many other factors that influence

patients’ health and satisfaction.

Health promotion: A philosophy of health or a set of

activities that takes as its aim the promotion of health,

not just the prevention of disease. See also mental

health promotion.

Health protection: Strategies for health promotion and

disease prevention that are related to environmental or

regulatory measures that confer protection on large

population groups.

Heavy use of alcohol: Defined in the NIDA Household

Survey on Drug Abuse, as drinking five or more drinks

on the same occasion (i.e., within a few hours) on 5 or

more days in the past 30 days.

Heroin: A strongly physiologically addictive narcotic

made from, but more potent than, morphine. Heroin is

classified by the Federal Government as a controlled

substance in Schedule I, the riskiest of five categories.

That means it has high potential for abuse and no

legally accepted medical use.

Herpes genitalis (genital herpes): A sexually transmitted disease (STD) caused by herpes simplex virus

(HSV), usually HSV-2. Symptoms include blister-like

sores in the genital region, but diagnosis is by an HSV

viral cell culture or antigen detection technique.

Potential complications include aseptic meningitis,

recurrent infections, and possible maternal to infant

transmission. There is no known cure. Compare herpes

labialis and ocular herpes (nongenital herpes).

Herpes labialis: A nongenital herpes simplex virus

(HSV) infection, usually caused by HSV-1. Herpes

labialis is primarily spread by oral secretions, usually

occurring as a concomitant of fever, but sometimes

also developing in the absence of fever or prior illness.

Symptoms include blister-like sores in the vermilion

border of the lips. Also called cold sore and fever

blister. Compare herpes genitalis, ocular herpes.

Herpes simplex virus (HSV) infection: A group of acute

infections caused by herpes simplex virus (HSV) type

1 (HSV-1) or type 2 (HSV-2), characterized by the

development of one or more small fluid-filled vesicles

with a raised erythematous base on the skin or mucous

membrane, and occurring as a primary infection or

recurring because of reaction of a latent infection. Type

1 infections usually involve congenital regions of the

body (see herpes labialis, ocular herpes), whereas in

type 2 infections, the lesions are primarily seen on the

genital and surrounding areas (see herpes genitalis).

High school: A secondary school offering the final years

of high school work necessary for graduation, usually

including grades 10, 11, and 12 (in a 6-3-3 plan) or

grades 9, 10, 11, and 12 (in a 6-2-4 plan).

High School and Beyond Survey: A national longitudinal survey of 1980 high school sophomores and

seniors conducted by the National Center for Education Statistics in the U.S. Department of Education.

The base year survey was a probability sample of 1,015

high schools with a target number of 35 sophomores

and 36 seniors in each of the schools. A total of 58,270

students participated in the base-year survey. Students

competed questionnaires and took a battery of cognitive tests. Followup activities took place in 1982, in

1984 (with about 12,000 members of the senior cohort

and about 15,000 members of the sophomore cohort),

and in the spring or 1986 (with samples about the same

size as those used in 1984). Several small groups in the

population were oversampled to allow for special

study of certain types of schools and students.

Hispanic: A person who identifies himself or herself as

of Hispanic origin, or, less typically, individuals with

Hispanic surnames identified by others (e.g., health

care providers identifying patients in surveys) as being

of Hispanic origin. Hispanics can be individuals whose

families or ancestors have emigrated directly from

Mexico, Puerto Rico, Cuba, Central or South America,

Spain, or other Spanish culture or origin, regardless of

race. Compare black, white, Asian or Pacific Islander,

and American Indian or Alaska Native.

Hispanic Health and Nutrition Examination Survey

(HHANES): A one-time survey, similar to the National Health and Nutrition Examination Survey

(NHANES), conducted from 1982 to 1984 that collected data on a 12,000-person sample of the three

major subgroups of the Hispanic population-MexicanAmericans in the Southwest; Cubans in Miami,

Florida, and Puerto Ricans in New York City.

Home-based mental health services: Mental health

services and referral to related services (e.g., social

services) delivered in the home, usually to the entire

family, as well as the identified client, usually in

response to a crisis.

Hopelessness: The state of being without one’s own

home, either on one’s own, with one’s family, living on

the street or in a shelter or other temporary situation

(e.g., with relatives or friends). See runaway, street

kid, and thrownaway.

Hormones: Chemical substances, formed in one organ or

part of the body and carried in the blood to another

organ or part, that can alter the functional activity (and

sometimes the structure) of another organ or organs.
II-71O . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Hot line: A telephone service that provides information

and referral and immediate counseling, frequently in a

crisis situation. An example is the National Runaway

Switchboard funded under the Federal Runaway and

Homeless Youth Act, which has served as the Adolescent Suicide hot line.

Household: As defined by the U.S. Department of

Commerce, Bureau of the Census, definition, all the

persons who occupy a housing unit (i.e., a house, an

apartment or other group of rooms, or a single room

occupied or intended for occupancy as separate living

quarters, that is, when the occupants do not live and eat

with any other persons in the structure and there is

direct access from the outside or through a common

hall).

Householder: In U.S. Department of Commerce, Bureau

of the Census, counts the first adult household member

listed on any census questionnaire. Census instructions

call for listing first the person (or one of the persons)

in whose name the home is owned or rented. If a home

is owned jointly by a married couple, either the

husband or the wife may be listed first, thereby

becoming the reference person, or householder, to

whom the relationship of other household members is

to be recorded. The term householder is used in the

presentation of data that had previously been presented

with the designation “head of household. ” See family,

family household, subfamily, and unrelated persons.

Human immunodeficiency virus (HIV): The virus that

causes AIDS. Two distinct subtypes of HIV have been

identified: HIV-l was first isolated in 1983 and has a

worldwide distribution. HIV-2 was first isolated in

1986 and is found mainly in West Africa.

Hyperthermia: Fever, especially therapeutic fever.

Hypnotics: Drugs that act to induce sleep.

Hypothermia: A body temperature below the normal

value.

Iatrogenic effects: Adverse conditions that are induced

inadvertently by a health care provider or by the

treatment.

ICD-9-CM: See International Classification of Diseases,

ninth revision, Clinical Modification.

Illicit drugs: In this Report, unless otherwise noted, a

term used to refer to drugs which are not legally

available to adults (e.g., marijuana, cocaine, hallucinogens, PCP, heroin) or the illicit use of prescription

drugs to get high or for other mental effects. The NIDA

Household Survey on Drug Abuse defines illicit drugs

as ‘marijuana, cocaine, inhalants, hallucinogens, PCP,

heroin, or nonmedical use of psychotherapeutics. ”

The Monitoring the Future/High School Seniors

Survey defines illicit drugs as “marijuana, cocaine,

heroin, or any use which is not under a doctor’s orders

of other opiates, stimulants, sedatives, or tranquilizers .

Illness: Generally, any departure from good health. The

term illness is sometimes used in this Report to refer

to a disease rather than an injury.

Impairment: A physiological, anatomical, or mental loss

or ‘‘abnormality’ caused by accident, disease, or

congenital condition. An impairment may be the

underlying cause of a disability. Compare disability

and handicap.

Incidence: In health epidemiology, the measure of the

number of new cases of a particular disease or

condition occurring in a population during a given

period of time. Incidence rate is the number of new

cases of specified disease divided by the number of

people in a population over a specified period of time,

usually 1 year. Compare prevalence. In the criminal

justice field, the term incidence is used somewhat

differently. See incidence rate for an offense.

Incidence rate for an offense: In the criminal justice

field, the number of offenses of a given type that occur

in a given population during a specified time period per

some population base. Arrest rates, offending rates,

and victimization rates are analogous to incidence

rates. Compare prevalence rate for an offense.

Independent living programs: Programs to help adolescents leaving foster care learn skills for living on their

own (e.g., managing finances, problem-solving, and

employment training). The programs are authorized by

Title IV-E of the Social Security Act. Compare

transitional living programs.

Indians: American Indians in the continental United

States, and American Indians, Aleuts and Eskimos in

Alaska.

Inhalants: Breathable chemicals that produce psychoactive (mind-altering) vapors. They include solvents

(e.g., model airplane glue, nail polish remover, lighter

and cleaning fluids, gasoline), aerosols (e.g., paints,

hairsprays), some anesthetics (e.g., nitrous oxide), and

other chemicals (e.g., amyl nitrite and butyl nitrite).

Injury: Harm or hurt inflicted to the body by an external

force.

Inpatient care: Care that includes an overnight stay in a

medical facility.

Inpatient psychiatric facilities: Psychiatric inpatient

units in State and county mental hospitals, general

hospital psychiatric units, and private psychiatric

hospitals. See also mental/psychiatric hospital.

Inpatient substance abuse treatment: Treatment for

psychoactive substance abuse problems that involves

an overnight stay in a hospital facility specializing in

addiction, a psychiatric hospital, or a general hospital.

Hospitals generally offer medically managed services,

such as medical detoxification, as part of treatment. In

addition, they usually offer therapy groups, individual

therapy, and onsite educational facilities. Compare

residential substance abuse treatment, outpatient substance abuse treatment.
Appendix A—Glossary of Abbreviations and Terms .11-711

Institutional environments: See juvenile justice facilities.

Intensive probation programs (for adolescent juvenile

offenders): Programs that provide intensive supervision of juvenile offenders as an alternative to placement in institutional juvenile justice facilities.

International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM) Coding: A

two-part system of coding patient medical information

used in abstracting systems and for classifying patients

into diagnosis-related groups (DRGs) for Medicare.

The first part is a comprehensive list of diseases with

corresponding codes compatible with the World

Health Organization’s list of disease codes. The

second part contains procedure codes, independent of

the disease codes,

Intravenous drug use: The intake of drugs (e.g., heroin,

cocaine, amphetamines) directly into the veins, usually

by means of a needle injection.

Job Corps Program: A program administered by the

Employment and Training Administration in the U.S.

Department of Labor, providing employment and

training in primarily residential centers for socioeconomically disadvantaged young people ages 16 to 21.

Job Opportunities and Basic Skills (JOBS) Program:

A program, authorized under the Family Support Act

of 1988 (Public Law 100-485), that is designed to

provide families receiving Aid to Families With

Dependent Children (AFDC) the opportunity to take

part in education, job training, and work experience

programs that will help them avoid long-term dependence on public assistance programs. Young single

parents with children over age 3 and with child care

and out-of-school youth ages 16 and over are expected

to participate.

Junior high school: A separately organized and administered secondary school intermediate between the

elementary and senior high schools, usually including

grades 7,8, and 9 (in a 6-3-3 plan) or grades 7 and 8 (in

a 6-2-4 plan),

Juvenile: A young person who has not yet reached the age

at which he or she should be treated as an adult for

purposes of criminal law. In some States, this age is 17.

In law, the terms juvenile and minor are usually used

in different contexts (juvenile when referring to young

legal offenders and minor when referring to legal

majority or capacity).

Juvenile court system: Juvenile courts and juvenile

detention and correctional facilities. See juvenile

justice system.

Juvenile detention and correctional facilities: See

juvenile justice facilities.

Juvenile justice facilities: Custodial facilities for juveniles. These can be classified along several, often

overlapping, dimensions that include purpose, term of

stay, type of environment (institutional or open), and

sponsorship (public or private). Juvenile detention

facilities and shelters typically hold adolescents while

they are awaiting adjudication or after adjudication

while they are awaiting disposition and long-term

placement. Juvenile correctional facilities hold adolescents after adjudication for the purpose of commitment or for supervision and treatment. Short-term

juvenile facilities, which include juvenile detention

facilities and shelters, are typically used for adolescents who are awaiting adjudication, adolescents who

have been sentenced to short periods of confinement,

or adolescents who are awaiting transfer to long-term

placements. Long-term facilities, which range from

training schools to less restrictive facilities such as

ranches, forestry camps, or farms to even less restrictive halfway houses and group homes, primarily serve

adolescents who have been adjudicated. Juvenile

facilities with institutional environments impose

greater restraints on residents’ movements than facilities with open environments. Public juvenile facilities are under the direct administration and operational

control of a State or local government and staffed by

governmental employees. Private juvenile facilities

are either profitmaking or nonprofit and subject to

governmental licensing but are under the direct administration and operational control of private enterprise;

such facilities may receive substantial public funding

in addition to their support from private sources.

Juvenile justice system: The system that includes law

enforcement officers and others who refer delinquent

and maltreated minors to the courts, juvenile courts

which apply sanctions for delinquent offenses and

oversee the implementation of child protective services, juvenile detention and correctional facilities, and

agencies that provide protective services and care (e.g.,

foster care) for minors who are victims of abuse and

neglect. The latter agencies intersect with the child

welfare or social services system.

Juvenile offender: A juvenile who has violated the law.

Juvenile private facilities: See juvenile justice facilities.

Juvenile public facilities: See juvenile justice facilities.

Larceny-theft (except motor vehicle theft): See serious

property offenses.

Late adolescence: Occurs for those individuals, typically

ages 18 to the mid-20s, who because of educational

goals and other social factors, delay their entry into

adult roles. Compare early adolescence, middle adolescence, younger adolescents, and older adolescents.

Latino: Of Latin American origin.

Learning disabilities: According to the National Conference on Learning Disabilities, ‘‘learning disabilities”

is a generic term that refers to ‘a heterogeneous group

of disorders manifested by significant difficulties in

the acquisition and use of listening, speaking, reading,

writing, reasoning, or mathematical abilities, or of

social skills. ’ These disorders are intrinsic to the
II-712 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

individual and presumed to be due to central nervous

system dysfunction.

Least restrictive environment: The setting for the

treatment of mental health problems that allows for the

greatest possible interaction between the patient and

his or her normal surroundings (e.g., family, school,

friends, community), within therapeutic constraints. It

is a generally accepted principal of mental health

professionals that care should be provided in the least

restrictive environment possible.

Legal access (to health services): In this Report, used to

refer to aspects of access that have to do with consent

and confidentiality. Compare financial access.

Leukemia: A malignant proliferation of blood leukocytes

(white blood cells), ultimately resulting in death.

Leukemias (followed by brain and nervous system

cancers) are the most common cause of cancer deaths

among U.S. adolescents. The most common form of

leukemia experienced by adolescents is acute lymphoblastic leukemia.

Life expectancy: Expected duration of life.

Life skills training: The formal teaching of the requisite

skills for surviving, living with others, and succeeding

in a complex society. Life skills training interventions

emphasize the teaching of social competence, cognitive skills, and decisionmaking skills.

Limitation of activity: See activity limitation.

Lipoprotein: Any complex or compound of lipids (fats)

with proteins, important for lipid transport and as

components of membranes. See cholesterol.

Locus of control (perceived): An individual’s general

sense that he/she either controls or is controlled by

events.

Longitudinal studies: Studies that examine the development of individuals or families or groups over a period

of time,

Long-term juvenile facilities: See juvenile justice facilities.

LSD (lysergic acid diethylamide): A hallucinogen made

from lysergic acid, which is found naturally in ergot,

a fungus that grows on grains. It is usually taken orally

in the form of tablets, squares of absorbent paper or

gelatin, or liquid. LSD’s potency can be extraordinarily high (about 1,000 times that of mescaline). LSD

is classified by the Federal Government as a controlled

substance in Schedule I, the riskiest of five categories.

That means it has a high potential for abuse and no

legally accepted medical use.

Major activity of daily living: As defined by the

National Health Interview Survey conducted by DHHS,

major activity for children 5 to 17 usually refers to

school attendance; for individuals age 18 and over, it

usually refers to a job, housework, or school attendance. See also activity limitation.

Malignant neoplasm: An expanding lesion composed of

proliferating cells; a tumor.

Malocclusion: Any deviation from normal alignment of

the upper and lower teeth.

Maltreatment: Physical, emotional, or educational neglect, or physical, emotional or sexual abuse, most

often perpetrated by a family member.

Marijuana: The dried leaves, stems, and flowers of the

hemp plant, Cannabis sativa, smoked or used in foods,

It produces distorted perception and sometimes hallucinogenic effects. In the NLDA Household Survey on

Drug Abuse, marijuana includes marijuana and hashish.

Maternal and Child Health (MCH) Services Block

Grant Program: A Federal block grant program

authorized under Title V of the Social Security Act,

that supports the provision of health services to

mothers and children, especially those with low

income or living in areas with limited availability of

health services. Funds are provided to States, which in

turn may provide them to local health departments.

Created by the Omnibus Budget Reconciliation Act of

1981, the MCH block grant consolidated several

categorical grant programs into one block grant. The

MCH Block Grant Program is administered at the

Federal level by the Bureau of Maternal and Child

Health in the Health Resources and Services Administration in DHHS.

Maternity care: Labor and delivery care.

Medicaid: A federally aided, State-administered program, authorized under Title XIX of the Social

Security Act, that provides medical assistance for

low-income people meeting specific income and

family structure requirements. Medicaid covers an

estimated 4.5 million individuals ages 10 to 18 and is

the major health care financing mechanism for the

adolescents in low-income families.

Menarche: The beginning of menstruation.

Menses: The monthly flow of blood from a woman’s

genital tract; menstruation.

Mental disorders: See diagnosable mental disorders.

Mental health organization: See specialty mental health

organization.

Mental health problems: Problems that include diagnosable mental disorders and subjective distress.

Mental health promotion: Efforts based on the general

philosophy that it is desirable to maintain welladjusted individuals able to function in psychologically healthy ways. The most widely used mental

health promotion programs are designed to enhance

individuals’ life skills and social competence by

strengthening their adaptive abilities and creating

mental-health-promoting environments. Some mental

health programs for adolescents are designed to

strengthen their autonomy and ability to cope with

stressors, while promoting their self-esteem and appropriate peer relationships.
Appendix A—Glossary of Abbreviations and Terms . II-713

Mental health services: Care for the treatment of mental

health problems. Third-party payment for mental

health services is usually limited to services for

diagnosable mental disorders and is not available for

services to relieve subjective distress without an

accompanying diagnosable mental disorder. According to the Child and Adolescent Service System

Program (CASSP), mental health services for children

and adolescents should include prevention, early

identification and intervention, assessment, outpatient

mental health care, home-based mental health services, partial hospitalization/day treatment, emergency

services, therapeutic foster care, therapeutic group

care, therapeutic camp services, independent living

services, residential treatment services, crisis residential services, and psychiatric hospitalization.

Mental health system: See mental health services.

Mental illness: For purposes of this Report, disorders

relating to the mind independent of the body. The

distinction is somewhat arbitrary, however, because

some mental disorders have a physiological basis.

Mental/psychiatric hospital: See psychiatric hospital.

Mentoring: The practice of acting over time as a guide,

tutor or coach, and sometimes as an advocate for

another, typically not biologically related, person.

Meta-analysis: A statistical or quantitative analysis of a

large collection of results from individual studies for

the purpose of integrating the findings.

Metabolism: The totality of the chemical processes

occurring in a living organism, especially those

associated with the exchange of matter and energy

between a cell and its environment.

Metropolitan Statistical Area (MSA): As defined by the

U.S. Office of Management and Budget, a county or

group of counties that includes either a city of at least

50,000 residents, or an urbanized area with at least

50,000 people that is itself part of a county/counties

with at least 100,000 total residents. Compare nonMetropolitan Statistical Areas.

Middle adolescence: Typically, a time of increasing

independence. Generally takes place during the period

from ages 15 through 17. For those adolescents who do

not go on to (and remain in) college, age 17 or

completion of high school marks the end of adolescence, in social terms. Compare early adolescence,

late adolescence, younger adolescents, and older

adolescents.

Minimum competency testing (MCT): Measuring the

acquisition of competence or skills to or beyond a

certain specified standard.

Minor: A person who is under the age of legal majority,

either age 18 or 19, depending on the State. Compare

juvenile.

Minor offenses: See Part II offenses.

Minorities: See racial and ethnic minorities.

Monitoring the Future/High School Seniors Survey: A

survey of high school seniors, with followup data

collected when the individuals are young adults (e.g.,

in college), conducted by researchers at the Institute for

Social Research at the University of Michigan with

support from the National Institute on Drug Abuse

within DHHS.

Mood disorders: Typically, depressive or anxiety disorders. Diagnoses of depressive disorder are made

when individuals suffer from prolonged and severely

disabling depression, as distinguished from the temporary and normal moods of unhappiness. Feelings of

worthlessness, hopelessness, or irritability and

thoughts of death or suicide are common. There is

some evidence that antisocial behavior, aggressiveness, or substance abuse may hide or mask clinical

depression but this notion remains controversial.

Diagnoses of anxiety disorders are made when

individuals are excessively apprehensive, tense, or

uneasy in anticipation of internal or external danger.

This anxiety is manifested by physiological changes

such as sweating, tremor, and rapid pulse.

Mortality rate: A measure derived by dividing the

number of deaths in a population in a given period by

the resident population at the middle of that period. It

is expressed as the number of deaths per 1,000

population. The rate may be restricted to deaths in

specific age, race, sex, or geographic groups (e.g., 15

deaths per 1,000 persons ages 15 to 19), or it may be

related to the entire population.

Motor vehicle theft: See serious property offenses.

Multiservice mental health organization: An administratively distinct organization that provides any combination of two or more services (inpatient, residential

treatment, residential supportive, outpatient or partial

care) in settings that are under the organization’s direct

administrative control.

Murder and nonnegligent manslaughter: See serious

violent offenses.

Muscular dystrophy: Any of a group of genetically

determined, primary degenerative myopathies of unknown etiology, characterized by various patterns of

selective atrophy and weakness of the voluntary

muscles, leading as a rule to progressive disability.

Myelodysplasia: Any developmental defect of the spinal

cord.

Narcotics: Drugs that produce narcosis (a nonspecific

and reversible depression of function of the central

nervous system marked by stupor or insensibility

produced by drugs). The term is applied especially to

natural or synthetic drugs that have morphine-like

actions.

National Adolescent Student Health Survey (N ASH S):

A survey conducted in 1987 by a consortium of groups

funded partially by the Federal Government that
11-714. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

questioned more than 11,000 8th and 10th graders

nationwide about their health.

National Ambulatory Medical Care Survey (NAMCS):

A continuing national probability sample of ambulatory medical encounters, sponsored by the National

Center for Health Statistics in DHHS. It collects data

on physician-patient encounters in the offices of a

sample of non-federally employed physicians classified as “office-based, patient care physicians. ” Sample physicians are asked to complete a patient record

information form for a systematic random sampling of

office visits occurring during a randomly assigned

l-week period.

National Assessment of Educational Progress: A

cross-sectional study designed and initially implemented in 1969 that has gathered information about

selected levels of achievement across the country. The

National Assessment of Educational Progress has

surveyed the educational attainments of 9-, 13-, and

17-year-olds and young adults (ages 25 to 35) in 10

learning areas to measure possible changes in educational achievement.

National Drug and Alcoholism Treatment Unit Survey

(NDATUS): A national survey that is designed to

measure the location, scope, and characteristics of drug

abuse and alcoholism treatment and prevention facilities, services, and activities throughout the United

States. The survey provides a cross-sectional look at

treatment patients on a given day annually (e.g., Oct.

30, 1987). It covers both private and publicly funded

programs. The 1987 NDATUS was a joint effort of the

National Institute on Drug Abuse and the National

Institute on Alcohol Abuse and Alcoholism in DHHS,

with cooperation from the Veterans Administration

and the Federal Prison System.

National Evaluation of School Nutrition Programs: A

survey, conducted occasionally by the U.S. Department of Agriculture, that collects information on U.S.

adolescents use of school nutrition programs such as

the National School Lunch Program.

National Health Examination Survey (NHES): A

continuing nationwide sample survey in which data for

determining health status were collected through direct

standardized physical examinations, clinical and laboratory tests, and measurements. The survey was

conducted by the U.S. Department of Health, Education, and Welfare in 1963-65 and 1966-70.

National Health Interview Survey (NHIS): A nationwide household interview survey in which personal

interviews with approximately 40,000 households are

used to obtain information health, illness, and disability status of the civilian noninstitutionalized population. Each year, the survey consists of a basic set of

questions on health, socioeconomic, and demographic

items, as well as one or more special questionnaires to

obtain more detailed information on issues of current

concern (e.g., on child adoption and cancer risk factors

in 1986, child health in 1988). For individuals under

age 17, information is collected from a proxy respondent, typically a parent or guardian. NHIS is conducted

by the National Center for Health Statistics in DHHS.

National Health and Nutrition Examination Survey

(NHANES): A survey in which data for assessing the

health status of the U.S. population are collected

through direct standardized physical examinations,

clinical and laboratory testing, and related procedures,

These examinations are the most authoritative source

for standardized clinical, physical, and physiological

data on the U.S. population. NHANES I was conducted from 1971 through 1974, and a major purpose

was to measure indicators of the nutritional status of

the civilian noninstitutionalized U.S. population ages

1 through 74. NHANES II was conducted from 1976

through 1980 and oversampled children ages 6 months

to 5 years, persons ages 60 to 74, and persons living in

poverty. NHANES III, being conducted from 1988

through 1994, will include 45,000 persons representative of the U.S. population and has been designed to

provide reliable estimates on a number of subgroups of

the population, including adolescents, NHANES is

conducted by the National Center for Health Statistics

in DHHS. See also Hispanic Health and Nutrition

Examination Survey.

National Hospital Discharge Survey (NHDS): A nationwide survey of a sample of short-stay hospitals in

the United States. The basic unit of estimation for

NHDS is the sample patient abstract. NHDS is

conducted by the National Center for Health Statistics

in DHHS.

National Household Surveys on Drug Abuse: See

NIDA Household Survey on Drug Abuse.

National Longitudinal Survey of Labor Market Experience-Youth Cohort (NLSY): A longitudinal survey sponsored by the U.S. Department of Labor that

began in 1979 and has been surveying a representative

sample of over 12,000 Americans who were ages 14 to

21 as of January 1, 1979 (with an oversampling of

blacks, Hispanics, and economically disadvantaged

whites).

National Medical Care Utilization and Expenditure

Survey (NMCUES): A series of several related

surveys on health, access to and use of medical (and

dental) services, associated charges and sources of

payment, and health insurance coverage during 1980.

The household portion of NMCUES consisted of: 1) a

national household survey of a sample of the civilian

noninstitutionalized population, and 2) a household

survey of the Medicaid-eligible populations of the

States of New York California, Texas, and Michigan.

These two surveys each consisted of five interviews

over a period of about 15 months to obtain information

on medical care utilization, expenditures, and other
Appendix A—Glossary of Abbreviations and Terms ● II-715

health-related information. A third survey, an administrative records survey, was designed to verify the

eligibility status of the household survey respondents

for the Medicare and Medicaid programs. The survey

was conducted by the National Center for Health

Statistics within DHHS.

National Nutrition Monitoring System: A system

operated by the U.S. Department of Agriculture and

DHHS that systematically monitors food consumption, dietary status, and the nutritional health of the

U.S. population. It includes the Continuing Survey of

Food Intakes by Individuals (CSFII) and the Nationwide Food Consumption Survey (NFCS).

National PRIDE Survey: A survey of adolescents’ use

of psychoactive substances conducted in the 1988-89

school year, based on a questionnaire devised by the

parents’ group National Parents’ Resource Institute for

Drug Education (PRIDE). The questionnaire was not

distributed to a random sample of schools, and

participating schools had the option of not reporting

results back to the National PRIDE office.

National School Lunch and Breakfast Programs:

Programs administered at the Federal level by the U.S.

Department of Agriculture that provide meals for

low-income school children free or at a reduced price,

depending on family income. Forty-three percent of

individuals in the National School Lunch Program and

24 percent in the National School Breakfast Program

are adolescents ages 13 to 18.

National Survey of Family Growth (NSFG): A household interview survey that has collected data from U.S.

women of childbearing age (ages 15 through 44) in

four cycles since 1974. NSFG collects data on the

demographic and social factors associated with childbearing, adoption, and maternal and child health—

including sexual activity, contraception and sterilization, marriage, pregnancy loss, and use of medical care

for family planning and prenatal care. Cycles I and II,

conducted in 1973 and 1976, interviewed about 10,000

ever-married women ages 15 to 44. Cycle III and IV,

conducted in 1982-83 and 1988, included all women

regardless of marital status. Cycle III oversampled

females ages 15 to 19 to provide more reliable data on

these groups. The samples for both included roughly

8,000 women ages 15 through 44 in the civilian

noninstitutionalized population. NSFG is conducted

by the National Center for Health Statistics in DHHS.

National vital statistics system: A system maintained by

the National Center for Health Statistics in DHHS to

collect and publish data on births, deaths, marriages,

and divorces in the United States. Information on

births and deaths is collected from the registration

offices of all States and the District of Columbia,

Puerto Rico, the U.S. Virgin Islands, and Guam.

Nationwide Food Consumption Survey (NFCS): A

survey, conducted by the Human Nutrition Service of

the U.S. Department of Agriculture every 10 years, that

is designed to collect information on foods used by

households and eaten by individuals. The most recent

survey was conducted in 1987-88.

Natural causes of death: Deaths caused by illness,

disease, or chronic conditions as opposed to death

caused by external causes such as accidental injuries,

homicide, and suicide.

Neglect: See physical neglect, emotional neglect, educational neglect.

Nicotine: A psychoactive substance that is contained in

tobacco. Nicotine is a behavioral stimulant.

NIDA Household Survey on Drug Abuse: A household

survey, sponsored since 1974 by the National Institute

on Drug Abuse within DHHS, that collect data on the

in use of marijuana and other illicit drugs, tobacco,

and alcohol among the U.S. population 12 years of age

and over living in households in the coterminous

United States. Youths (12 to 17 years of age) and

young adults (ages 18 to 25 years of age) are

oversampled, as are blacks and Hispanics.

Nongenital herpes: See herpes labialis, ocular herpes.

Nonmedical use of any psychotherapeutic: In the NIDA

Household Survey on Drug Abuse, this refers to the

nonmedical use of four classes of prescription drugs:

1) sedatives (e.g., downers, barbiturates, and SeconalR);

1) tranquilizers (e.g., antianxiety drugs like LibriumR,

VidiumR

, AtivanR, and MeprobamateR); 3) stimulants

(e.g., uppers, amphetamines, speed, and Preludin®);

and 4) analgesics (e.g., DarvonR

, DemerolR, PercodanR

, and TylenolR with codeine). NIDA defines

psychotherapeutics as prescription medications which

also can be used illicitly to get high or for other mental

effects. Compare nonmedical use of drugs. See psychotherapeutic drugs.

Nonmedical use of drugs: In the Drug Abuse Warning

Network (DAWN) of the National Institute on Drug

Abuse (NIDA), nonmedical use of drugs is defined as:

1) the use of prescription drugs in a manner inconsistent with accepted medical practice; 2) the use of

over-the-counter drugs contrary to approved labeling;

or 3) the use of any substance (heroin, marijuana,

peyote, blue, aerosols, etc.) for psychic effect, dependence, or suicide). Compare nonmedical use of any

psychotherapeutic.

Non-Metropolitan Statistical Areas: Those areas of the

United States that are not part of a Metropolitan

Statistical Area (MSA), according to the U.S. Bureau

of the Census. Such areas include small communities,

rural nonfarm areas, and rural farm areas.

obesity: Can be defined in different ways: 1) body mass

index (BMI)-weight in kilograms divided by height

in meters squared [m2

])--greater than or equal to the

95th percentile of a similar population group (usually

by age); or 2) 20 percent or more over “normal”
II-716 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

weight. Being obese is a more serious problem than

being overweight.

Ocular herpes: A congenital herpes simplex virus (HSV)

infection, evidenced by blisters in and around the eyes.

Compare herpes genitalis, herpes labialis.

Offending rate: The number of offenses that occur in a

given population during a specified time period per

some population base (e.g., 5 offenses per 100,000

population). The offending rate is usually based on

offenses that are self-reported by offenders. Like the

arrest rate, the offending rate is analogous to an

incidence rate.

Offenses (serious and minor): Infractions of the law

irrespective of the age of the offender. For purposes of

this Report, serious offenses are Federal Bureau of

Investigation Part I offenses (see below) even though

individual Part I offenses may not be considered

serious by other definitions. Minor offenses are

Federal Bureau of Investigation Part II offenses (see

below) even though individual Part II offenses may not

be considered minor by other definitions. See also

minor offenses, Part I offenses, Part II offenses,

serious property offenses, serious violent offenses.

office visit: As defined by DHHS’s National Center for

Health Statistics for the purpose of the National

Ambulatory Medical Care Survey, any direct personal

exchange between an ambulatory patient and a physician or members of his or her staff for the purposes of

seeking care and rendering health services.

Older adolescents: As defined in most of DHHS’s

National Center for Health Statistics data analyses,

adolescents ages 15 to 19. Compare younger adolescents.

opiates: Any psychoactive substances containing or

derived from opium (e.g., heroin, morphine); also, any

drugs that induce sleep.

opioids: Any synthetic narcotics that have opiate-like

activities but are not derived from opium.

Opium: A crude resinous exudate from the opium poppy,

Papaver somnferum.

Oppositional defiant disorder: A mental disorder defined in DSM-III-R as a behavior disorder that is

diagnosed on the basis of a pattern of hostile and

defiant behavior. Adolescents with oppositional defiant disorder are often argumentative, resentful, and

easily annoyed by others, but not physically aggressive

or prone to violate social norms.

Oral contraceptives: Birth control pills. One advantage

of these for adolescents is that they exert a protective

effect against pelvic inflammatory disease (PID).

Orthodontics: The area of dentistry concerned with the

bite and how teeth mesh together.

Orthodontic Treatment Priority Index (TPI): An index

of the need for orthodontic treatment based on a score

ranging from O (normal occlusion, or bite) to 10 (very

severe malocclusion, with treatment mandatory). A

score of 4 to 6 is considered a definite malocclusion,

but treatment is elective.

Osteoporosis: Reduction in bone density, often the result

of reduction in estrogen secretion in the ovaries during

amenorrhea or menopause, Symptoms include vertebral fractures and “dowager’s hump. ”

Outcome evaluation: Measures an intervention’s result

(e.g., increased knowledge, changed behavior). Compare process evaluation.

Outpatient care: Generally, medical care that is provided

in a hospital and does not include an overnight stay.

Sometimes (as in mental health services) used to refer

to ambulatory care.

Outpatient mental health care: Mental health services

provided to ambulatory patients or clients who do not

need either 24-hour supervision or partial hospitalization. As a general matter, outpatient services include

psychotherapy and psychotropic prescriptions in outpatient clinics and private practice, crisis services such

as home-based treatment, and services in emergency

rooms.

Outpatient mental health services provided in organized mental health settings: See outpatient mental

health care and specialty mental health organizations.

outpatient substance abuse treatment: Treatment for

substance abuse problems provided to patients or

clients who are not deemed to need 24-hour supervision, or for whom such care is not available. The most

intensive outpatient treatment programs are day treatment programs, in which the participant arrives early

in the day and returns home in the evening. Outpatient

drug-free programs are oriented around counseling

rather than medical intervention. If a person needs

medically managed detoxification, that is handled in a

different setting.

Over-the-counter (OTC) drugs: Drugs that can be

legally purchased at a drug store without a prescription.

Overweight: Can be defined as body mass index (BMI)

(weight in kilograms divided by height in meters

squared [m2

]) greater than or equal to the 85th

percentile of a similar group. Compare obesity.

Own children: As defined by the U.S. Department of

Commerce, Bureau of the Census, “own” children in

a family are sons and daughters, including stepchildren

and adopted children, of the householder.

Paraphimosis: Retraction of foreskin affected by phimosis, causing a painful swelling of the glans that, if

severe, may cause dry gangrene unless corrected.

Parental consent requirement (applicable to health

care of minors): As used in this Report, a legal

requirement, grounded in common law, that a parent or

other guardian of a minor child must give prior consent

to the delivery of medical or surgical care to that child.

Over the years, the number of exceptions to the
Appendix A—Glossary of Abbreviations and Terms . //-717

parental consent requirement applicable to the health

care of minors has grown significantly.

Part I offenses (index offenses): Under the Federal

Bureau of Investigation’s reporting system, these are

violent offenses against a person (i.e., murder and

nonnegligent manslaughter, forcible rape, robbery,

and aggravated assault) and specified property offenses (i.e., burglary, larceny-theft, motor vehicle

theft, and arson). For purposes of this Report, Part I

offenses are considered serious offenses. See also

serious violent offenses and serious property offenses.

Part 11 offenses: Under the Federal Bureau of Investigation’s reporting system, these are any offenses not

classified as Part I offenses. Part II offenses include

two categories of offenses: 1) acts other than Part I

offenses that are considered crimes if committed by

adults (e.g., involvement with stolen property, driving

under the influence, assault without weapons, engaging in prostitution); and 2) status offenses (acts such as

running away from home that are considered offenses

only because they are committed by minors). For

purposes of this Report, Part 11 offenses are considered

serious offenses.

Partial hospitalization/day treatment: A planned program of mental health treatment services generally

provided in sessions of 3 to 6 hours to groups of

patients or clients who do not require 24-hour supervision. This level of care offers more intensive treatment

than the usual outpatient care (once a week psychotherapy) and provides a range of treatment modalities

(individual and group therapy, education, and rehabilitation). Partial care/day treatment can be offered in

general hospitals with separate psychiatric services,

psychiatric hospitals, freestanding psychiatric outpatient clinics, or rnultiservice mental health organizations.

PCP (phencyclidine): A drug developed in the 1950s as

an anesthetic that was taken off the market in 1967

when it was realized that it caused hallucinations in

some people. PCP is not easily categorized because, in

addition to being able to cause hallucinations, PCP can

relieve pain or act as a stimulant. It can also produce

violent or bizarre behavior. Some surveys (e.g., the

NIDA Household Survey on Drug Abuse and in the

Monitoring the Future/High School Seniors Survey)

consider PCP a hallucinogen. In the American Psychiatric Association’s Diagnostic and Statistical Manual

of Mental Disorders (DSM-II1-R), PCP is considered

separately from hallucinogens. PCP is now used

legally only in veterinary medicine as an immobilizing

agent.

Peer tutoring: Using older or same age students to work

individually with students to teach a particular content

area.

Pelvic inflammatory disease (PID): A sexually transmitted disease (STD) among females, the symptoms of

which include abdominal pain, fever, chills, vomiting,

foul-smelling discharge, and postcoital bleeding. Potential complications include sterility, chronic pain,

chronic infections, and even death. Methods of prevention include limiting the number of sexual partners,

using of condoms, and avoiding the use of intrauterine

contraceptive devices. Treatment is with antibiotics.

Periodontal disease: Any disease of the tissue surrounding the teeth. The two most prevalent periodontal

diseases are gingivitis (inflammation confined to the

gums) and periodontitis (inflammation of both the

gum and the other supporting structures of the teeth).

Phenylketonuria: A genetic disorder of amino acid

metabolism characterized by the inability to metabolize the amino acid phenylalanine. If diagnosis and

dietary treatment is not begun within 30 days of birth,

severe mental retardation will result.

Phimosis: Constriction of the orifice so that the prepuce

(foreskin) cannot be retracted back over the glans of

the penis. Compare paraphimosis.

Physical abuse: Physical violence, including kicking,

biting, hitting with one’s fist, beating, burning, or

scalding, and using a weapon.

Physical illness: For purposes of this Report, disorders of

the body independent of the mind. The distinction is

somewhat arbitrary, however, because some mental

disorders have a physiological basis.

Physical neglect: As defined by DHHS’s National Center

on Child Abuse and Neglect, physical neglect can take

seven forms: refusal to provide health care for physical

problems, as recommended by a competent health care

professional; delay in providing health care for a

serious physical problem; desertion of a child without

arranging for reasonable care and supervision (abandonment); other blatant refusals of custody, such as

permanent or indefinite expulsion of a child from the

home; other custody issues, such as chronically and

repeatedly leaving a child with others for days or

weeks at a time; inadequate supervision; and other

physical neglect, such as conspicuous inattention to

avoidable hazards in the home.

Place: As defined by the U.S. Department of Commerce,

Bureau of the Census, a place is either: 1) an

incorporated place such as a city, a borough, a town, or

village; or 2) a closely settled population center that is

outside an urbanized area, does not have corporate

limits, and (unless it is in Alaska or Hawaii) has a

population of at least 1,000.

Plaque: A soft deposit of bacteria and other materials on

the surface of a tooth.

Preclinical: The period preceding clinical manifestations.

Preconscious: Pertaining to mental events, processes,

and contents that are for the most part capable of

reaching or being brought into conscious awareness of

the act of focusing attention.
11-718. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

Pregnancy Discrimination Act of 1978 (Public Law

95-555): An act that amended the Civil Rights Act of

1964 and requires that employment-based health plans

cover pregnancy, childbirth, and related medical conditions as they cover other medical care.

Pregnancy rate: The number of pregnancies per 1,000

population.

Prenatal care: Medical services related to fetal, infant,

and maternal health, delivered from time of conception

to labor.

Prevalence: In health epidemiology, a measure of the

number of individuals in a given population who have

a specific disease or other condition at a designated

time (or during a particular period).

—Point prevalence: the proportion of individuals

in a population who have a given condition, which is

measured at a particular point in time.

—Annual prevalence: the proportion of individuals in a population who have a given condition during

a single year.

—Lifetime prevalence: a measure of individuals

considered at a point in time who have ever had an

illness or condition which is under study.

In the criminal justice field, the term prevalence is

used somewhat differently. See prevalence rate for an

offense.

Prevalence rate for an offense: In the criminal justice

field, the ratio of the number of persons involved in a

given activity at a particular time period to the number

of persons in that population. It is often expressed as

the percentage of persons in a population who engage

in one or more offenses of a given type during a given

time period.

Prevention: The averting of a disease or condition,

traditionally characterized as primary, secondary, and

tertiary prevention. Primary prevention is aimed at

reducing the incidence of a disease or health problem.

Secondary prevention strategies detect and/or treat

the condition in its early stages of development, with

the hope of improving outcome. Tertiary prevention

attempts to arrest further deterioration in individuals

who already suffer from a condition. Alternative

terminology includes universal (prevention) interventions (analogous to primary prevention and selected

(prevention) interventions (analogous to secondary

prevention).

Preventive health services: Services intended to prevent

the occurrence of a problem (e.g., disease or condition). Preventive services typically recommended for

adolescents include routine physical examinations,

immunizations, and certain diagnostic tests (e.g.,

hematocrit, urinalysis), and preventive procedures

including pap smears and screening for sexually

transmitted diseases among the sexually active. Compare treatment services.

Primary care: Optimally, primary care includes the

following elements: first contact ‘care, comprehensive

care, coordinated or integrated care, and care that is

longitudinal over time rather than episodic. First

contact care is the extent to which a patient contacts the

source of care whenever he or she perceived a new

need for care. Coordination of care entails a health care

provider’s ability to provide for continuity of information from visits to other providers (e.g., specialists and

emergency facilities) as well as from earlier visits to

him or herself. Longitudinal.ity of care is the extent to

which a provider serves as a source of care over time

regardless of the presence or absence of a particular

type of problem.

Primary prevention: See prevention.

Private psychiatric hospital: A hospital operated by a

sole proprietor, partnership, limited partnership, corporation, or not-for-profit organization, primarily for

the inpatient care of persons with mental disorders.

Problem behaviors (in adolescence): Those behaviors

that have been deemed socially unacceptable or that

lead to poor health outcomes (e.g., unprotected sexual

intercourse, delinquent acts, psychoactive substance

abuse).

Process evaluation: The evaluation of aspects of a

program’s implementation and operation. Compare

outcome evaluation.

Prospective study: A study that collects data from the

time the research is initiated. Potentially has the

advantage of the researcher’s being able to assign

individuals or groups to experimental and control

conditions, and to arrange for collection of a broader

range of data. Compare retrospective study.

Prostatitis: Inflammation of the prostate, a gland in the

male that surrounds the neck of the bladder and the

urethra. The prostate contributes to the seminal fluid a

secretion that accounts for the liquefaction of coagulated semen.

Protective services: An aspect of social services designed to prevent neglect, abuse, and exploitation of

children by reaching out with social services to

stabilize family life (e.g., by strengthening parental

capacity and ability to provide good child care). The

provision of protective services follows a complaint or

referral, frequently from a source outside the family,

although it maybe initiated by an adolescent himself/

herself.

Psychiatric hospital: A medical facility that offers

short-term intensive inpatient treatment and prolonged

inpatient treatment to persons suffering from a variety

of mental or psychiatric disorders, including alcohol

and other drug-related disorders, Such facilities can be

public or private. Compare residential treatment

centers.

Psychiatric hospitalization: Hospitalization in a specialty mental health facility (e.g., psychiatric hospital)
Appendix A—Glossary of Abbreviations and Terms ● II-719

or in a general hospital for purposes of mental health

evaluation or treatment.

Psychiatrist: A physician who specializes in the diagnosis, treatment, and prevention of mental disorders.

Psychoactive: Mind-altering.

Psychoactive substance: For the purpose of this Report,

the term psychoactive substance, unless otherwise

noted, means alcohol, tobacco (nicotine), or an illicit

drug. The American Psychiatric Association defines

the term as any substance that falls into one of the

following classes associated with both psychoactive

substance abuse and dependence (alcohol; sedatives,

hypnotics, or anxiolytics; cannabis; cocaine; amphetamine or similarly acting sympathomimetics; hallucinogens; inhalants; opioids/opiates; and phencyclidine

(PCP) or similarly acting arylcycloheylamines) or is a

form of the substance nicotine, which is associated

with dependence but not abuse.

Psychoactive substance abuse: For the purpose of this

Report, the term psychoactive substance abuse, unless

otherwise noted, means drug use that results in injury,

incapacity, dysfunctionality, destruction or damage to

self and others. It is important to note, however, that

what constitutes psychoactive substance abuse among

adolescents—i.e., any use at all or ‘‘problem’ use-is

a matter of controversy. The Office for Substance

Abuse Prevention within DHHS is of the view that any

use of psychoactive substances by adolescents should

be considered abuse. In contrast, the American Psychiatric Association’s Diagnostic and Statistical Manual

of Mental Disorders (DSM-III-R) distinguishes between psychoactive substance use, abuse, and dependence (without drawing distinctions by age group).

According to DSM-III-R, psychoactive substance

abuse is a mental disorder defined as a residual

category for noting maladaptive patterns of use of a

psychoactive substance use that have never met the

criteria for psychoactive substance dependence. The

maladaptive pattern is indicated by at least one of the

following: 1) continued use despite knowledge of

having a persistent or recurrent social, occupational,

psychological, or physical problem exacerbated by use

of the substance; or 2) recurrent use in situations in

which use is physically hazardous. The diagnosis is

made only if some symptoms of the disturbance have

persisted for at least 1 month or have occurred

repeatedly over a longer period of time.

Psychoactive substance dependence: As noted above,

the American Psychiatric Association’s Diagnostic

and Statistical Manual of Mental Disorders (DSM-IIIR) distinguishes between psychoactive substance use,

abuse, and dependence. According to DSM-III-R,

psychoactive substance abuse is mental disorder characterized by compulsive behavior and the active

pursuit of a lifestyle that centers around searching for,

obtaining, and using a psychoactive substance. The

diagnosis is made only if at least three of nine

diagnostic criteria (e.g., substance often taken in

greater amounts or over a longer period than the person

intended, great deal of time spent in activities to get the

substance; frequent intoxication or withdrawal symptoms when expected to perform major role functions)

are met and symptoms of the disturbance have

persisted for at least 1 month or have occurred

repeatedly over a longer period of time.

Psychotherapeutic drugs: According to the Monitoring

the Future/High School Seniors Survey, there are four

major classes of these drugs: 1) amphetamines, 2)

barbiturates, 3) minor tranquilizers, and 4) opiates

other than heroin.

Psychotherapy: Broadly defined, all procedures that use

psychological methods to influence behavior in a

therapeutic direction. The term psychotherapy is

usually used to refer to a defined type of treatment that

involves interaction by a patient/client and a therapist,

either in a dyad or group. Typical therapeutic maneuvers in psychotherapy include suggestion (the induction of a mental state in the patient that is somewhat

contrary to reality or the patients experience or logical

expectations), abreaction (the bringing to consciousness and open expression of important feelings and

ideas held in repression), manipulation (attempts to

neutralize or to mobilize certain preexisting emotional

systems [e.g., dependency needs] in the patient),

clarification (attempts to bring into focus some of

those things that a patient knows only vaguely, either

consciously or preconsciously), and interpretation

(addition of new information to the data already

available to the patient, generally in the form of a

hypothesis that explains material that is not otherwise

understandable to the patient).

Psychotropic: Exerting an effect upon the mind; capable

of modifying mental activity; usually applied to drugs

that affect the mental state.

Puberty: The period of becoming first capable of

reproducing sexually, marked by maturing of the

genital organs, development of secondary sex characteristics (e.g., breasts, pubic hair), and in humans and

higher primates, the first occurrence of menstruation in

the female.

Puerperium: The period after childbirth.

Pulpal: In the context of dentistry, of or relating to dental

pulp, the soft sensitive tissue that fills the chamber of

a tooth.

Quasi-experimental design: A research design involving an experiment that has a treatment, an outcome

measure or measures, and experimental units, but does

not use random assignment to create the comparisons

from which treatment-caused change is inferred.

Instead, the comparisons depend on nonequivalent

groups that differ from each other in many ways other

than the presence of a treatment whose effects are
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being tested. The task confronting those who try to

interpret the results from quasi-experiments is basically one of separating the effects of a treatment from

those due to the initial noncomparability between the

average units in each treatment group.

Race: Races can be distinguished by usually inherited

physical and physiological characteristics without

regard to language or culture (caucasoids, negroid,

mongoloid). Beginning in 1976, the Federal Government’s data systems classified individuals into the

following racial groups: white (caucasoid), black

(negroid), Asian or Pacific Islander, or American

Indian and Alaska Native (mongoloid). See ethnicity,

Hispanic, Indian. Compare ethnicity.

Racial and ethnic minorities: In this Report, individuals

who are not “white, non-Hispanic. ” Includes black,

Asian, Hispanic, and American Indian and Alaska

Native individuals.

Rampant caries: A rapidly progressing form of dental

caries which by definition involves extensive breakdown of enamel and dentin, pulpal pathosis, and can

occur in patients with or without a significant caries

history.

Recidivism: Tendency to relapse into a previous condition or mode of behavior, especially delinquent or

criminal behavior.

Recommended dietary allowances (RDAs): The major

dietary standard used in the United States. Established

by the Food and Nutrition Board of the National

Academy of Sciences, RDAs are recommendations for

daily dietary intakes of specific nutrients, based on

nutritional studies and expert judgment. RDAs differ

by gender and age group, For protein, vitamins, and

minerals, RDAs meet the needs of 90 to 95 percent of

healthy individuals. For energy allowances, the daily

allowance meets the average needs of persons of

average height and weight in the population.

Remedial education: Instruction for a student lacking the

reading, writing, or math skills necessary to perform

work at the level required by the attended institution,

Reproductive health care: Can include a wide range of

services related to the male or female reproductive

systems, including gynecological treatment services

(i.e., examination and treatment of the female reproductive organs), and preventive services related to the

use of contraception (e.g., counseling, prescribing

contraceptive methods, dispensing contraceptives).

See also prenatal care.

Residential substance abuse treatment: Treatment for

psychoactive substance abuse in a residential (overnight 24-hour) setting. Residential programs may have

locked units, employ nursing and counseling staff very

much like those in psychiatric hospitals, and include

structured routines. They frequently operate on the

28-day model, with a high level of structure in the

initial stages and diminished structure as the client

earns privileges through program participation and

responsibility. There are various models of residential

treatment, including the halfway house, the therapeutic

community, wilderness challenge programs, and ‘boot

camp” or ‘‘shock incarceration. ”

Residential treatment centers (for emotionally disturbed children): Residential organizations, not licensed as psychiatric hospitals, whose primary purpose is the provision of individually planned programs

of mental health treatment services in conjunction with

residential care for children and youth primarily under

the age of 18, Programs must be directed by a

psychiatrist, social worker, or psychiatric nurse who

has a master’s and/or a doctorate degree. At least half

of the admissions must be for mental illnesses that can

be classified by DSM-II/ICDA-8 or DSM-III/ICD-9-

CM codes other than mental retardation or substance

abuse codes.

Restitution programs (for adolescent juvenile offenders): Programs for juvenile offenders that require

offenders to pay money to their victims to compensate

the victims for their loss or require offenders to

perform an equivalent amount of public service.

Sometimes, restitution programs also involve direct

mediation between offenders and their victims,

Restricted-activity day: As defined by the National

Health Interview Survey conducted by DHHS, any day

on which a person cuts down his or her usual activities

for more than one-half day because of an illness or an

injury. Restricted-activity days are unduplicated

counts of bed-disability days, work-loss days, and

school-loss days, and other days on which a person

cuts down on his or her usual activity.

Retrospective study: A study that uses data collected

before the research plan has been devised. For

example, a study begun in 1991 of hospital discharge

abstracts prior to 1991. Has the advantage of the

available data not having been influenced beforehand

by theories and hypotheses of the researchers, but does

not allow for random assignment of research subjects

and other beneficial aspects of experimental design.

Compare prospective study.

Risk factors: Factors that put a person at risk for health

or other problems.

Risk-taking behavior: An activity that may involve a

risk to one’s health. For adolescents especially, risktaking generally carries a negative connotation, but

some risk-taking is essential to the further development of competence, and thus some risk-taking can

have positive health and other benefits.

Robbery: See serious violent offenses.

Runaway: A young person who is away from home at

least overnight without the permission of a parent or

caretaker. Compare hopelessness, throwaway, and

street kid.
Appendix A—Glossary of Abbreviations and Terms . II-721

Rural: As strictly defined by the U.S. Department of

Commerce, Bureau of the Census, rural refers to places

of 2,500 or fewer residents.

Safer sex practices: Sexual practices designed to avoid

actual and potential transmission of HIV infection and

other sexually transmitted diseases (e.g., avoiding

exchange of body fluids, use of condoms).

Salpingitis: Inflammation of the uterine tube.

Schizophrenia: A severe and disabling mental disorder—

most likely a group of disorders (’‘schizophrenic

disorders")--characterized in DSM-III-R as involving

delusions, hallucinations, or certain disturbances in the

form of thought; deterioration from a previous level of

functioning in such areas as work, social relations, and

self-care; duration of at least 6 months; and occurring

before age 45, usually in late adolescence or early

adulthood.

Schizophrenogenic: Causing schizophrenia,

School climate: The social system and culture of a

school, including the organizational structure and the

expectations within it.

School-linked health center (SLHC): Any school health

center that provides a wide range of medical and

counseling services for students (and sometimes for

the family members of students and/or school dropouts) and is located either on or near school grounds

and is associated with the school. Some SLHCs also

provide a wider range of services (e.g., child care,

employment training, tutoring, social services, recreational opportunities).

School-loss day: As defined by the National Health

lnterview Survey conducted by DHHS, any day on

which a child did not attend school for at least of his

or her normal school day because of a specific illness

or injury. School-loss days are determined only for

children 5 to 17 years of age, beginning in 1982. See

also restricted-activity day.

Scoliosis: A curvature of the spine in which there is an

observable and measurable lateral deviation of part of

the spine from the normally straight vertical line.

Secondary prevention: See prevention.

Secondary school: A school comprising any span of

grades beginning with the next grade following an

elementary or middle-school (usually 7,8, or 9) and

ending with or below grade 12. Both junior and senior

high schools are included.

Sedatives: Psychoactive substances that allay activity

and excitement. In the NIDA Household Survey on

Drug Abuse, the term sedatives refers to “barbiturates

and other sedatives, ’ also called ‘‘downers, ’ that

people take “to help them go to sleep or to help them

calm down during the day or for some other reason.

Selected interventions: Interventions that focus specifically on high-risk groups.

Self-help groups for substance abusers: Support groups

organized by and for substance abusers to help their

members achieve and maintain abstinence from and/or

cope with the effects of alcohol or illicit drugs.

Examples are Alcoholics Anonymous and Narcotics

Anonymous.

Self-report data: An indication of a survey respondent’s

attitudes, knowledge, or behavior that is reported by

the respondent himself or herself.

Serious injuries: Injuries receiving a score of 3 or greater

on the Maximum Abbreviated Injury Scale, a commonly used trauma seventy scale.

Serious offenses: See Part I offenses.

Serious property offenses: For purposes of this Report,

these are Federal Bureau of Investigation Part I

property offenses-i. e., burglary, larceny-theft, motor

vehicle theft, and arson. Burglary is the unlawful entry

of a house or structure with the intention to commit a

felony or a theft; it includes attempted forcible entry

(e.g., by breaking a window). Larceny theft (excluding motor vehicle theft) is the unlawful taking,

carrying, leading, or riding away of property from the

possession or constructive possession of another or the

stealing of any property or article which is not taken by

force and violence or by fraud (e.g., thefts of bicycles,

shoplifting, pocket-picking); it includes attempted

larcenies. Motor vehicle theft is the theft or attempted

theft of a motor vehicle that is self-propelled and runs

on the ground (excluding airplanes, rail vehicles, farm

equipment). Arson is any willful or malicious burning

or attempt to burn with or without intent to defraud, a

dwelling house, public building, motor vehicle, aircraft, personal property of another, etc.

Serious violent offenses: For purposes of this Report,

these are Federal Bureau of Investigation Part I violent

offenses against a person-i. e., murder and nonnegligent manslaughter, forcible rape, robbery, and aggravated assault. Murder or nonnegligent manslaughter is the willful (nonnegligent) killing of one human

being by another. Forcible rape is gaining carnal

knowledge of (having sexual intercourse with) a

female forcibly and against her will; it includes rape by

force and attempts or assaults to rape. Robbery is

taking or attempting to take anything of value from the

care, custody, or control of a person or persons by force

or threat of force or violence and/or by putting the

victim in fear. Aggravated assault is the unlawful

intentional inflicting of serious bodily injury or death

by means of a deadly or dangerous weapon with or

without actual infliction of injury.

Seropositive: Showing a high level of antibody.

Seroprevalence: Prevalence based on blood tests.

Settlement houses: Institutions of the 19th century that

provided various community services, especially to

large city populations.

Sex education: Instruction about human sexual development, the process of reproduction, and related topics.

Currently, the content and process of many sex
II-722 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

education programs have been broadened, and such

programs are often known as family life education.

Sexual abuse: As defined by DHHS’s National Center on

Child Abuse and Neglect, sexual abuse can take three

forms: actual penile penetration; molestation with

genital contact; and other unspecified acts not known

to have involved actual genital contact (e.g., fondling

of breasts or buttocks, exposure), or inadequate or

inappropriate supervision of a child’s voluntary sexual

activities.

Sexual activity rate: As typically used in the literature,

the number of individuals who have ever had sexual

intercourse, per some population base.

Sexually active: As typically used in the literature,

sexually active denotes ever having had sexual intercourse (as opposed to currently being sexually active).

Sexually transmitted disease (STD): Any infectious

disease transmitted through sexual intercourse or

genital contact. Examples are chlamydial infection,

gonorrhea, herpes genitalis, pelvic inflammatory disease (PID), syphilis, and AIDS. Formerly (and sometimes, in law) called venereal disease.

Short-stay hospitals: As defined by DHHS’s National

Center for Health Statistics for the National Hospital

Discharge Survey, hospitals in which the average

length of stay is less than 30 days.

Short-term juvenile facilities: See juvenile justice facilities.

Sickle-cell disease: A lifelong disorder due to an

inherited abnormality of the hemoglobin molecule,

characterized by chronic anemia, a sickle-shaped

deformity of red blood cells, and intermittent occlusions of the blood vessels.

Simplified oral Hygiene Index (OHI-S): A measure of

oral cleanliness and plaque control, with a low score

denoting good oral hygiene.

Social competence: Competence in aspects of interpersonal interaction, including: managing social transactions such as entry into social situations; ability to

maintain satisfying personal and work relationships;

ability to resolve interpersonal problems so that there

is both mutual satisfaction in the encounter and

preservation of valued goals; ability to improvise

effective plans of action in conflicted or disrupted

situations; and ability to reduce stress and contain

anxiety within manageable limits. The mediating

factors affecting social competence that have been

found to be susceptible to life skills training include the

individual adolescent’s: 1) motivation (i.e., to acquire

knowledge and skills to enhance social competence);

2) knowledge base (i.e., about developmentally relevant health and social concerns); and 3) social skills

(e.g., communication, empathy, ability to regulate

one’s own behavior).

Social environment: The aggregate of social and cultural

conditions that influence the life of an individual or

community. Aspects of the social environment particularly important to adolescents include the adolescents’

families, other adults with whom adolescents come in

contact, schools, workplaces, recreational facilities,

and the media.

Social marketing: The design, implementation, and

control of programs calculated to influence the acceptability of social ideas and involving considerations of

product planning, primary, communications, distribution, and marketing research. It is different from health

education in that it promotes specific products (e.g.,

condoms) rather than abstract ideas (e.g., disease

prevention).

Social services: Services provided in order to support the

functioning of individuals or family units, including

those services termed: 1) “supportive” or “protective

services’ 2) supplementary (i.e., financial assistance,

home aid services (e.g., homemaker, caretaker, and

parent aide services), respite care); and 3) “substitute”

services (e.g., shelter services, foster care, adoption).

Social Services Block Grant Program: A Federal

program, established by 1981 amendments to Title XX

of the Social Security Act, of block grants to States for

the provision of social services for the purpose of

assisting individuals to: 1) achieve or maintain economic self-support; 2) achieve or maintain selfsufficiency; 3) prevent or remedy neglect, abuse, or

exploitation of children and adults unable to protect

their own interests; 4) prevent or reduce inappropriate

institutional care; 5) secure referral or admission for

institutional care when other forms of care are not

appropriate, or provide services to individuals in

institutions. Services that can be supported by social

services block grants include protective so-vices;

employment, education, and training services for

disabled people; foster care and adoption services; and

health-related services (e.g., prevention, intervention,

residential care). The program is administered at the

Federal level by the Office of Human Development

Services in DHHS.

Social support: Can involve the provision of any or all

of: 1) supportive aid, including practical services and

material benefits; 2) personal affirmation, including

feedback that raises self-esteem and strengthens personal identity; and 3) supportive affect, particularly

affection, caring, and nurturance. Compare parental

support programs.

Socioeconomic status: Generally used in this Report as

a synonym for income levels, typically those of an

adolescent’s family of origin. In some cases, however,

socioeconomic status refers more broadly to a combination of factors such as father’s education, mother’s

education, family income, father’s occupation, and

household items. See poor, near-poor.

Special Supplemental Food Program for Women,

Infants, and Children (WIC): A program, adminis-
Appendix A—Glossary of Abbreviations and Terms ● II-723

tered at the Federal level by the Food and Nutrition

Service of the U.S. Department of Agriculture, the

purpose of which is to improve the health of lowincomne pregnant, breastfeeding and postpartum women,

infants and children up to their fifth birthday by

providing food packages designed to supplement each

participant’s diet with foods that nutritional research

indicates are typically lacking in the WIC target

population and by providing eligibles nutrition education and access to health services. Only 3 percent of

those participating in the WIC program are pregnant,

breastfeeding, or postpartum females under age 18.

Specialty mental health organizations: According to

the National Institute of Mental Health (NIMH) in

DHHS, any organizations designed primarily to provide mental health services. NIMH does not have a

specific definition of a mental health organization,

As part of its survey of mental health organizations, it

collects data on patient care episodes from eight types

of mental health organizations: State and county

mental hospitals, private psychiatric hospitals, Department of Veterans Affairs (formerly Veterans Administration) psychiatric organizations, general hospitals

with separate psychiatric services, residential treatment centers for emotionally disturbed children, freestanding psychiatric partial care organizations, and

multiservice mental health organizations. The survey

excludes data on patient care episodes outside of

mental health organizations (e.g., in private offices of

mental health providers).

Spermicides: Contraceptive agents that work by killing

sperm. Spermicides come in various forms (e. g., jellies

or creams to be used in diaphragms, contraceptive

vaginal sponges, spermicidal condoms). Spermicides

decrease the transmission of some sexually transmitted

diseases (STDs), including gonorrhea.

Standardized test: A test composed of a systematic

sampling of behavior, administered and scored according to specific instructions, capable of being interpreted in terms of adequate norms, and for which there

are data on reliability and validity,

Standard Metropolitan Statistical Area (SMSA): See

Metropolitan Statistical Area (SMA).

State and county mental hospital: A psychiatric hospital operated under the auspices of a State or a county

government or operated jointly by both a State and

county government.

Statistically significant: A judgment, based on commonly agreed to statistical principles, that there is

relatively little likelihood (typically from below 1 to

below 5 percent) that an observed relationship between

or among variables has occurred by chance.

Status offenses: Offenses that are considered offenses

only because they are committed by a minor (a person

below age 18 or 19, depending on the State). Such

offenses (e. g., purchase of intoxicating liquor, truancy,

curfew violations) would not be considered offenses if

committed by an adult. Under the Federal Bureau of

Investigation’s reporting system, status offenses are

considered Part II offenses.

Stimulants: Psychoactive substances that stimulate the

central nervous system, including amphetamines, caffeine, and heroin. In the NIDA Household Survey on

Drug Abuse, the term stimulants refers to “amphetamines or other stimulants, ’ also called ‘uppers, ’ that

people take ‘‘to help them lose weight or for some

other reason. In the Monitoring the Future/High

School Seniors Survey, the term similarly means

amphetamines.

Street kid: A long-term runaway, thrownaway, o r

otherwise homeless child or adolescent who has

become adept at fending for him or herself “on the

street,’ ‘ usually by illegal activities.

Subclinical: Not detectable or producing effects that are

not detectable by the usual clinical tests.

Subfamily: By U.S. Department of Commerce, Bureau of

the Census, definition, a subfamily is a married couple

with or without children, or one parent with one or

more own never-married children under 18 years old,

living in a household and either related or unrelated to

the person or couple who maintains the household.

One example of a related subfamily is a young

married couple sharing the home of the husband’s or

wife’s parents. An unrelated subfamily can include

persons such as guests, partners, roommates, or

resident employees and their spouses and/or children.

Compare unrelated persons.

Subjective distress: Feelings of sadness, hopelessness,

discouragement, boredom, stress, dissatisfaction, or

being worn out or exhausted, that are self-reported by

individuals but are not necessarily symptoms of

diagnosable mental disorders.

Substance: See psychoactive substances.

Substance abuse: See psychoactive substance abuse.

Substance dependence: See psychoactive substance

dependence.

Suicide and suicidal ideation: Suicide is the taking of

one’s own life. Suicidal ideation involves preoccupation with thoughts about committing suicide and may

be a precursor to the act itself. Suicide and suicidal

ideation are not diagnostic categories included in

DSM-III-R but are behavioral symptoms of underlying

problems, many, but not all, of which may relate to the

mental health status of an individual.

Supply reduction substance use prevention strategies:

Strategies related to the prevention of drug use and

abuse that do not involve the delivery of personal

health care services or attempt to change behavior by

changing attitudes. Include restrictions on the manufacture, purchase, sale, possession, and use of alcohol

and other drugs. Also sometimes considered ‘‘health

protection strategies, ” to distinguish them from dis-
II-724 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

ease prevention and health promotion strategies. Compare demand reduction substance use prevention

strategies.

Survival sex: Engaging in sexual intercourse in exchange

for food, shelter, money, or drugs.

Syndrome: The aggregate of symptoms considered to

constitute the characteristics of a morbid entity: used

especially when the cause of the condition is unknown.

Syphilis: A sexually transmitted disease (STD) caused by

the bacterial agent Treponema pallidum, resulting in

symptoms including chancre (primary syphilis); skin

rash, malaise, anorexia, nausea (secondary syphilis);

and eventually, central nervous system abnormalities

and other serious problems (tertiary syphilis).

Technology: The application of organized knowledge to

practical ends. In 1978, OTA defined medical technology as the drugs, devices, and medical and surgical

procedures used in medical care and the organizational

and supportive systems within which such care is

provided.

THC (tetrahydrocannobinol): The psychoactive ingredient in marijuana, hashish, and other preparations of

hemp (Cannabis sativa).

Therapeutic alliance: An approach to psychotherapy

which refers to the patient and therapist’s collaborative

effort in observing the patient’s psychological processes. A replacement for outmoded notions of effective

procedures in psychotherapy with children and adolescents.

Therapeutic foster care: In the spectrum of mental

health services, the least restrictive type of residential

(overnight) care. Therapeutic foster care essentially

involves the following features: placement of a child

with foster parents who have specifically been recruited to work with an emotionally disturbed child;

provision of special training to the foster parents to

assist them in working with the child; placement of

only one child in each special foster home (with

occasional exceptions); a low staff-to-client ratio,

thereby allowing clinical staff to work very closely

with each child, with the foster parents, and with the

biological parents if they are available; creation of a

support system among the foster parents; and payment

of a special stipend to the foster parents for working

with the emotionally disturbed child, and for participating in the training and other program activities.

According to one group of observers, therapeutic

foster care is simply conducting foster care at its best.

Third-party payment (for health care): Payment by a

private health insurer or government program to a

health care provider for care given to a patient.

Thrownaway: A child or adolescent who has been told

to leave the household, has been abandoned or

deserted, or who has run away and no effort has been

made to recover him or her.

Title V of the Social Security Act: See Maternal and

Child Health Block Grant Program.

Title XIX of the Social Security Act: See Medicaid.

Title XX of the Social Security Act: See Social Services

Block Grant Program.

Title X family planning clinics: Family planning clinics

that receive funds under Title X of the Public Health

Service Act,

Title X program (Family Planning Services and

Research Program) under the Public Health Service Act: A Federal program that provides Federal

grants to help support about 4,000 family planning

clinics operated by public or private nonprofit entities

across the country, as well as funds for training and

research to improve the delivery of family planning

services. The Title X program is administered at the

Federal level by the Office of Population Affairs

within DHHS. In 1990, Congress appropriated $130

million for the Title X program. Family planning

clinics that receive Title X funds offer contraceptives

and other family planning services (not including

abortion). The services offered by family planning

clinics are provided free or at rates determined on a

sliding-fee scale and are confidential. About one-third

of the patients of such clinics are adolescents ages 15

to 19. See also family planning services authorized by

Title X of the Public Health Service Act.

Title XX program (Adolescent Family Life Program)

under the Public Health Service Act: A Federal

program that awards Federal grants for demonstration

projects that seek to prevent adolescent pregnancy by

encouraging adolescents, within the context of the

family, to abstain from premarital sexual activity and

for demonstration projects that provide health and

social services for pregnant or parenting adolescents,

The Title XX program is administered by the Office of

Population Affairs within DHHS. In fiscal year 1990,

Congress appropriated $9.5 million for the Title XX

program.

Tobacco: In this Report, cigarettes or other products

prepared for smoking or chewing from the plant

Nicotiana tabacum. Such products contain nicotine, a

psychoactive substance associated with dependence.

Tracking: The assigning of students to a particular

curricular track, usually on the basis of estimated

ability.

Tranquilizers: Psychoactive substances that are prescribed as antianxiety or antipsychotic agents. Unlike

sedatives, they produce their calming action without

primary interference with consciousness arid thinking.

Transitional living programs: Structured programs that

provide shelter to runaway and homeless youth while

helping them develop the skills they need to live on

their own. The programs are authorized by the

Runaway and Homeless Youth Act. Compare independent living programs.
Appendix A—Glossary of Abbreviations and Terms . //-725

Trauma: An injury to the body, especially one resulting

from an external force; or a psychological shock

especially one having a lasting effect on the personality.

Treatment services: Services intended to cure or ameliorate the effects of a disease or other health problem

once the problem has occurred. Compare preventive

health services.

Trichomoniasis: Infection with the protozoa Trichomonas. Vaginal trichomoniasis is a sexually transmitted disease (STD) caused by infection with Trichomonas vaginas, found in the vagina and male genital

tract. Vaginal trichomoniasis is sometimes symptomatic but may be manifested by severe vaginifis

associated with discharge in females or with urethritis

or epididymitis in males.

Unemployment rate: The numerator for calculating the

unemployment rate is the number of civilians who had

no employment but were available for work and: 1) had

engaged in any specific jobseeking activity within the

past 4 weeks, 2) were waiting to be called back to a job

from which they had been laid off, or 3) were waiting

to report to a new wage or salary job within 30 days.

The denominator for calculating the unemployment

rate is the labor force. In the second quarter of 1991,

66,2 percent (125,51 1,000 individuals) of the civilian

noninstitutional population were estimated to be in the

labor force; 8,553,000 individuals were estimated to be

unemployed, and the unemployment rate (seasonally

adjusted) was estimated to be 6.8 percent.

Unintended births: A combination of births arising from

mistimed and unwanted pregnancies.

Unintentional injuries: See accidental injuries.

Universal interventions: interventions for all members

of a particular population.

Unprotected sexual intercourse: Sexual intercourse

without precautions taken to prevent pregnancy or the

transmission of AIDS or other sexually transmitted

diseases.

Unrelated persons: As defined by the U.S. Department

of Commerce, Bureau of the Census, unrelated

individuals are persons of any age who are not

members of families or subfamilies. Unrelated persons

can also be members of unrelated subfamilies.

Urethritis: Inflammation of the urethra (the membranous

canal conveying urine from the bladder to the exterior

of the body).

Vaginitis: Inflammation of the vagina.

Variable: In an experiment, a factor that is changeable

and subject to variation. The independent variable

establishes the value of the dependent variable(s)

when a defined relationship exists between them.

Veterans Administration psychiatric organization: An

organization that is operated and controlled by the

Veterans Administration and provides mental health

services.

Victimization rate for an offense: The number of

offenses experienced by a given population per some

population base during a given time period. The

victimization rate is analogous to the incidence rate for

an offense.

Vital statistics system: See national vital statistics

system.

Waived case: A case that is transferred from the juvenile

court to the criminal court.

Work-loss day: As defined by the National Health

Interview Survey conducted by DHHS, any day on

which an individual did not work at his or her job or

business for at least part of his or her normal workday

because of a specific illness or injury. The number of

work-loss days is determined only for currently

employed persons. See also restricted-activity day.

Younger adolescents: As defined in most DHHS data

analyses, adolescents ages 10 to 14. Compare older

adolescents.

Youth Risk Behavior Surveillance System (YRBSS):

This system, recently developed by the Centers for

Disease Control in DHHS, will monitor the prevalence

of priority risk behaviors among samples of schoolaged adolescents by collecting data from a periodic

school-based survey combined with special supplemental data on youth risk behavior from the National

Health Interview Survey conducted by DHHS. The

system will be implemented in 1991, 1995, and 2000.

Zidovudine (RetrovirR

): A drug used to reduce symptoms prolonging the lives of persons infected with

human immunodeficiency virus (HIV). This drug was

formerly called azidothymidine (AZT).
INDEX
Index

Note: This index incorporates key terms from Volume 1, II, and III of OTA’s Report, AdolescentHealth. The index is also available

as a separate document from OTA (202/224-8996).

A

Abortion

II: 38, 305-306, 325-326, 329-331,

336-337,338, 345-346,347,

351, 355,368, 397-398,411,

418

III: 263, 285

alternatives to

Lr: 399

III: 177,243

consent and confidentiality

I: 57,60, 61,62, 112

II: 398

III: 128-129, 132, 135, 137, 140,

141, 142, 143, 144-145, 150-

151

cost factors

II: 377, 398

funding

III: 92-93, 174,243

insurance

III: 92-93, 174

Medicaid

n: 414

III: 174

minorities

H: 353-354

ILI: 185

statistical programs

I: 95

II: 325-326, 329-331

Absenteeism from school

II: 67, 119, 131-132, 157, 158, 175,

670

m: 54, 168

Access to services

I: 1,2,23,25-27,46-65,72,76, 78,83,

87,97,98, 12 4

II: 5

III: 3, 65-66, 159-210

AIDS drugs, clinical trials

II: 296-297,309

consent and parental notification

III: 134-135, 136, 138, 151, 152

contraceptives

II: 356,357, 366, 370,371,372-

389, 398,410-411

HI: 54, 135

correctional facilities, inmates

1: 26, 106

II: 633

cost factors, general

I: 46,47, 51,53, 54-57,59-60, 83,

110-112

II: 294

111: 1, 30, 63,77-120, 188, 189,

198-199

drug abuse

1: 102

In: 19

financial barriers

I: 46,47,51,53, 54-57,59-60, 83,

110-112

III: 1, 30,63,77-120, 188, 189,

198-199

homeless adolescents

I: 107

II: 669

hospital-based

LII: 32, 34

information on

I: 46,63-64, 72

legal issues

I: 46,47,57-62,63, 83

H: 296-297,309

III: 134-135, 136, 138, 151, 152

mental health

I: 98-99, 100, 111

II: 466-469,482

minorities

I: 27

II: 467,468

III: 187-196

policy options

I: 43-64, 106-117

poverty and

I: 117

III: 169-171

recreational

I: 25,74,81-82

II: 3,59-60, 88-103, 104,217-218

rural areas

III: 198-199

school-linked health centers

I: 31,47,49-54, 109-110

II: 82-83,378

III: 3,41-56

sports and recreation

I: 25,74, 81-82

II: 3,59-60, 88-103, 104,217-218

see also Outreach services; Referral to

services; Utilization of services;

specific health problems;

specific health services

Accidents and injuries

I: 4,7-8, 16,90

II: 117-141,638

In: 59, 216,244, 245, 246,262, 283

age factors

II: 118, 122-127 (passim), 131,

134-135, 136-137

cost of

-II-72!+

I: 18, 19

II: 131, 135, 140

droWning

II: 120-121,123-124,127, 128,530

Federal programs

I: 88

II: 138-139

III: 233-235,244-246,252-253

gender differences

I: 17, 19,88

II: 118-119, 122, 124, 125, 127,

129, 131, 132, 157-158

hospital-based services

II: 120, 121, 124, 127

medical services

II: 119-120, 121, 124, 127, 136-

137, 141

minorities

I: 20,88

II: 123, 124, 127-129

III: 183, 184, 186

morbidity and mortality, data

1: 7-9,20, 88,90

II: 117-132, 139-140

motor vehicle

I: 2, 14, 16,76, 88,89

II: 118, 120, 121-123, 126, 127-

128, 129-131, 133, 139,529-

530,585

III: 183, 186, 197,217-218,235,

244, 245,246, 252-253,262

policy options

1: 88

prevention

I: 25, 88-90

II: 132-136, 140

III: 235, 244,245, 246,262

research

I: 90

H: 139, 141

III: 252, 253-254

rural areas

I: 115

11: 128, 129

III: 197

safety equipment

I: 76,88-89

II: 130-131, 134-136

III: 252-253

school-linked health centers

III: 44

sports and recreation

11: 121, 124-126, 213

statistical programs

II: 117-132, 140-141

whites
II-730 ● Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

I: 20, 88

III: 183

Accreditation Council for Graduate

Education

III: 26

Acne

I: 11, 17, 108

II: 154, 179-181

III: 10,20,47,61,63

ACTION

I: 35,65

II: 94, 102-103,563

III: 172-173,216,244

Acute diseases and disorders

I: 20

II: 149, 153-154, 156-158

see also Emergency semices, Schoollinked health centers

Administration for Children, Youth,

and Families

I: 65

II: 682,688

III: 176, 192

Administration for Native Americans

III: 192-193

Administration on Developmental

Disabilities

III: 176

Adolescent Alcohol Prevention Trial

II: 536-537

Adolescent Family Life Program

II: 411-412

Adolescent health, conceptual issues

I: 2-5,83-84

Adolescent health care clinics

III: 31-34

Adolescent Health Promotion

I: 120

Adolescent Health Youth Advisory

Panel

I: 72, 128-129

III: 60

Adoption

II: 50,51, 326, 338-339,351, 354,

355,398-399,471

III: 177,286

Adoption Assistance and Child

Welfare Act

II: 50,51

Adults, nonfamily

II: 14,88,287,440

III: 188, 190

attitudes toward adolescents

I: 45, 107

drug abuse

II: 512-513,538

mentor influence

II: 389, 390-391

III: 173, 191

Advertising

II: 543

Advisory bodies

community

III: 42,51,200

multidisciplinary

I: 73

III: 57

research

I: 64-65,73-74, 127-129

study panel

1: 127-128

youth panels

I: 128-129

III: 59,60

African Americans, see black

Americans

Age factors

I: 15, 118

II: 17-18,60, 157-158, 162-163

accidental injuries

II: 118, 122-127 (passim), 131,

134-135, 136-137

age of majority

1: 57,58

II: 545,568, 673

III: 123, 134-135, 138, 141-148,

150

AIDs

II: 261

birth rates

II: 328-329

child abuse

II: 45,48

chronic diseases

I: 16-17

II: 159, 160, 166, 167, 180, 181

competence v.

1: 57,58

III: 123, 134-135, 138, 141-148,

150

consent requtiments

I: 57,58

III: 123, 124-125, 126, 128, 130,

136, 141-146, 150

definitional issues

I: 2,6

II: 117, 163

III: 213, 219-224

delinquency and crime

I: 102

II: 585,589,596-597,614, 618,

619,628,631,633

dental and oral health

II: 232,235, 238,239

drug abuse

II: 512-513,518-519, 543,547,

551,566

elderly persons

I: 119, 120

III: 109-110, 172, 244

hopelessness

II: 673

Medicaid

HI: 95, 289

nutrition

II: 198, 199, 216

physician utilization

m: 9-1o

sexual activity and outcomes

II: 262,270,334,340-341, 342,343

statistical aggregations

I: 159-160

workforce

I: 121-122

see also Developmental processes

Agricultural workers

II: 237-238,414

III: 176, 177,213, 237

Aid to Families With Dependent

Children

I: 19,55

II: 323,348, 350-351,401,415-416,

617,664,679

III: 79,95-98,100,116,152, 162,173,

174, 175,225, 229,253-255

AIDS and HIV infection

1: 11-12,92-94

II: 37,42,257-268,271-272, 275-294,

296-311,373,415,676

III: 11,89,93-94,243,254, 255,262,

285

CDC programs

II: 258,261, 279,285, 289,295,

298, 299-300,302,303,304,

310

consent and cotildentiality

I: 62

III: 127-128, 132, 138

demonstration projects

II: 297, 303, 304, 305

drug abuse and

II: 257,258, 271,272, 277,293,

296

drugs, prescribed

II: 296-297,309

education on

II: 272,275,279-280,286, 308,358

ILL 235

family interventions

II: 279-280,308

Federal efforts

1: 92-94

II: 258,280, 298-306, 309-311

III: 233-235,239-241

local programs

II: 280, 286-288, 295, 358

minorities

I: 21, 196

II: 262,263, 268,271, 272,279,

280, 286,304, 309

III: 183, 185, 195, 196, 241

policy options

I: 92-94

regional programs and trends

II: 263, 272, 294-295

screening
Index . //-731

I: 62

III: 132

State efforts

II: 258,276, 280, 284,293, 294,

306,309-31 0

Alabama

III: 29,41-42,82,97,103,105, 107,

111, 124

Alan Guttmacher Institute

II: 325-326,330-331,355, 358,397

Alaska

II: 476

III: 82,97, 103, 105, 107, 111, 124,

129

Alaska Nati\es

I: 88

H: 356,437,562

III: 162, 186, 250

Alcohol abuse

I: 2, 14,99-101, 102

II: 448,499,500,512,513, 516-517,

527, 529-530,533,543,559-

560, 561-562

III: 229-230, 253, 254, 287

block grants

I: 60

II: 478-479, 561, 5@l, 679

III: 153

clinical semices

III: 35-39 (pa.SSinl)

consent and confidentiality in

treatment

I: 61

IH: 129-130, 131, 133, 135, 137,

153

counseling

III: 17-18, 47

II: 557

delinquency and corrections

II: 611, 640, 645

driving while intoxicated

I: 14, 16, 88

II: 122, 129-130, 516, 529-530

III: 18, 137

homeless persons

II: 665-666,675, 678,681

insurance for treatment

III: 88-89

minority groups

II: 520-522,524, 551, 566

III: 183, 185, 186, 193, 196,229

parents

II: 522-523

physician diagnosis and counseling

III: 17-19, 63, 102

policy options

I: 99, 100, 102

school-linked health centers

II: 536-538

m: 47,54

treatment

II: 547,548

Alcohol, Drug Abuse, and Mental

Health Administration

I: 33

11: 302,499, 510,533, 560,561-562

III: 17, 193-194,214,229-233, 253

Alcoholics Anonymous

II: 548-549

Allergies

II: 158, 167, 172

American Academy of Child and

Adolescent Psychiatry

III: 26

American Academy of Family

Physicians

III: 26, 52, 136

American Academy of Pediatrics

HI: 102, 109, 136, 213

primary and comprehensive services

delivery

11: 641

III: 12-13, 14, 25,28,52,62

American College of obstetricians

and Gynecologists

II: 346

III: 52, 136-137

American College of Physicians

III: 26

American Conservation and Youth

Corps

H: 102

American Dental Association

II: 243,244

American Humane Association

II: 4344

American Indians

I: 2,21, 27,97

LI: 85, 128, 237, 239, 356,437,468

III: 27, 180, 186, 192-193, 194, 195,

229,250, 252, 254

accidental injuries

1: 88

Alaska Natives

1: 88

II: 356,437,562

HI: 162, 186, 250

dropouts

I: 20

Hawaiian Natives

II: 600

III: 186-187, 188, 191

poverty

I: 27

III: 162, 174, 175, 192

see also Indian Health Service

American Medical Association

1: 27, 76

II: 137,673

III: 17-18, 25-26,52

American Psychiatric As..ociation

II: 503-504

American Psychological Association

II: 463

III: 25

American Society for Adolescent

Psychiatry

I: 31

III: 63

American Society of Addiction

Medicine

II: 557

Anemia

II: 20,209, 212,213

III: 185

Anti-Drug Abuse Acts

II: 559-560,687-688

III: 231-232

Apprenticeships

II: 87

III: 252

Arizona

III: 82,97, 103, 105, 107, 111

Arkansas

III: 50, 82,97, 103, 105, 107, 111,

127, 129

Asian Americans

IL 356,468

KII: 180, 182, 183, 185-186, 188, 190

Assessment, see Diagnosis; Evaluation

issues; Screening

Associations, see Professional

associations; Youth associations and

organizations

Athletics, see Sports and recreation

Attitudes of adolescents toward

adults, nonfamily

I: 45, 107

dental health

I: 92

II: 244-245

drug abuse

m: 19

health problems

11: 161-162, 167-168,175-176, 181

health professionals and services

I: 107

II: 161, 177-178, 182-183, 190

III: 7, 8, 12, 14-15, 20-23, 32-33,

51-52,60, 62-63, 109

hormonal changes

II: 19

nutrition

II: 216

others/selves, general

II: 66,71,72,88, 92, 176, 216

III: 181, 191,262

school influences and semices

I: 86

III: 43,52, 60, 66,71, 72, 88,92

sexual activity

II: 328,356, 357, 358, 367-368

sexually transmitted diseases

II: 273-274, 275, 284, 294,296,

304, 308

suicide
II-732 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

n: 450

Attitudes of nonadolescents

I: 45,51, 118

II: 24,328,346, 387-388

III: 58

health professionals

I: 107, 108-109

II: 161, 177-178, 182-183, 190,

264,271,377-378,410

HI: 7, 12-13, 15, 17,22-23,24,

28-29,30,51-52,62-63, 109

parents

II: 67,77-78,91,162-163, 182-183,

347

m: 50-51,55

racial prejudice

III: 181, 183, 184, 190

school-linked health centers

III: 43,50-52

teachers

I: 86-87

II: 66-67,73-76, 104

see aZso Public opinion

Automobiles, see Motor vehicles

B

Barriers, see Access to services

Bicycles

II: 126, 129, 133-134, 139

III: 252,255

Birth rates

I: 21-22,94,95

II: 325,328-329, 334,350-351,353,

355, 356,378

Black Americans

I: 19-20

II: 160, 177, 208, 236,436,447,468

III: 180, 182, 183-185, 188, 190, 191

accidental injuries

II: 123, 124, 127-128

birth rates

II: 328-329,355

delinquency and corrections

I: 15, 102

II: 589,598-599,601,613-614,

618,631,646,648

dental health

II: 239,248

dropouts

I: 8-9,20

II: 66

pregnancy and parenthood

II: 324,342,351,352-353, 354,378

role models

m: 171

school-based services

III: 46

sexual activity and sexually

transmitted diseases

II: 262,263,268,271,324, 342,

351,352-353

uninsured

III: 79-80

utilization of services

III: 11-12,46, 179, 188

see also Minorities

Block grants

I: 40

LI: 679

III: 174, 175,229, 251

alcohol, drug abuse, and mental health

I: 60

II: 478-479,561,564,679

HI: 153

maternal and child health services

I: 60

II: 400,414,415,679

III: 153, 177, 194,235-236

Boys and Girls (Hubs of America

II: 92-93

Boys Clubs of America, see Boys and

Girls Clubs of America

Boy Scouts

II: 92

Budget Enforcement Act

I: 119, 120

Bureau of the Census

II: 36,663,667

Bureau of Health Care Delivery and

Assistance

II: 414

III: 176-177,200

Bureau of Indian Affairs

III: 193, 217

Bureau of Justice Statistics

II: 611,612

Bureau of Maternal and Child Health

II: 172, 173,243,246-247,414, 562-

563

III: 177, 263

Burroughs Wellcome Co.

II: 287-288

c

California

II: 124,284, 289,368,403,475-476,

538,617,666,672,673, 675,

676,677,678,682-683, 687

III: 21,29,34-36,82,97, 103, 105,

107, 111, 171

Canada

II: 96, 162-163,290

III: 14-15

Cancer

II: 168, 174-179,211

Carnegie Council on Adolescent

Development

I: 26,71-72, 120

II: 28,94

Casey v. Population Services

International

III: 128

Center for Population Options

II: 368,472

m: 41-47

Centers for Disease Control

1: 11,33-34, 121

II: 42, 138, 141, 183-184,212, 220-

221, 242,243,246,326, 331,

560, 562,565

III: 214-215,221,233-235, 253,506,

509,519

models

I: 26-27,71-72

II: 295-296

sexually transmitted diseases

including AIDs

II: 258,261,279,285, 289,295,

298,299-300,302,303, 304,

310

Chancroid

II: 270

Child abuse and neglect

I: 8, 85

II: 40-51,52,471,606-607, 614,628,

676-677

III: 61, 125, 126, 130, 175, 196,250

sexual abuse

I: 8, 19

II: 43,46,48,49, 676-677

III: 37

Child Abuse Prevention and

Treatment Act

III: 176

Child and Adolescent Service System

Program

II: 479,482

Children’s Bureau

III: 257-258

Child Support Enforcement Program

II: 416

III: 173-174

Child Welfare League of America

II: 399

Chinese Exclusion Act

III: 180

Chlamydia

II: 264-265,268,306,640

Chronic physical diseases and

disorders

I: 10, 11,91

II: 149-186

III: 13, 284

acne

I: 11, 17, 108

II: 154, 179-181

III: 10,20,47, 61,63

age factors

I: 16-17

II: 159, 160, 166, 167, 180, 181

cancer

II: 168, 174-179,211

costs of

1: 18

II: 164-168,169-171,178-179, 180,

440-441
●

Index . //-733

diabetes

I: 21

II: 211,215

III: 91,235

gender differences

I: 17

II: 166

hemophilia

II: 261, 277

herpes

II: 269

hospital-based sewices

II: 151, 152, 153-154, 155, 169

insurance

II: 176, 178-179

III: 93-94

medical services

II: 151, 152, 153-154, 155, 169-

173, 175, 176, 177-179, 180-

182

menstrual distress

I: 11

II: 42, 181-183

minorities

I: 90

III: 186

morbidity data

I: 10-11, 17,89-90, 91

II: 150-161, 163-168, 174-175

nutrition and fitness

II: 195,200,202,210-211, 215,221

osteoporosis

II: 211

policy options

I: 89

poverty

1: 90

II: 158, 159

III: 168

prevention

II: 168-169, 176-177

respirato~ diseases

I: 17, 89

II: 151, 154, 157, 158, 159, 172

see also Diseases and disorders

Civilian Conservation Corps

II: 100

Civil Rights Act of 1964

III: 90

Cognitive factors

1: 46

age v. competence

I: 57,58

III: 123, 134-135, 138, 141-148,

150

delinquency

II: 605,608-609, 622

developmental

I: 6-7,25, 27, 31,54,72-74, 118

II: 20-23, 29, 339

III: 123, 134-135, 138, 141-148,

150

discretionary time

II: 88,92,96-97

educationally handicapped persons

I: 7, 86

II: 215,584,585,608-609

III: 176, 186,229

emancipated and mature minors

II: 297,673,678

III: 125, 126-127, 136, 140, 149-

150, 151

intelligence

I: 103

II: 68-69,70,342,609,616, 621

III: 125, 128, 140, 147

see also Decisionmaking

Colorado

II: 237-238

III: 50,82,97, 103, 105, 107, 111

Commitment (involuntary)

I: 58,60-61, 62,99

II: 458-459,471,567

III: 130, 140, 144

Communicable diseases, see AIDS and

HIV infection; Sexually

transmitted diseases

Community-based programs and

activities

II: 93-94, 95, 217-218, 247, 286-288

advisory bodies

III: 42, 51,200

comprehensive health care

1: 31,47,49-54,72, 83, 109-110,

111

III: 1, 29-32,34-41,35-38, 170-

171, 176-177,213,225

consent and confidentiality

I: 50, 54

cost factors

I: 49,50, 52,53

II: 638-639

III: 36

de fried

I: 50

II: 294

delinquency

II: 590,603,614,615,623, 636-

639,643

drug abuse

II: 535,540,549-550,552, 561

Federal support of

1: 51-54

II: 4144.15,561

financial factors

1: 49,50, 52,53

m: 33, 39

homeless shelters

H: 668,678-681

mental health

II: 450-451,470,483,486, 549,552

models

I: 53

II: 79-83

HI: 35-41,56-57

physicians

I: 53

political factors

1: 50,51

pregnancy and parenthood

II: 358,368-372,414

runaways

II: 682-685

sexual activity and sexually

transmitted diseases

II: 277,286-288,358,360-372

staffing

I: 50

III: 45,55,56,64

Community Mental Health Centers

Act

II: 477

Community service

I: 82-83, 87

II: 93, 101-104

Comprehensive health care

I: 31,47,49-54,72,83, 109-110, 111

II: 487

HI: 1,5-73, 104, 106, 170-171, 176-

177

American Academy of Pediatrics

II: 641

III: 12-13, 14,25,28,52,62

clinical services

1: 47,49-54

III: 31-41

cotildentiality

1: 50,54

costs

I: 49,50,52,53

defined

I: 50

demonstration projects

II: 475477

III: 30, 31

evaluation

I: 52-57,72, 109

II: 475477

III: 30,32,33,36,38,51,52-57, 64,

171

Federal role

1: 51-54

II: 475477

financial factors

1: 49,50,52, 53

funding

I: 50-52,53-54, 87

III: 30-31, 33,38, 39,4748,50

integrated services

III: 56, 57-59,66

legislation, general

I: 52-54

models

I: 53

II: 79-83,475-477

III: 35-41,56-57
//-734 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

political factors

I: 50,51

pregnancy and pmmthood

II: 403,408,414

psychological services

II: 453

III: 39

regulation of

I: 52-54

rural areas

I: 115, 117

school-linked

I: 31,47,49-54, 109-110

III: 41-57,6$-65, 104, 106, 171

Staffing

I: 50

III: 45,55,56,64

Comprehensive Stress Management

Program for Children

II: 443,445

Condoms

I: 11,93

II: 271-272,277,286,289-293, 304,

308,310,370,372,373, 388-

389

Condyloma acuminatum

II: 269

Conference on Health Futures of

Adolescents

III: 57,58

Confidentiality, see Consent and

confidentiality

Congressional committees

I: 40-44,67

II: 644

III: 259-261

Congressional Budget office

II: 346-347,348

Connecticut

III: 49,82,97, 103, 105, 107, 111

Consent and confidentiality

I: 29,46, 57-62, 112-113

III: 1,8, 121-155, 195, 254

abortion

I: 57,60, 61,62, 112

II: 398

III: 128-129, 132, 135, 137, 140,

141, 142, 143, 144-145, 150-

151

abused and neglected minors

III: 126

access to services, general

III: 134-135, 136, 138, 151, 152

age factors

I: 57,58

III: 123, 124-125, 126, 128, 130,

136, 141-146, 150

ADS

I: 62

III: 127-128, 132, 138

alcohol abuse treatment

I: 61

III: 129-130, 131, 133, 135, 137,

153

commitment (involuntary)

I: 58,60-61, 62,99

XI: 458-459,471,567

III: 130, 140, 144

community comprehensive service

centers

I: 50,54

competency of minors

KII: 123, 134-135, 138-150, 151

contraceptive services

I: 57,60,61,93-94, 112

II: 377-378,410,411

III: 128-129, 132, 135, 140, 150-

151, 153

drug abuse treatment

I: 60,61

II: 566

III: 129-130, 131, 133, 135, 137,

138, 153

emergency services

III: 126>127, 131, 137

family pl arming services

III: 128-129, 132-133, 135

financial aspects

III: 125, 135, 137, 138

f~eatms purchases

I: 80

hospital-based clinics

III: 32

infectious disease services

III: 127-128, 132

insurance reimbursement

I: 60

III: 117, 136, 170

legislation, general

1: 47,57,58,60-62,99, 112-113

III: 123-134, 150, 152

litigation

I: 57,60,61, 112

II: 39 8

III: 123, 125-133 (pa.SSiIll), 139-

140, 149-151

Medicaid

III: 152, 153, 175

mental health services

I: 57,58,62,99

III: 130, 131, 133-134, 140, 144,

145-146, 147, 153

peer influence

III: 143, 147-148

physician attitudes

II: 377-378,410

III: 15,62-63

policy options

I: 57-62, 111-113

pregnancy-related services

I: 61

III: 129, 133, 137, 141, 142, 143,

144-145

primary care

I: 107, 10 8

III: 62-63

professional associations, positions

I: 57-58

III: 136-138

professional ethics

I: 59,62

III: 134-138, 140-141, 151-152

regulations

I: 60

III: 132, 137, 152

school-linked health centers

I: 31

III: 50-51, 52

sexually transmitted disease services

I: 57,60,61,62

III: 127-128, 132, 135, 137

socioeconomic factors

III: 144-145, 146-147

standards of competency

III: 125, 126-127, 131, 136, 140,

149-150

State laws

I: 47,57,58, 60-62,99, 112-113

III: 123-135, 138, 139-140, 150,

151-152, 153

Consumer Product Safety

Commission

H: 120, 121, 126, 139

III: 216, 244,245, 246

Continuing Survey of Food Intakes by

Individuals

II: 195

Contraception and contraceptives

I: 16,52-53, 96

II: 38326,328, 340-341,343, 344,

345,349-350,352,359, 365,

366,370,371,395,408, 410-

411

III: 177, 240,285

access to services

II: 356,357, 366,370, 371, 372-

389, 398,410-411

III: 54, 135

clinical services

III: 35, 37

condoms

I: 11,93

II: 271-272,277,286, 289-293,

304, 308,310,370,372,373,

388-389

consent and cordldentiaiity

I: 57,60,61, 93-94, 112

II: 377-378,410,411

III: 128-129, 132, 135, 140, 150-

151, 153

cost factors

II: 377,398

counseling

1: 53, 110

II: 368,387-388,395

III: 21,44,51,53-54,56
index .11-735

Federal efforts

Ill: 177,243

insurance

III: 93,96, 100, 101, 103

physician competence

III: 21

public opinion

I: 110

II: 368, 387-388, 395

school-linked health centers

II: 386-387

III: 44,51,53-54,56

utilization by poor adolescents

III: 169

Controlled Substances Act

11: 560

Coordination

Federal

I: 40, 65-68, 76

II: 417,477,479-480, 688

III: 3, 193, 194,250,252,253-256,

257-258

health care providers

III: 57-59

local

III: 57-59, 250

mental health services

II: 453454,469-472,477,479-480

State-level

I: 65

III: 263

Correctional programs

I: 15, 18, 26, 103-104, 106

II: 240, 250,280,440,470-471, 550,

583, 611,617, 625-645,647-

648

UI: 167,255

probation

II: 633,637

see also Delinquency; Juvenile courts

Cost factors

abortion

III: 398

access to services

1: 46,47,51,53,54-57,59-60, 83,

110-112

II: 294

III: 1,30,63,77-120, 188, 189,

198-199

accidental injuries

1: 18, 19

II: 131, 135, 140

chronic diseases

1: 18

II: l@-168, 169-171,178-179,180,

4404 1

community-based services

I: 49, 50, 52,53

II: 638-639

III: 36

comprehensive health services

I: 49,50,52, 53

contraceptives

II: 377

delinquency and corrections

I: 18

11: 616-617,638

disabilities

1: 18, 19

II: 164-168, 169-171

dropouts

II: 63

drug abuse

II: 533-534,552-553,556-557

employment programs

III: 252

free clinics

II: 294

III: 34, 3741, 60

health insurance

III: 83, 84-85, 87, 88,93, 94, 114

health problems, general

I: 16, 18-19, 72, 123

Medicaid

I: 56

II: 323

III: 4,95,96, 116

mental health services

11: 461,474,477

pregnancy and parenting by

adolescents

II: 323

school-linked health centers

III: 47-48,50,56

Counseling

alcohol and drug abuse

II: 547-549,555, 557-558,566

HI: 17-18,47

11: 557

chronic conditions

II: 172

at clinics

H: 411

III: 36, 37, 39-40

consent and cofildentiality

III: 137, 144

contraception and sexual activity

I: 53, 110

II: 368,387-388,395

III: 21,44,51,53-54,56

eating disorders

II: 214

homeless persons

II: 684

by nurses

III: 35

by physicians

III: 10, 14-15, 17-18,20-21,62

pregnancy

I: 97

LI: 401-402,411

school-linked health centers

III: 43-44,47, 53,56

self-help groups

II: 474-475,547-549,557, 637

suicide

II: 453

see also Psychological and

psychiatric services

Court cases, see Juvenile courts;

Litigation; specific court cases

Cranston-Gonzales National

Affordable Housing Act

II: 665,681-682

Crimes and criminals

I: 16,20

II: 37,95,98

III: 169,250,255, 287

age factors

I: 102

II: 585,589,596-597,614, 618,

619,628,631,633

definitions

II: 583-587,622,629-630, 641

drug abuse and

II: 508,516-517,532,534

!%UM’IS and

I: 81, 102, 103

II: 611-614,615,647

minorities

I: 15, 20, 102, 103

H: 598-600,601,613-614, 618,

619,628,630-631,632, 646,

648

KII: 171, 183, 184-185, 187, 196,

250

police

II: 538,626

III: 146, 184

rape

I: 19

II: 584,593, 619,677

school influences

I: 86

II: 70,71, 104,609,621-622,624

Ill 255

victims

I: 15, 19,20, 103, 105

II: 583,587,589,591,593, 598,

612-613,616-617,618-620,

628,633-634,637,647

III: 169, 183, 197-198

see also Child abuse and neglect;

Delinquency; Homicide;

Juvenile courts

Cultural factors

I: 21, 115

II: 36,99, 180

III: 55, 160, 188, 189, 190,229

Hispanics

III: 188, 189, 190

language issues

II: 76, 104

III: 189, 192

minorities

H: 67,99,601
II-736 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

III: 179-181, 182, 183, 184, 186-

192 (paSSi@, 194, 196, 201,

202,250

religious influences and organizations

II: 95-96,342

III: 51,56, 190, 191, 192

rural areas

III: 198, 199

Current Population Survey

III: 77, 161, 162

D

Deaths, see Accidents and in@ries;

Cancer; Chronic physical

diseases and disorders;

Homicide; Morbidity and

mortality; Suicide

Decisionmaking

I: 107-108

II: 21,22, 23-24, 38, 284

III: 230,254

assertiveness training

I: 27

II: 357,358,365-368,535, 565

commitment (involuntary)

I: 58,60-61,62,99

II: 458-459,471,567

III: 130, 140, 144

competency of minors

I: 57,58

III: 123, 134-135, 138, 141-148,

150

empowerment approaches

I: 63,64-65,67, 72, 82-83, 124,

128-129

II: 39-41,99, 104, 172,366-367,

395,443-444,445,566-567

III: 36,58, 59,60

schools

I: 85-86,87

II: 66,67,70-71,357,358, 365-368

skills

III: 230

training in

II: 279,284, 285, 357, 358,389,

390

III: 148

see also Advisory bodies; Consent

and cotildentiality

Definitional issues

accidental injury

Ix: 117

adolescence

I: 2,3-6

II: 13-17, 117,585

III: 213,219,224

adolescent health

I: 2, 3-5, 23, 71, 83-84

II: 13, 24-28

age factors

I: 2,6

II: 117, 163

III: 213,219-224

child abuse

1: 85

II: 42,43,604

chronic conditions

II: 150, 170

community services

I: 50

II: 294

competence

III: 139-141

consent

III: 123

delinquency, crime, and corrections

II: 583-587,622,629-630, 641

demonstration projects

I: 71

drug abuse

II: 499-504,507-508,509, 525,

527,533,534,558,566, 584

emancipated and mature minors

III: 126, 136

family autonomy

Ill: 125

funding

I: 5, 119-120

hopelessness

II: 663,665

Medicaid physician participation

Ill: 110

mental health

11: 454,455,464,549

minorities

Ill: 180

nutrition

II: 193,202, 208

parenting styles

1: 83,85

II: 40,46-47,50-51,524

III: 125

physical fitness

II: 193,202

poverty

m: 159

prevention

I: 24

primary health care

III: 7,62

Delaware

III: 82,99, 103, 105, 107, 111

Delinquency

I: 101-105, 106

II: 583-648,677-678

III: 197, 217,253, 255,287

age factors

I: 102

II: 589,589,596-597,614, 618,

619,628,631,633

alcohol abuse

II: 611,640, 645

Black Americans

I: 15, 102

II: 589,598-599,601,613-614,

618,631,646,648

cognitive factors

II: 605,608-609,622

community factors

II: 590,603,614,615,623, 636-

639,643

costs of

I: 18

II: 616-617,638

deftitional issues

II: 583-587,622,629-630, 641

demography, general

II: 596-601,615,628,630-632, 646

drug abuse

II: 534,557, 611,645

family factors

II: 603-607,614,620-621, 624,

637-638,642

Federal programs

I: 104-105

II: 621-622,644-648

gender factors

I: 15,20, 102

II: 597-598,618,628, 639-640

historical perspectives

II: 591-596,632-633,644

mental illness

II: 583,629-630,639-640

minorities

I: 15,20, 102, 103

U: 598-599,601,613-614, 618,

619,628,630-631,632, 646,

648

III: 171, 184-185, 187, 196,250

parental factors

II: 604-607,614,620-621

peer influences

II: 609-610

policy options

I: 101-105, 106

poverty and

I: 102

II: 600-601,614,633

III: 169, 171

prevention

I: 23, 103

II: 586,620-625,642-644

III: 250, 251,258

prostitution

II: 676

research

I: 106

II: 646-647

rural areas

schools and

I: 86, 106

II: 70,71, 104,609,621-622,624

III: 250,255

see also Correctional programs;

Juvenile courts

Demography
Index . //-737

II: 6,397,584

accidental injuries

II: 126-129

chronic conditions

II: 151-152, 160

delinquency and corrections

II: 596-601,615,628,630-632, 646

drug abuse

II: 517-519,525

family life and

II: 35-36

immigration and immigrants

III: 181, 182, 186, 192

pregnancy

II: 348-356

school population

II: 60,61,66

uninsured

III: 77-81

workforce

I: 121-123

II: 14, 15, 36

III: 165, 178-179

see also Age factors; Gender

differences; Minorities;

Morbidity and mortality;

Socioeconomic status

Demonstration projects

I: 69-72

II: 102, 138, 172-173,561

III: 172-173, 177, 194,200,244,246,

247, 252, 253, 254-255,262

AIDS and other sexually transmitted

diseases

II: 297, 303, 304, 305

comprehensive health centers

II: 475477

III: 30,31

educational

I: 64,69,70,71-72

III: 33

employment

II: 390, 391-393

evaluation

1: 71

III: 33-34,52,252

health insurance

III: 77-81, 100

Medicaid

III: 99, 100

mental health services

II: 472477,482

pregnancy and parenthood

II: 403-406,411-412

preventive services

1: 69, 70, 71-72

II: 243

recreational

1: 81, 87

school

I: 87

II: 80-86

statistical programs

I: 74-75

Dental and oral health

I: 11,91-92

II: 231-249,684

III: 61, 177, 186,284-285

fluoridation

I: 16,92

II: 241-242, 246

III: 235

insurance

II: 245,248

In: 91, 93

policy options

I: 91-92

school-linked health centers

HI: 44,47

Department of Agriculture

I: 35

II: 195,200,201,202,208, 217,219,

220,221,399,680

III: 177-178, 196,216, 219,245, 246

Department of Commerce

I: 35

II: 36

III: 216,219

Department of Defense

I: 35, 119, 120

III: 216,219,245,246-247

Department of Education

I: 36

LI: 78, 83-86,563, 669

III: 196,217,219-220,245, 247-250,

258

Department of Health and Human

Services

I: 33,45,67-68, 117

II: 25-26,232,245-247,413, 645

III: 173-177,214-216,220-223, 253,

256,258

accidental injuries

II: 138-139

consent and conildentiality

regulations

1: 60

drug abuse

II: 560-563

Healthy People 2000

I: 76,77-78, 80

II: 26, 203, 204-205, 218

hopelessness

II: 663,671,680,681

minority programs

III: 190, 192-196

nutrition and fitness

11: 194-195, 200, 201, 208,220

sexually transmitted diseases

including AIDS

II: 298-306

spending

I: 32

III: 225-244

see also specific constituent agencies

Department of Housing and Urban

Development

II: 564

Department of the Interior

III: 217,223

Department of Justice

I: 36, 104, 106

II: 508,589,611,612,617, 644,

671-672

III: 196,217,223,245,250, 251,253,

258

Department of Labor

I: 36

II: 87,324, 332,390,391,404,564

III: 178,217,223,245,251-252

Department of Transportation

I: 36-37

II: 129, 139

III: 217-218, 223,245,252-253

Depression, clinical

II: 176,434,436,465

III: 186

Dermatologists

II: 180

III: 19-20

Developmental Disabilities Act

III: 176

Developmental processes

I: 6-7,91, 118

II: 3, 16-23,3941,302,352,433, 499

III: 183

cognitive

I: 6-7,25, 27, 31,54,72-74, 118

II: 20-23,29,399

III: 123, 134-135, 138, 141-148,

150

dental and oral health

II: 231-232

disabilities

1: 7, 86

II: 215,585,608-609,614

III: 176, 186,229

discretionary time

II: 88,92, 96-97

diseases and

II: 88,92

drug abuse

II: 531

emancipated and mature minors

II: 297,673,678

III: 125, 126-127, 131, 136, 140,

149-150, 151

information and

I: 54

interventions and

I: 25, 27, 31, 72

minorities

Hl: 181

nutrition

H: 194-195, 198, 199, 206

puberty
II-738 Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

II: 16, 17-19,206,231-232,342

XII: 61

research

I: 72-74

II: 22

school transitions

I: 85,86

II: 66-67,71-72, 104,444,445

Diabetes

I: 21

II: 211,215

III: 91,235

Diagnosis

ADS

II: 293-295

drug and alcohol abuse

I: 108

II: 499,504,553-554,556-557, 566

HI: 17-19,63, 102

gender factors

m: 11

insurance

ill: 85-86

Medicaid

1: 55,56

III: 1,48,99, 100, 101-104, 116,

117, 174

mental health problems

I: 97, 108

II: 433,434,437,439,467

III: 16-17,31,63

physician skills

III: 15-22,23,29,63

sexual activity and related disorders

II: 258,271,342

III: 127-128

skin diseases

III: 19-20

Diet, see Nutrition

Diet and Health Knowledge Survey

II: 195

Dietary Guidelines for Americans

II: 200-201, 208

television

II: 90-91,208

Disabilities

III: 93-94, 168, 176, 186,229

see also Chronic physical diseases

and disorders; Handicapped

persons

Disadvantaged Minority Health

Improvement Act of 1990

III: 196,243

Discretionary time

I: 25,79,81-82, 83,85-87

II: 3,59-60, 88-103, 104

III: 61

see also Sports and recreation

Diseases and disorders, physical

acne

I: 11, 17, 108

II: 154, 179-181

III: 10,20,61,63

anemia

II: 20, 209,212,213

III: 185

developmental processes

II: 88,92

diabetes

I: 21

III: 91,235

homeless persons

II: 668-671,673-674

nutrition and tlrness

II: 195,200, 209-211

obesity

I: 21,91

II: 37,202,208,209-210,218-219

III: 185

respiratory diseases

I: 17,89

see also Accidents and injuries; Acute

diseases and disorders; Chronic

physical diseases and disorders;

Diagnosis; Drug abuse;

Handicapped persons; Mental

health and illness; Morbidity

and mortality; Screening;

Sexually transmitted diseases

District of Columbia

II: 186,464,624

III: 50, 82,97, 103, 105, 107, 111,

129, 189

Divorce

II: 35-36,444,531,605

Door, The

III: 36-41

Dropouts

I: 5,8-10,20,86

II: 61-63,86,285,391,393, 530,609

III: 55,61, 198

minorities

I: 8-9,20

II: 61-63,66

III: 185

poverty

II: 62, 391

III: 55, 168

Drowning

I: 88

II: 120-121, 123-124, 127, 128,530

Drug abuse

I: 2, 14, 16, 22,99, 101, 102

II: 308, 344, 346,447-448,451,462,

499-567

III: 19,214,230-231,233,237, 253,

254,287-288

age factors

II: 512-513,518-519,543, 547,

551,566

AIDs

II: 257,258, 271,272, 277,293,

296

athletes, steroids

II: 213

block grants

I: 60

II: 478-479,561,564,679

m: 153

clinical services

III: 35-39 (passirn)

community-based programs and

activities

II: 535,540,549-550,552, 561

consent and cordidentiality

I: 60,61

II: 566

III: 129-130, 131, 133, 135, 137,

138, 153

cost of

II: 533-534,552-553,556-557

counseling

II: 547-549,555,557-558, 566

III: 17-18,47

crime related to

II: 508,516-517,532, 534

deftitional issues

II: 499-504,507-508,509, 525,

527,533,534,558,566, 584

delinquency and corrections

II: 532,555,611,645

demography

II: 517-519,525

diagnosis

1: 108

II: 499,504,553-554,556-557, 566

III: 17-19,63, 102

educational interventions

II: 535,541-542,563,564

emergency services

II: 514-516,555-556

evaluation of services

II: 536-542,551-559,566, 567

family factors

II: 522-524,603-607,614, 620-

621,624,637-638,642

Federal effoxts

I: 104-105

II: 505-506,507-508,555, 558-

565,621-622,644-648

III: 193-194,229-232

funding

II: 552-553,558-565

gender factors

I: 15,20, 102

II: 509,510-511,514, 530,533,

597-598,618,628,639-640

health care professionals, role of

1: 101

II: 538,555-556,557-558

historical perspectives

II: 591-596,632-633,644

III: 19

homeless persons

II: 674-675,681

insurance
Index . II-739

I: 111

III: 83,88-89, 102, 108, 115, 117,

170

mass media

II: 534,535,536,540,541, 543

Medicaid

III: 102, 108

methodological issues, studies

I: 99

II: 520-522,524,551,566

minorities

II: 517,551,599,618,621, 648

III: 193, 194, 196,229

morbidity and mortality

I: 99, 101, 102

II: 505-520,529-530

outpatient care

n: 549

III: 108

parents

II: 522-524,525-526,541-542, 566

peers

II: 524-525,537-538

physician competence

III: 17-19, 22,23, 29

policy options

1: 99, 100, 102

poverty and

III: 169

prevalence

I: 99, 101, 102

II: 505-520,521

prevention

I: 100-101

II: 85,462,534-544,545-546, 560-

565

III: 173,254

professional education

I: 101

II: 538,555-556,557-558

III: 19

research

I: 102

II: 520-522,523, 558-559,561,

562,564-565,567

school influences

III: 47,54

II: 526, 530,535,536-541,544,

554-555,563

school-linked health centers

rrr: 44,47,54

sexual activity and

II: 530,531

social factors, general

II: 523,525,527,534,537-538,

539-540

socioeconomic factors

III: 169

II: 517-518

treatment

I: 101

II: 544-559,564-567

see also Alcohol abuse; Tobacco use

Drug Abuse Education and

Prevention Act

III: 229

Drug Abuse Resistance Education

Program

II: 538

Drug Abuse Warning Network

II: 507-508,514-515,555-556

Drug-Free Schools and Communities

Act

II: 563,564

Drugs, prescribed

acne

II: 180

AIDS and sexually transmitted

diseases

II: 296-297,309

birth control

II: 372,373, 376-377

HI: 44

mental health treatment

II: 465466

E

Early and Periodic Screening,

Diagnosis, and Treatment

program

I: 55,56

II: 247,478

HI: 1,44,48,99, 100, 101-104, 116,

117, 174

Eating disorders

II: 213-214,434

Economic factors

II: 13,24

hopelessness

II: 664

incentives, safety equipment use

n: 133-134

independent minors

III: 126

pregnancy and parenthood

II: 337-338,348,394

rural areas

III: 198

see also Cost factors; Financial

factors; Funding; Income;

Poverty; Socioeconomic status

Education and Human Services

Consortium

III: 57

Educational factors

I: 5

II: 63,244

III: 235

accident prevention

II: 132-134

AIDS

II: 272,275,279-280,286, 308,358

III: 235

delinquency, alternatives

II: 624

developmental disabilities

I: 7, 86

II: 215,584,585,608-609

drug abuse

II: 535,541-542,563, 564

families, sex and AIDS education

II: 279-280,308

Federal role

I: 36,65

LI: 78, 83-86,563, 564,619-620

III: 176, 196,217, 219-220,245,

247-250, 258

homeless persons

II: 669-671, 677, 678, 684-685

job training and aiding

II: 69,87, 173,389-394,401,415-

416, 622,684-685

III: 178, 217,225, 251-252,255

minorities

III: 187, 196

models

I: 26-27,71-72

pregnancy and parenthood

LI: 342,344, 349

research

I: 64

II: 401

sexual activity and sexually

transmitted diseases

I: 93-94,96-97

II: 272,275, 278-288,307-308,

357-372,395

III: 243

see also Counseling; Dropouts;

Preventive health and education

measures; Professional

education; School influences and

services; Universities and

colleges

Education for All Handicapped

Children Act

II: 183,454,456,457,471, 479-480

III: 262

Eisenstadt v. Baird

III: 128

Elderly persons

III: 172, 244

Medicare

I: 119, 120

III: 109-110

Elementary and Secondary

Education Act

II: 85, 86, 103

Emancipated and mature minors

II: 297,673,678

III: 125, 126-127, 131, 136, 140,

149-150, 151

Emergency services

II: 120, 121, 124, 136-137

consent and confidentiality

III: 126, 127, 131, 137
II-740. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

drug abuse and

II: 514-516,555-556

homeless persons

II: 668,678-687

telephone hot lines

II: 277,287,452,468

m: 51,54, 174

Employee Retirement and Income

Security Act

I: 57

III: 83

Employer mandates for health

insurance

m: 110, 113

Employment and Training

Administration

II: 390

III: 178,251,252

Employment and unemployment

agricultural workers

II: 237-238,414

III: 176, 177, 213,237

discretionary time

II: 89,96

drug abuse

II: 526-527

education and

II: 63

Federal programs

II: 87,390,391-393,415-416, 564

III: 29, 173, 178,217,251-252,

251-252,255

females

II: 36,88

health insurance benefits

I: 47,55,56-57,98-99, 111-112

II: 347-348

III: 80,83-94 (pi3SSilIl), 110, 112,

113, 117

job training and aiding

II: 69,87, 173,389-394,401,415-

416,624,684-685

III: 178,217, 225,251-252,255

minorities

I: 122-123

II: 63

III: 178-179, 181

poverty and

II: 87,98,389-394,401,415-416

III: 165, 169, 170, 178

pregnancy, panmthood, and

II: 389-390, 391-394,397,401,

415416

research

III: 252

school-linked health centers

m: 44,49

self-employed, and insurance

III: 80, 110, 113

workforce demography

1: 121-123

II: 14, 15,36

III: 165, 178-179

Empowerment approaches

I: 63,64-65,67,72, 82-83, 124

II: 39-41,99, 104, 172,366-367,395,

443444,445,566-567

HI: 36,58,59,60

youth panels

I: 128-129

III: 59,60

Environmental factors

II: 25-26,29,448

III: 3

delinquency

I: 106

hopelessness

I: 107

nutrition and fitness

I: 92

policy options

I: 44,45,76-83

regulations

I: 32,77-78

see also Access to services; Social

factors

Epidemiology, see Centers for Disease

Control; Morbidity and

mortality

Ethics

AIDS drugs, clinical trials

II: 296-297,309

of contldentiality

I: 59,62

III: 134-138, 140-141, 151-152

pregnancy prevention nsearch

II: 357,376

Ethnicity, see Cultural factors;

Minorities; specific groups

Evaluation issues

comprehensive service centers

I: 52-57,72, 109

III: 30,32,33,36,38,51,52-57, 64,

171

consent and confidentiality

I: 57,58

III: 123, 134-135, 138, 141-150,

151

correctional programs

I: 103-104

II: 632-644

III: 250

delinquency-related programs

II: 620-626

demonstration projects

I: 71

II: 252, 285

III: 33-34,52

drug abuse

II: 536-542,551-559,566, 567

integrated services

III: 57-58,66

local services

II: 286-288

III: 255

juvenile justice

I: 103-104

III: 250

mental health programs

II: 443-445,449-451,462-466, 486

methodology

I: 25, 120

minority-oriented services

III: 189, 191

professional education

I: 30-31,62,63

III: 28-29,33,57

school-linked health centers

II: 358

III: 51,52-57,64

schools

II: 81,85

sexual activity, interventions

I: 93-94,96-97

II: 277, 278,281-295,308,356-

357, 358=$08

ITI: 243

Exercise, see Physical fitness

F

Families

I: 8,78-80, 83,84-85

II: 3-6,35-52,88,208,347

III: 34,61, 125,230,282

adoption

II: 50,51, 326,338-339,351, 354,

355,398-399,471

III: 177,286

Aid to Families With Dependent

Children

1: 19,55

II: 323,348,350-351,401, 415-

416,617,664,679

III: 79,95-98, 100, 116, 152, 162,

173, 174, 175, 225,229,253-

255

chronic illness, costs to

II: 171, 178-179

counseling

III: 44

delinquency and corrections

II: 603-607,614,620-621, 624,

637-638,642

divorce

II: 35-36,444,531, 605

drug abuse

II: 522-524,603-607,614, 620-

621,624,637-638,642

Federal programs

III: 173

hopelessness

II: 663-665,666-671,688

insurance costs

III: 83

legal issues

I: 58-59,60
Index . II-741

n: 49

III: 123, 125, 131

legislation

I: 67

marriage

II: 334,346,347,603

III: 126, 198

mental health problems

II: 440.4’41, 448,473

minority

II: 45,49,279

III: 179, 187, 188, 190

policy options

I: 78-80,84-85

poverty

III: 159-161, 162, 169-170, 173-

174,243

research on

II: 37,51,52

sex and AIDS education

II: 279-280,308

siblings

II: 440,441,605, 615

single-parent

II: 35-36,38,323,331-332, 338,

348,353,402,666

III: 162, 173-174, 190

support by, general

I: 23,25

III: 159-160, 184, 188, 190

support for, general

I: 78-80, 106

ill: 190, 196

see also Child abuse and neglect;

Foster care; Parents and

parenting

Family Impact Seminar

II: 49,51

Family planning, see Contraception

and contraceptives; Pregnancy and

parenting

Family Support Act

II: 403,406,415

III: 173

Family Support Administration

I: 33

II: 401,416,417

III: 173-175, 192,214,220,225

Federal Bureau of Investigation

II: 508,617

Federal Emergency Management

Agency

II: 680

Federal Government

I: 1,32-44,65-76,83, 117-118, 124

III: 2-3,29, 171-178, 191-196, 199-

200,213-263

accidental injuries

II: 138-139

III: 233-235, 244-246,252-253

agency survey for OTA study

I: 130

AIDs

II: 258,280,298-306,309-311

budget deficit

I: 119-120

child abuse

I: 8

II: 43-45,47,49

chronic physical diseases

II: 141, 183-184

community-based comprehensive

service centers

1: 51-54

II: 414-415,561

comprehensive services

1: 51-54

KI: 475477

congressional committees

1: 40-44,67

II: 644

IU: 259-261

consent and confidentiality

III: 123, 128-129, 152-153

coordination of services

I: 40,65-68,76

II: 417,477,479480,688

III: 3,193, 194,250,252,253-256,

257-258

delinquency

1: 104-105

II: 621-622,644-648

dental and oral health

II: 242,245-249

drug abuse programs

I: 104-105

H: 505-506,507-508,555, 558-

565,621-622,644-648

education, general

I: 36,65

II: 78,83-86,563,564,621-622

III: 176, 196,217,219-220,245,

247-250

employment programs

KI: 87,390,391-393,415416, 564

III: 29,173,178,217,251-252, 255

evaluation issues

1: 65

III: 65-66

funding

1: 32,38-39,40,47,59,72, 87,

119-121

II: 78,83,86,97-98,102,103, 104,

141, 183-184,247,298, 303,

304-306,309-310,376-378,

408-417,478-480,483-484,

558-565,644,673,678-683,

687

III: 29,48,55,64,65,92-93, 117,

174-178, 193, 194, 196, 200,

224-253 (paSSiI@

health insurance

I: 47,54-55,56-57, 119

III: 114-115, 117

hopelessness

I: 106

II: 678-690

local governments, cooperation with

II: 60,87, 101-103,563,681-683,

685-687

III: 176, 192,232-233,235,243,

250,252,255,262

mental health

I: 99

II: 477-480,487-488

III: 190, 191-196,232-233,235,

241, 243

military service

II: 96

III: 126,255

minorities

III: 190, 191-196,241,243

national youth service

1: 78,82-83,87

II: 100, 101-103

III: 173,262

nutrition

II: 204-205,219-221

policy options related to executive

branch

I: 65-76, 117

poverty

III: 171-178

pregnancy and parenthood

II: 398,399,408418

preventive health measures, general

I: 32

III: 258

professional education

III: 29

research

I: 23,32, 32-37,66, 67,68, 72-74,

76, 81, 115, 117

n: 141

III: 250,262

rural areas

III: 199-200

schools

II: 78,83-86

sexually transmitted diseases

including MIX

II: 258,280,298-306,309-31 1

States, cooperation with

I: 47, 121

II: 242,280

III: 65, 110, 173, 176, 192,232-

233,235,236,250,252, 263

States, funding conditions

I: 47,52-53,60,61-62,65

II: 60-61,86,87, 101-103,310,

414,644,681-682

III: 65,250

statistical programs, general

I: 32,66,67,74-76

II: 152-153

III: 235, 262
II-742 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

see also Block grants; hgislation

(specific Federal); Medicaid;

Policy issues and options;

specific Federal agencies;

specijic health issues

Females

Aid to Families With Dependent

Chiidren

I: 19,55

II: 323,348,350-351,401, 415-

416,617,664, 679

III: 79,95-98, 100, 116, 152, 162,

173, 174, 175, 225, 229, 253,

255

AIDS education

II: 286

anemia

III: 185

birth control

II: 359,372,373,376-377,408, 410

In: 44

delinquency

II: 640

developmental processes

II: 17-18

chug abuse

II: 530

employment

II: 36,88

genital disorders

I: 11, 17

II: 42, 181-183,269,270-271

mental health problems

I: 11, 14

II: 213-214,446-447,448, 451,452

nutrition

I: 11,90-91

II: 195, 198, 199-200,208,211,

212-214,216,221

parenthood and pregnancy, general

II: 323,348,350-351,353, 359,

373,390,394,530

school transitions

I: 85,86

II: 72, 104,336-337,444,445

sexual activity

II: 324,342-344,352,353, 354-

355,359,373, 390,675-676

single parents

II: 35-36,38,323,331-332, 338,

348,353

Ilk 162, 173-174, 190

see also Abortion; Birth rates; Gender

differences; Menstruation;

Pregnancy and parenting

Financial factors

access to services

I: 46,47, 51,53, 54-57,59-60,83,

110-112, 113-117

III: 1,30,63,77-120, 188, 189,

198-199

child support, absent parents

II: 416

m: 173-174

community-based comprehensive

senfice centers

I: 49,50,52,53

III: 33,39

consent and confidentiality

III: 125, 135, 137, 138

mental health services

II: 478-479,483484

professional liability

I: 59

m: 130

school-linked health centers

I: 31,51

III: 45,47-50

see also Cost factors; Funding; Health

insurance; Staffiig

Firearms

1: 79,80-82, 88,89, 102, 103

II: 5, 124,447,448,451,611-614,

615,647

Fitness, see Physical fitness

Florida

II: 464

HI: 49,50,82,97, 103, 105, 107, 111

Fluoridation

1: 16,92

II: 241-242,246

III: 235

Food assistance

II: 416

HI: 178, 246,255

Football

II: 121, 124-125

Ford Foundation

II: 404

Foster care

I: 8, 19,85

II: 49-51,471,474,617,664, 666,685

III: 172

Foster Grandparent Program

II: 49-51

ID: 172

Foundations, see Nonprofit

organizations

4-H clubs

I: 87

II: 92

III: 200, 246

Free clinics

III: 34,37-41,60

Funding

1: 1

II: 97

III: 35, 175

abortion

II: 243

III: 92-93

comprehensive service centers

I: 50-52,53-54, 87

III: 30-31,33,35,38,39,47-48, 50

deftitional issues, and

I: 5, 119-120

drug abuse programs

II: 552-553,558-565

family pl arming clinics

II: 376-378

Federal

1: 32, 38-39,40,47, 59,72, 87,

119-121

II: 78,83,86,97-98,102, 103,104,

141, 183-184,247298,303,

304-306,309-310,376-378,

408-417,478-480,483484, “

558-565,644,673,678-683,

687

III: 29,48, W, 65,92-93, 117,

171-178, 193, 194, 196,200,

224-253 (paSSim), 258,263

Federal funding conditions for States

I: 47,52-53,60,61-62,65

II: 680

III: 65, 250

hopelessness

II: 673,678-683,685

local

II: 61,95,483,685

III: 47-48,52,54,55

matching

1: 52,54,81

mental health services

II: 478-480,483-484

pregnancy and parenthood programs

II: 376-378,408-417

recreational programs

I: 81-82

research

I: 23,32, 72-74,81

II: 141,298,303

school-linked health centers

III: 47-50

school services

I: 87

II: 78, 83, 85, 86

sports programs

I: 87

see also Block grants

G

h Re Gault

II: 643

Gay, lesbian, and bisexual

adolescents, issues affecting

II: 261,262, 271-272,277,279,285,

286, 309-310,665,676,689

Gender differences

accidental injuries

1: 17, 19, 88

II: 118-119, 122, 124, 125, 127,

129, 131, 132, 157-158

child abuse

II: 4546
Index ● //-743

clinic utilization

m: 35

chronic diseases

I: 17

II: 166

competency of minors

111: 146

delinquency

I: 15, 20, 102

II: 597-598,618, 628,639-640

drug abuse

I: 15, 20, 102

II: 509,510-511,514,530, 533,

597-598,618,628, 639-MO

hopelessness

II: 672-673,677-678

mental health

I: 11, 14

KI: 213-214,446-447,448, 451,

452,458

morbidity and mortality

I: 17, 19

II: 437

nutrition

1: 11,90-91

II: 195, 198, 199-200,202-203,

212-213,216, 221

school factors

H: 66

sexual activity and sexually

transmitted diseases

II: 268,269, 270, 271, 273-274,

306,326,640

suicides

I: 98

II: 446447,448,451,514

tobacco use

II: 511

utilization of services

H: 458

III: 9-10, 35,46, 146

see also Females; Males

General Accounting office

I: 54

II: 285,417,531, 667,685,687

Genetic factors

II: 183,215,234, 244,610

Genital disorders

I: 11, 17

menstrual distress

I: 11

II: 42, 181-183

pelvic infl amrnatory disease

II: 269,270-271

see also Sexually transmitted diseases

Geographic factors

I: 22

II: 36,88, 160, 166,418

m: 177

see a{so Regional trends; Rural areas;

Suburban areas; Urban areas;

specijic States

(jeorgia

II: 289,367

III: 82, 97, 103, 105, 107, 111

Girls Clubs of America, see Girls Inc.

Girls Inc.

H: 92-93

Gonorrhea

II: 265, 268-269, 306

Government role, see Federal

Govemment; State-level

programs and activities;

Taxation

Graduate Medical Education

National Ad\’isory Committee

H: 467

Griswold v. Connecticut

III: 128

Guns, see Firearms

H

Handicapped persons

I: 82-83

H: 131-132, 150, 167-173, 183-184,

214-215,239-240

III: 13, 258, 262

costs

I: 18, 19

II: 164-168, 169-171

educationally

I: 7,86

II: 215,585, 608,614

III: 176, 186, 229

insurance

III: 93-94

poverty

III: 168

Hawaii

III: 82,97, 103, 105, 107, 111, 191

Hawaiian Natives

II: 598

III: 186-187, 188, 191

Head Start program

I: 65

II: 621-622

III: 176

Health Care Financing

Administration

I: 33,56

II: 246,478

III: 174-175, 192,214,220,225,229,

289

see also Medicaid

Health care professionals

I: 24,62-63, 106-111

III: 147-148

attitudes of

I: 107, 108-109

II: 161, 177-178, 182-183, 190,

264,271377-378,410

KII: 7, 8, 12, 14-15,20-23,32-33,

51-52,62-63, 109

attitudes toward

I: 107

III: 7, 12-15, 17, 20-23,24,28-29,

30, 32-33,51-52,62-63, 109,

190

availability of

III: 23-26

in comprehensive service centers

I: 53

drug abuse

I: 101

II: 538,555-556,557-558

education of

1: 5,29,30-31,46,48,53, 57,

62-63,64,67, 108-109

II: 467,483,484-485

m: 190,202

ethics of confidentiality

I: 59,62

III: 134-138, 140-141, 151-152

Federal programs

HI: 29, 196

heahh educatom

III: 25

insurance, nonphysicians

III: 94, 115, 117

liability

I: 59

III: 130

Medicaid, nonphysicians and

III: 104

minority

III: 190, 196

nurses and nursing

m: 31, 35,55, 99, 104, 115, 117,

145, 240

nutritionists

III: 22-23

policy options

1: 62-63, 106-111

psychologists

III: 23-24

social workers

III: 23-24,25

student aid

III: 190, 195

training of

III: 26-29

see also Nurses and nursing;

Physicians; Professional

associations; Specialists;

Staffiig

Health insurance

m: 77-94, 115, 117, 170, 190

abortion

H: 174

III: 92-93

aJcohol abuse treatment

III: 88-89

chronic physical diseases

II: 176, 178-179

m: 93-94

consent and confidentiality
II-744 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

I: 60

III: 117, 136, 170

contraceptives

III: 93

cost

III: 83,84-85,87,88,93,94, 114

definition of adolescent health and

I: 5

demonstration project

III: 77-81, 100

dental and oral health

II: 245,248

m: 91,93

diagnostic services

III: 85-86

disabled persons

III: 93-94

drug abuse treatment

I: 111

III: 83,88-89, 115, 117

as employee benefit

I: 47,55, 56-57, 98-99, 111-112

II: 347-348

III: 80,83-94 (paSSim), 110, 112,

113, 117

families, costs

III: 83

Federal action

health maintenance organizations

1: 111

HI: 17,31,34,35-36,83,84, 85,

87-88,89,93,99

historical perspectives .

II: 188, 189, 190

III: 79,83-84

hopelessness

II: 674

Medicaid, relation to private insurers

III: 99, 110, 112-113

Medicare

I: 119, 120

III: 109-110

mental health services

1: 98-99, 111

II: 459,461,467,482483

III: 83, 86-88, 115, 117

minorities

III: 79-80

nonphysicians, payment for services

III: 94, 115, 117

physicians and

1: 111

III: 50,84,99, 104, 105, 108-110,

111, 116-117, 175

policy options

I: 47,54-57

III: 114-115, 117

p~gl’laXICy and

1: 29,97

II: 347-348,414

III: 84,90-93,98

preventive services

I: 111

III: 85-86

psychological and psychiatric

services

III: 86,87

regional trends

III: 80-81

regulation of

I: 47,54

III: 83,87,90-91,92,110,112, 115

school-linked health centers

III: 50

screening services

III: 85-86,88

socioeconomic factors

III: 77-81

underinsured/uninsured

I: 26,27,29,46, 110-111

II: 674

III: 46,52,77-81, 82,83,94, 110,

111-114, 169-170, 175

see alw Medicaid

Health maintenance organizations

I: 111

III: 17,31,34,35-36,83,84, 87-88,

89,93,99

Health Resources and Services

Administration

1: 34

II: 138-139,300,306,309, 562-563

III: 29, 176, 194-195,215,222,235-

237

Healthy People 2000

1: 76,77-78,80

II: 26,203,204-205,218

III: 241

Hemophilia

II: 261,277

Herpes

II: 265,269

High-Intensity Treatment and

Supervision program

II: 555

High School and Beyond Survey

II: 63-66,325-326

Highway Safety Act of 1970

II: 139

Hispanic Health and Nutrition

Examination Survey

III: 185, 188

Hispanics

III: 179, 180, 185, 191, 195,436,468

Arm

I: 21, 196

II: 286

III: 185, 195, 196,241,262

cultural factors

III: 188, 189, 190

delinquency

II: 599,618,621,648

dropouts

1: 8-9,20

II: 66

nutrition

II: 194,208

III: 185, 188

poverty

III: 162

pregnancy and pa.nmthood

I: 20-21

II: 351,354-356

school influences

III: 46

uninsured

III: 79

see also Minorities

Historical perspectives

II: 13-17,25,91, 100,327,328,

330-331,353,378,438

chronic physical conditions

II: 164

civil rights

III: 180

clinics

III: 35,37,39

delinquency

II: 591-596,632-633,644

drug abuse

II: 519-520,521,534

III: 19

families

II: 35

health insurance

III: 79,83-84

interagency coordination

III: 254-256,257-258

Medicaid

In: 79

minorities

m: 188,201

nutrition

II: 208-209

physicians

III: 62

professional associations

III: 25-26

rural areas

III: 198

school-linked health centers

III: 41

schools

II: 61

utilization of serviees

II: 459462

III: 182

WV

see AIDS and HIV infection

Hodgson v. Minnesota

III: 132-133

Hopelessness

I: 16-17,26,27,29,85, 105-106, 107

II: 51,85,263,280,663-690

III: 61, 167, 174, 176, 192, 193,213,

229, 237,249,254,287
Index ● //-745

alcohol abuse

II: 665-666,675,678,681

diseases

II: 668-671,673-674

drug abuse

II: 674-675,681

education of

11:669-671,677,678,684-685

Federal efforts

I 106

gender differences

11:672-673,677-678

methodological issues

I 107

11:663,666-667

policy options

1105-106,107

refugees

m:192

as risk factor

I: 16, 105-106

11:667-671,688

State-level trends

11:664,681-682

statistical programs

I: 107

11:663,666-667,671-673

seea[so Runaways

Homicide

1:2,8,19,20,81,104

11:48,117,586,592,612-614, 616,

619,647

111:59,184,284

Homosexuals, see Gay, lesbian, and

bisexual adolescents, issues

affecting

Hospitals and hospitalimtion

II: 617,681

III: 11-12, 199

access to services

III: 32,34

accidental injuries

II: 120, 121, 124, 127

chronic physical conditions

II: 151, 152, 153-154, 155, 169

clinics

I: 109

III: 17,31, 32-34,35-36

drug abuse

II: 550

III: 108

mental health

1: 62

II: 452-453,459-461,462463, 469,

486

III: 34, 86-87, 106-108, 130, 134,

145

minorities

m: 11-12

physician screening of hospitalized

adolescents

m: 20

utilization, general

HI: 11-12,32,34,87

see also Commitment (involuntmy)

Household Survey on Drug Abuse, see

NIDA Household Survey on

Drug Abuse

I

Idaho

Ut: 82,97, 103, 105, 107, 111, 127

I Have a Dream Project

II: 80-81

Illinois

II: 476477

III: 49,82,97, 103, 105, 107, 111

Immigration and immigrants

III: 181, 182, 186, 192

Immigration Reform and Control Act

III: 192

Immunizations, see Vaccines

Improving Social Awareness/Social

Problem-Solving Project

II: 443,445

Income

I: 5, 119, 160

11: 348

III: 78, 162, 167-169

see also Poverty; Socioeconomic

status

Indian Education Act

III: 249

Indian Health Service

I: 27,3 4

II: 237,562

III: 193, 195,215, 222, 237

Indiana

III: 82,97, 103, 105, 107, 111

Indians, see American Indians; Alaska

Natives

Individual benefits management

III: 94

Individual differences

II: 26,79,345-347,525-526

m: 147

delinquency factors

II: 607-614

emancipated and mature minors

II: 297,673,678

III: 125, 126-127, 131, 136, 140,

149-150, 151

intelligence

I: 103

II: 68-69,70,342,609,616, 621

III: 125, 128, 140, 147

mental illness

II: 439-440,44648

nutrition

II: 195

resilient children

III: 166-167

sexual activity

II: 340-341

Infants and children of adolescents

II: 339,399,401-417 (passim)

III: 44

Injuries, see Accidents and injuries

The Injury Fact Book

II: 128

Inpatient care, see Hospitals and

hospitalization; Residential

treatment programs

Institute of Medicine

II: 373,465,469,477,488, 546, 558

III: 30,255

Insurance, see Health insurance;

Medicaid; Medictue

Intelligence

I: 103

II: 68-69,70,342,609,616, 621

HI: 125, 128, 140, 147

Interdisciplinary approach, see

Multidisciplinaq approach

International Center for Integrative

Studies

m: 41

Iowa

III: 49,82,97, 103, 105, 107, 111

J

Job Corps

II: 390,391,416,564

III: 252

JOBS program

II: 415416

III: 173

Job training and aiding

II: 69,87, 173,389-394,401,415-

416,624,684-685

III: 178,217,225,251-252, 255

Job Training Partnership Act

II: 87,416

III: 178, 217,251-252

Juvenile courts

I: 103-104

II: 470-471,555,585,626-628, 636-

637,648

III: 125, 126, 171, 183, 196,250,253

Juvenile delinquency, see Correctional

programs; Delinquency;

Probation

Juvenile Justice and Delinquency

Prevention Act

II: 633,644,672,682

III: 250,253

K

Kaiser Permanence

III: 35-36

Kaleidoscope Program

II: 476477

Kansas

III: 82,97, 103, 105, 107, 111, 124

Kentucky
II-746 . Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

III: 49,82,97, 103, 105, 107, 111

L

Labeling

II: 217

Language issues

II: 76, 104

III: 189, 192

Legal issues

abortion

II: 338

access to semices

I: 46,47,57-62,63,83, 111

II: 296-297,309

III: 134-135, 136, 138, 151, 152

AIDs drugs, clinical trials

II: 296-297,309

child support, absent parents

II: 416

III: 173-174

commitment of minors

I: 58,60-61,62,99

II: 458459,471, 567

III: 130, 140, 144

consent and contldentiality

I: 47,57, 58,60-62,99, 112-113

II: 377-378,398,410,411, 458-

459,471,566,567

III: 123-135, 138, 139-140, 150,

151-152, 153

of delinquents

II: 633,645

families

I: 58-59,60

II: 49

III: 123, 125, 131

financial liability

I: 59

III: 124, 125, 130

powerlessness of adolescents

1: 4

II: 27

see also Consent and cofildentiality;

Correctional programs; Crimes

and Criminals; Delinquency;

Juvenile courts; Litigation

Legislation

access to services (model State

statute)

ItI: 47,59-60

comprehensive service centers

1: 52-54

consent and parental notification

I: 47,57,58,60-62,99, 112-113

III: 123-135, 138, 150, 152

contraceptives

II: 378

drug abuse

II: 528,543

families

I: 67

firearms

II: 451,612

health insurance

III: 83

safety equipment, vehicles

I: 89

II: 130-131, 134-136

Legislation (specific Federal)

Adoption Assistance and Child

Welfare Act

II: 50,51

Anti-Drug Abuse Acts

II: 559-560,687-688

III: 231-232

Budget Enforcement Act

I: 119, 120

Child Abuse Prevention and

Treatment Act

III: 176

Chinese Exclusion Act

III: 180

Civil Rights Act of 1964

m: 90

Community Mental Health Centers

Act

II: 477

Comprehensive Planning for

Mentally Ill Individuals Act

II: 454

Controlled Substances Act

II: 560

Cranston-Gonzales National

Affordable Housing Act

II: 665,681-682

Developmental Disabilities Act

III: 176

Disadvantaged Minority Health

Improvement Act

III: 196,243

Drug Abuse Education and

Prevention Act

III: 229

Drug-Free Schools and Communities

Act

II: 563,564

Education for All Handicapped

Children Act

II: 183,454,456,457,471,479-480

III: 262

Elementary and Secondary Education

Act

II: 85,86, 103

Employee Retirement and Income

Security Act

I: 57

HI: 83

Family Support Act of 1988

II: 403,406,415

m: 173

Highway Safety Act of 1970

rI: 139

Immigration Reform and Control Act

of 1986

III: 192

Indian Education Act of 1988

III: 249

Job Training Partnership Act of 1982

II: 87

III: 178, 217,251-252,416

Juvenile Justice and Delinquency

Prevention Act

II: 633,644,672,682,687

III: 250,253

Missing Children’s Assistance Act of

1984

II: 687

National and Community Service Act

of 1990

1: 78,82-83, 87

II: 101-103

III: 173,262

National Apprenticeship Act of 1937

II: 87

III: 252

National Consumer Health

Information and Health

Promotion Act of 1976

III: 241

Native Hawaiian Health Care Act

III: 191

Omnibus Budget Reconciliation Acts

I: 55, 119

II: 400,411,413,478

III: 79,98,99-100, 101, 103, 110,

115, 116, 117, 175

Omnibus Crime Control and Safe

Streets Acts

II: 644

Pregnancy Discrirnination Act of 1978

I: 97

II: 347,399-400

III: 90-91,82, 115, 117

Public Health Service Act

1: 60

II: 285, 305, 345, 398, 399,408-

413,671

III: 43,50,99, 132, 153, 177,

243-244

Runaway and Homeless Youth Act

II: 671,682-683,685,688

III: 176,229,254

Runaway Youth Act

HI: 37

Ryan White Comprehensive AIDS

Resources Emergency Act of

1990

II: 306

School Dropout Demonstration

Assistance Act

II: 86

Secondary Schools Basic Skills

Demonstration Assistance Act

II: 86

Social Security Act

I: 60
Index ● II-747

II: 138,399,400,414415

III: 100, 153, 173-177, 194,229,

235

State Comprehensive Mental Health

Services Plan Act

I: 99

II: 479

Stewart B. McKinney Homeless

Assistance Act

II: 671,679-681

III: 249,262

Uniform Minimum Drinking Age Act

II: 543

Young Americans Act of 1990

1: 65, 67

Leisure time, see Discretiormy time;

Sports and recreation

Libraries

II: 96

Licenses and permits

I: 81

IL 134-135,557, 566

Life Planning Project

II: 390

Life Skills Training program

II: 444,445,539-540

Litigation

consent and confidentiality

I: 57,60, 61, 112

II: 398

III: 123, 125-133 (PaSSiIll), 139-

140, 149-151

mental health services

II: 471

pregnancy counseling

II: 411

torts

III: 124, 125, 139

see also Juvenile courts; Supreme

Court; specific cases

Local programs and activities

chronic physical conditions

II: 173

coordination

HI: 57-59, 250

delinquency

II: 286-288

III: 255

dental

II: 245

evaluation

II: 286-288

III: 255

family support

II: 50

Federal cooperation with

II: 60, 87, 101-103,563,681-683,

685-687

III: 176, 192, 232-233, 235, 243,

250, 252,255, 262

funding by

II: 61,95,483, 685

III: 47-48,52, 54,55

homeless persons

II: 681-682

matching finds

I: 52,54

mental health

II: 483

sex and AIDS programs

II: 280,286-288,295, 358

statistical programs

1: 74-76

see ako Community-based programs

and activities; School

influences and services; specific

States

Longitudinal studies, methodology

I: 23, 25

II: 70,71, 337-338,524,585,589-

590,60 6

III: 169, 171,254

Long-term care

III: 93-94

Louisiana

HI: 82,97, 103, 105, 107, 111

M

Maine

UI; 82, 97, 103, 105, 107, 111

Males

II: 325,326, 351

accidental injuries

1: 17, 19, 88

AIDs

LI: 258, 261, 262, 263

delinquency

II: 589,603, 613-614,615,618,

677-678

developmental processes

H: 18

fathers, adolescent

II: 332,333,341,347,405-406, 416

homeless

II: 664,677-678

mental health problems

I: 11, 14

II: 447,448,451

minority

I: 15,20

H: 332,333, 341,347, 351,352,

589,603,613-614,615, 618

III: 196,243

nutrition

H: 213

school-linked health centers

III: 46, 56

sexual activity and outcomes

1: 93-94,96-97

II: 332,351,352,377,388-389, 418

III: 243, 325, 332

see also Gender differences

Marriage

II: 334,346, 347,531,605

III: 126, 198

divorce

II: 35-36,444,531,605

Maryland

II: 289, 337-338,339,445

III: 29,53,82,97, 103, 105, 107, 111

Massachusetts

II: 136-137,242-243,277, 290,638,

668-669,670,676,684-685

III: 27, 82,97, 103, 105, 107, 111

Mass media

II: 90-91, 277,287-288, 326, 368

III: 51, 56, 148

drug abuse prevention

n: 534,535, 536,540,541,543

television

II: 90-91,208,287-288, 345,368

Medicaid

I: 5, 19,27,40,47,54, 55-57

III: 48,79,81,94-110, 111, 112-113,

115-117, 174-175,229

abofiion

II: 414

III: 174

age factors

III: 95, 289

consent and confidentiality

III: 152, 153, 175

correctional facilities

1: 104

II: 640

cost factors

I: 56

II: 323

III: 4,95,96, 116

demonstration programs

HI: 99, 100

dental and oral health care

II: 242,247,248

drug abuse treatment

III: 102, 108

eligibility

I: 56, 104, 111-112, 116-117

II: 642,669

Ill 65,94,95-100, 105, 107, 108,

116-117, 170, 175, 229

enrollment and expenditures

III: 4,95,96, 116, 175,289

family pl arming services

III: 93,96

medically needy programs

HI: 96-97

mental health services

II: 467,478,482

HI: 106, 108

nonphysicians, payment for services

III: 104

outpatient services

III: 106, 107, 108

outreach services

1: 56-57

pediatricians
II-748 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

m: 99, 109, 115

physicians’ participation

I: 111, 119

III: 50,99,104, 105, 108-110, 111,

115, 116-117, 175

policy options

I: 47,54-56

pregnancy and parenthood se~ices

II: 400,413414

preventive services

I: 55

private health insurance, relation to

III: 99, 110, 112-113

regional differences

III: 98, 108, 116-117

school-linked health centers

III: 46,48,50,52

screening

1: 55,56

III: 1,48,99, 100, 101-104, 116,

117, 174

specialists

m: 111

State-level issues

I: 52,56-57,60

III: 94-117 (passim), 152,170,174,

175, 199,229

utilization of services

III: 4,95,96, 116, 175, 289

see also Early and Periodic Screening,

Diagnosis, and Treatment

program

Medical services and treatments

accidental h~es

II: 119-120, 121, 124, 127, 136-

137, 141

adequacy of for adolescents

m: 61-64

chronic physical conditions

II: 151, 152, 153-154, 155, 169-

173, 175, 176, 177-179, 180-

182

consent and confidentiality

III: 123-153

correctional facility inmates

II: 633,639-642,645

definition of adolescent health and

I: 4

school-linked health centers

m: 43,44

vaccines

l.11: 145, 188,235,240

see also Diagnosis; Emergency

services; Health care

professionals; Hospitals and

hospitalization; Outpatient cam;

Screening

Medicare

1: 119, 120

III: 109-110

Menstruation

I: 11

11: 42, 181-183, 195, 213

Mental health and illness

I: 4, 11, 14, 18,97-99, 100

II: 99, 159, 171-173, 336-337,338-

339,433-488,526,551, 556

III: 61,254,255,286

access to services

I: 98-99, 100, 111

II: 466-469,482

block grants

I: 60

II: 478-479,561,564,679

III: 153

commitment of minors

I: 58,60-61,62,99

II: 458-459,471,567

m: 130, 140, 144

community-based efforts

II: 450-451,470,483,486, 549,552

consent and confidentiality

I: 57,58,62,99

III: 130, 131, 133-134, 140, 144,

145-146, 147, 153

coordination

II: 453-454,469-472,477, 479480

cost factors

II: 461,474,477

deftitional issues

II: 454,455,464,549

delinquency

LI: 583,629-630,639-640

demonstration projects

II: 472-477,482

depression

II: 176,434,436,465

m: 186

diagnosis

I: 97, 108

II: 433,434,437,439,467

III: 16-17,31,63

drugs for treatment

II: 465-$66

eating disordem

II: 213-214,434

evaluation

II: 443-445,449451,462-466, 486

families

II: 440-441,448,473

Federal programs

1: 99

II: 477-480,487488

III: 153, 190, 191-196,232-233,

235, 241,243

financial factons

II: 478-479,483484

funding

II: 478-480,483484

gender factors

1: 11, 14

II: 213-214,446447,448,451,

452,458

homeless persons

IX: 668-669,674

hospital-based services

I: 62

II: 452-453,459-461,462-463,469,

486

III: 34,86-87, 106-108, 130, 134,

145

identity development

II: 20,21

insurance

I: 98-99, 111

II: 459,461,467,482-483

III: 83, 86-88, 115, 117, 170

Medicaid

II: 467,478,482

III: 106, 108

minorities

II: 436,447,458,461-462, 467,

468,482483

III: 183, 185, 186, 188, 193-194

morbidity data

1: 97, 100

II: 433-441,446-448,486

multiple problems

I: 22-23,25,26,29

III: 61

nutrition and eating disorders

II: 213-214,215-216,221

outpatient care

I: 62

II: 460-461,464-465,482

III: 87, 106-108, 134, 145

policy options

I: 97-99, 100

preventive measures

II: 448-477,481-482

research

I: 99, 100

II: 480,482,485486

rural areas

III: 198

school-linked health centers

II: 443-444,449-450,453, 471+72

III: 44,46-47

school transitions

I: 85,86

II: 66-67,71-72, 104,444,445

social factors

II: 441,442,448,474-475

State-level programs

II: 471,479

statistical activities

I: 100

II: 438,454-456,482

stress and injury

II: 131, 167-168

utilization of services

1: 98-99

II: 454462

III: 87

see also Alcohol abuse; Counseling;

Drug abuse; Psychological and
Index ● II-749

psychiatric services; Suicide

Mentor influence

II: 389,390-391

III: 173, 191

Method of OTA’s study

I: 6, 127-141

Methodological issues

child abuse

II: 45,606

confidentiality studies

I: 108

delinquency treatment studies

II: 635-636

drug abuse studies

I: 99

II: 520-522,524, 551,566

evaluation, general

1: 25, 120

hopelessness

I: 107

II: 663,666-667

longitudinal studies

I: 23,25

II: 70,71,337-338,524,585, 589-

590,606

III: 169, 171, 254

Medicaid enrollment and

expenditures

III: 4,95, 289

nutrition and fitness

1: 90

pregnancy prevention research

II: 357,365

prevention program design

I: 23-25, 120

II: 445446

suicide studies

II: 439

see also Definitional issues

Michigan

II: 96,238

III: 49,82,97,103,105,107, 111,191

Migrant and seasonal workers

II: 237-238,414

III: 176, 177,213,237

Military service

II: 96,262,263

III: 126,255

Minnesota

1: 14

II: 47, 161, 238, 132-133,272,285,

386,437,439,505,507

III: 41,51,82,97, 103, 105,107, 111,

133, 181, 198, 199

Minorities

I: 1,2, 10, 19-20,29,91, 115, 116

III: 1-2, 178-196, 199,201,241,243,

328-329

abortion

III: 185

II: 353-354

access to services

I: 27

II: 467,468

III: 187-196

accidental injuries

1: 88

II: 123, 124, 127-129

III: 183, 184, 186

AIDS

1: 21, 196

II: 262,263, 268,271, 272,279,

280,286,304,309

III: 183, 185, 195, 196,241

attitudes

III: 181, 191,262

child abuse

II: 45

chronic physical diseases

I: 90

II: 166

III: 186

competency of minors

III: 147

cultural factors

II: 67,99,599

III: 179-181, 182, 183, 184, 186-

192 (passim), 194, 196,201,

202,250

delinquency and corrections

I: 15,20, 102, 103

II: 598-600,601,613-614, 618,

619,628,630-631,632, 646,

648

III: 171, 183, 184-185, 187, 196,

250

dental and oral health

II: 232,235,236-239,244-245,

247-248

developmental processes

III: 181

discretionary time

II: 93

dropouts

I: 8-9,20

II: 61-63,66

III: 185

drug and alcohol abuse

II: 520-522,524,551,566

III: 183, 185, 186, 193, 194, 196,

229

education

III: 187, 196

employment

I: 122-123

II: 63

III: 178-179, 181

evaluation of services

III: 189, 191

families

II: 45,49, 279

III: 179, 187, 188, 190

Federal programs

III: 190, 191-196,241,243

health problems, general

I: 19-21

III: 183-187

historical perspectives

m: 188,201

hospitalization

III: 11-12

insurance, uninsured

III: 79-80

males

I: 15,20

II: 332,333, 341,347, 351,352,

589,603,613-614,615, 618

KII: 196, 243

mental health and illness

II: 436,447,458,461462,467,

468,482483

Ill: 183, 185, 186, 188, 193-194

policy options

1: 117

poverty

1: 21,27, 102, 116, 117, 123

III: 161, 162, 164, 165, 179, 188,

191

pregnancy and parenthood

I: 20-21

II: 332-335,342,349,351-356,

378,676

III: 183, 185, 186187

prejudice toward

III: 181, 183, 184, 190

preventive health interventions

III: 188,254

professionals

III: 190

regional trends

III: 184, 199

risk factors, general

III: 179, 182-187

school influences and programs

I: 86,87

II: 67,69,70,78,82, 103-104

III: 46, 196

sexual activity and sexually

transmitted diseases

II: 263,268,271,272, 279,280,

286,304,309, 351,352-356

III: 183, 185

urban uas

III: 182, 184, 185

utilization of servicxx

II: 378

III: 10-12,46, 179, 182-183, 188

workforce

I: 122-123

III: 178-179

see also Cultural factors; specific

groups

Miranda rights

ill: 146

Missing Children’s Assistance Act of

1984
11-750. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

II: 687

Mississippi

III: 82,97, 103, 105, 107, 111, 127

Missouri

n: 391

III: 82,97, 103, 105, 107, 111

Models

community comprehensive service

centers

I: 53

II: 79-83,475-477

III: 35-41, 56-57

delinquency

I: 103

educational

I: 26-27,71-72

health insurance

III: 117

integrated service delive~

III: 57,58

legislation

I: 47,59

parenting

I: 83, 85

II: 50-51

school-hked health centers

III: 41-57

see also Demonstration pro~cts; Role

models

Monitoring the Future/High School

Seniors Survey

II: 505,506,509-510,517, 519,520,

590

Montana

III: 82,97, 103, 105, 107, 111

Morbidity and mortality

I: 2,4, 7-8, 9-23, 75

IX: 25, 26,48

III: 4,57, 282-288

accidental injuries

I: 88,90

II: 117-132, 139-140

blacks

I: 19-20

III: 183-185

chronic physical diseases and

disorders

I: 10-11, 17,89-90,91

II: 150-161, 163-168, 174-175

dental diseases

I: 91-92

II: 231, 232, 235-240

drug abuse

I: 99, 101, 102

II: 505-520,529-530

gender differences

I: 17, 19

II: 437

mental health problems

1: 97, 100

n: 433441,446-448,486

minorities

III: 183-187

nutrition and fimess

I: 90-91,92

II: 202-203,205,208,210-211,

214,215

rural adolescents

III: 197-198

sexual activity outcomes

I: 93,94

II: 257-271,326-337

see also Accidents and injuries;

Homicide; Suicide

Motor vehicles

accidental injuries

I: 2, 14, 16,76, 88,89

II: 118, 120, 121-123, 126, 127-

128, 129-131, 133, 139,529-

530,58 5

III: 183, 186, 197,217-218,235,

244,245,246,252-253, 26 2

driver education

II: 133

intoxicated drivers

I: 14, 16,88

II: 122, 129-130,516,529-530

III: 18, 137

Multidisciplinary approach

I: 72,73

LI: 470

III: 57-59

clinical services

II: 297

III: 31,35,36,3741,57

professional education

I: 62

III: 29, 57,64

see also Comprehensive health care

N

Narcotics Anonymous

II: 548-549

National Academy of Sciences

II: 196-199,200,201,202, 203,208,

210,340,342,343,344, 345,

357,395, 396,397,405,411

III: 250

National Adolescent Student Health

Survey

I: 63,80, 88,98

II: 124, 127, 130, 216,217,221, 272,

275,280,289,294,437, 505,

506,510

III: 254

National Ambulatory Medical Care

Survey

II: 119-120, 152, 154, 179-180,454,

456,673

III: 8-11, 13, 182

National and Community Service Act

of 1990

I: 78,82-83,87

II: 101-103

III: 173, 262

National Apprenticeship Act of 1937

II: 87

ill: 252

National Association of Addiction

Treatment Personnel

II: 556-557

National Association of Alcoholism

and Drug Abuse Counselors

II: 557

II: 294

National Association of State Boards

of Education

I: 27

National Cancer Institute

II: 179,221

National Center for Health Statistics

II: 117-118, 120, 185,221,324,325,

354,438

III: 8, 165, 182, 236

National Center on Child Abuse and

Neglect

I: 8

II: 43-45,47,49

National Children and Youth Fitness

Studies

II: 206,208

National Coalition for the Homeless

II: 670

National Commission on the Role of

the School and Community in

Improving Adolescent Health

I: 27,71-72

National Commission To Prevent

Infant Mortality

II: 407,417

National Conference of Catholic

Bishops

I: 53

III: 51

National Consumer Health

Information and Health

Promotion Act

III: 241

National Crime Survey

II: 589,590,594

National Drug and Alcoholism

Treatment Unit Survey

II: 546-547,550,553,566

National Electronic Injury

Surveillance System

II: 121

National Evaluation of School

Nutrition Programs

II: 195

National llealth and Nutrition

Examination Survey

II: 153, 159, 161, 162-163, 181, 194,

221, 239,258

III: 165, 184

National Health Interview Study

I: 17, 19, 152-153
Index ● II-751

H: 42, 118-119, 149, 150, 156-159,

164, 194, 221, 280,436,454-

455,456,457

111: 8-12, 165, 167-168, 197,235,254

National Health Policy Forum

rI: 50,415

National Ileart, Lung, and Blood

Institute

n: 221

National Highway Traffic Safety

Administration

II: 117-118, 135, 139

III: 252-253

National Hospital Discharge Survey

II: 151, 152, 153-154

National Institute for Child Health

and Human Development

II: 139,301,302

National Institute of Dental Research

II: 232,235-239,247,248

National Institute of Justice

KII: 250,253

National Institute of Mental Health

II: 303,440,454,455-456, 457-462,

477,480,488, 526

III: 193-194, 232-233

National Institute on Alcoholism and

Alcohol Abuse

II: 559,560,561-562,564, 681

National Institute on Child Health

and Human Development

1: 32, 121

LII: 240

National Institute on Drug Abuse

II: 503,505-506,507-508, 510,513,

514-515,517-520,555, 558-

559, 561,562, 564,681

III: 230-232

National Institutes of Health

I: 34

II: 221,243,300-301,304, 305

III: 200, 215-216,222-223,237-241

National Invitational Conference on

Health Futures of Adolescents

II: 28

National Longitudinal Survey of Labor

Market Experience

II: 324, 332, 334, 348, 349

National Longitudinal Survey of Young

Adults

n: 530

National Medical Care Utilization and

Expenditure Survey

II: 131, 169, 170-171

National Mental Health Association

KI: 456,470

National Plan for Research on Child

and Adolescent Mental

Disorders

I: 99

National PRIDE Survey

II: 505,506,511,519

National Research Council

II: 135, 373

National School Safety Center

11: 124

National Science Foundation

I: 36

III: 216

National Statistical Survey of

Runaway Youth

II: 671

National Survey of Adolescent Males

II: 325,326,351

National Survey of Children

n: 339

National Survey of Family Growth

II: 324,326, 327,350, 352,354,373

National youth service

I: 78,82-83,87

II: 100, 101-103

III: 173, 262

National Youth Survey

II: 589-590,594,595,598, 599,611,

646

Nationwide Food Consumption

Survey

II: 195

Native Americans, see Alaska Natives;

American Indians; Hawaiian

Natives

Native Hawaiian Health Care Act

m: 191

Native Hawaiians

III: 186-187, 188, 191

Nebraska

Ill: 82,97, 103, 105, 107, 111, 124

Nevada

III: 82, 97, 103, 105, 107, 111, 127

New Chance

II: 405

New Hampshire

III: 82,97, 103, 105, 107, 111, 127

New Jersey

I: 51-52

II: 677,687

III: 43,49,82,97, 103, 105, 107, 111

New Mexico

III: 82,97, 103, 105, 107, 111

New York

I: 52

II: 297,539,640,666,670, 676,677

III: 34-35,39-41,43,49,82, 97, 103,

105, 107, 111, 191

NIDA Household Survey on Drug

Abuse

11: 505-506,510,513, 517-520

Nonprofit organizations

I: 26,71-72, 120-121

11: 678

III: 65, 252,256

Ford Foundation

rI: 404

involvement in study

I: 127

National Science Foundation

I: 36

III: 216

Pew Memorial Trust

II: 676

Robert Wood Johnson Foundation

II: 472,477, 673,676

III: 33,41,42,46,47,56, 170-171

school-linked health centers funding

m: 47

NORPLANT

II: 376

North Carolina

II: 124,471

III: 82,97, 103, 105, 107, 111

North Dakota

IKI: 82,97, 103, 105, 107, 111

Nurses and nursing

rI: 370

m: 31,35,55,99,104, 115, 117, 145,

240

Nutrition

I: 11,90-91, 92

II: 193-206,207,208-214, 243-244,

639, 673,679-680

III: 47, 61, 176, 178, 185-186, 188,

193,225,235,246,254, 255,

284,668

age factors

II: 198, 199, 216

chronic diseases, and fimess and

II: 195,200,202,210-211, 215,221

definitional issues

II: 193,202, 208

developmental processes

II: 194-195, 198, 199, 206

eating disorders

11: 213-214,434

females

I: 11,90-91

II: 195, 198, 199-200,208,211,

212-214,216,221

food assistance

H: 416

III: 178,246,255

policy options,

I: 90-92

professionals

III: 22-23

0

obesity

1; 21,91

II: 37, 202, 208, 209-210, 218-219

III: 185

Oftice for Substance Abuse

Prevention

II: 25-26,503,522, 561

Ilk 229

Office for Treatment Improvement

II: 561
II-752 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

III: 229

Oftlce of Child Support Enforcement

III: 173-174

Office of Community Services

III: 174

Office of Disease Prevention and

Health Promotion

III: 241,253,563

Office of Family Assistance

II: 401

III: 173

Office of Human Development

Services

I: 33

II: 417,560-561,562

III: 175-177, 192-193,220,229

Office of Juvenile Justice and

Delinquency Prevention

II: 644-645,648

Office of Minority Health

II: 280,301,304

III: 185-196,241,243

OffIce of National Drug Control

Policy

II: 559,560,561,564

Office of Population Affairs

.II: 301, 305,411

III: 177,243-244

Office of Refugee Resettlement

III: 192

Ohio

III: 29,37-38,82,97, 103, 105, 107,

111

Ohio v. Akron Center for

Reproductive Health

III: 133

Oklahoma

11: 284

III: 82,97, 103, 105, 107, 111

Omnibus Budget Reconciliation Acts

I: 55, 119

II: 400,411,413,478

III: 79,98,99-100,101,103, 110,115,

116, 117, 175

omnibus Crime Control and Safe

Streets Act

II: w

Options, legislative, see Policy issues

and options

Oregon

II: 50,538

HI: 49,82,97, 103, 105, 107, 111,

124, 129

(osteoporosis

II: 211

Outpatient care

drug abuse

II: 549

III: 108

Medicaid

III: 106, 107, 108

mental health

I: 62

II: 460-461,464465,482

III: 87, 106-108, 134, 145

see also School-linked health centers

outreach services

1: 31,56-57

II: 378,684

III: 39,54,56

P

Parental notification, see Consent and

confidentiality

Parents and parenting by adolescents

I: 11, 13, 19, 80,94-97,98

II: 323-326,331-335, 337-340,397-

408

III: 39,254,255,285,286

block grants for health services

affecting

I: 60

II: 400,414,415,679

III: 153, 177, 194,235-236

comprehensive services

II: 403,408,414

employment

II: 389-390,391-394,397, 401,

415-416

fathers

II: 332,333, 341, 347

see also Pregnancy and parenting

Parents and parenting of adolescents

I: 1,46,49,78-80, 83,84-85, 106

II: 35-52,287,358,368,372, 437,

440-441

III: 124-138, 147-148,230,254

Aid to Families With Dependent

Children

I: 19

II: 323, 344-345,347, 348,350-

351,401,415416,617,664,

679

III: 79,95-98, 100, 116, 152, 162,

173, 174, 175,225,229,253-

255

alcohol abuse

II: 522-523

attitudes

II: 67,77-78, 162-163, 182-183,

347

III: 50-51,55

child support payments, absent

parents

m: 173

conflicts

I: 26,46,58,59, 85

III: 173,250

consent and confidentiality

III: 129

delinquency

II: 604-607,614,620-621

drug abuse

II: 522-524,525-526,541-542, 566

models

I: 83,85

II: 40,46-47,50-51,524

III: 125

negative, general

II: 41-51,88,522-524,604-607

policy options

1: 78-80,84-85

positive, general

1: 25,4546,64

II: 3741

punishment

II: 71,604,605

research

1: 84-85

II: 522-523

school involvement

1: 87

II: 77-78,85-86, 104

III: 50-51,55,56

single-parent families

II: 35-36,38,323,331-332, 338,

348,353,402,666

III: 162, 173-174, 190

uninsured

III: 78-80

see also Adoption; Child abuse and

neglect; Consent and

cordldentiality; Families;

Foster care

Parham v. J.R.

III: 130

Participatory approaches, see

Empowerment approaches

Partnership for a Drug-Free America

II: 536

Pediatricians

I: 31, 108

II: 641

III: 12-14,62

American Academy of Pediatrics

II: 641

III: 12-13, 14,25,28,52,62, 102,

109, 136,213

attiiudes

III: 21,51-52,62-63, 109

diagnostic skills

III: 15-20

education

I: 109

III: 26-29

Medicaid

m: 99, 109, 115

Peer influence

I: 23

II: 69,79,79,88,89-90,91, 93, 130,

175-176,439

III: 36, 187,230

assertiveness training

I: 27

II: 357,358,365-368,535, 565

III: 144
Index . II-753

consent and confidentiality

III: 143, 147-148

delinquency

II: 609-610

drug abuse

II: 524-525,537-538

self-help groups

II: 474=$75, 547-549,557, 637

sexual activity and outcomes

II: 279, 284,285, 308,345, 353,

365-368,394,402

Pelvic inflammatory disease

II: 269,270-271

Pennsylvania

II: 391,474,638,669,670

III: 82,97, 103, 105, 107, 111

Pew Memorial Trust

II: 676

Phenylketonuria

II: 215

Physical fitness

1: 11,27, 90-91, 92

II: 125, 182, 193,202,206,209,211,

212-213,214-215,217-218, 222

III: 188,283

nutrition and

II: 199, 202,212-213

physical education

II: 206,217,218, 222

policy options

I: 90-92

research, nutrition and

I: 92

II: 211, 221

statistical programs, nutrition and

I: 92

II: 194-195,202

see also Sports and recreation

Physicians

I: 31

H: 325-326,454

III: 13-14,62, 199

accidental injuries treated by

II: 119-120

attitudes of

I: 107, 108

II: 264,377-378,410

III: 7, 12, 15, 17,20-22,23,51-52,

62-63, 109

chronic physical conditions,

treatment of

II: 154, 155, 156, 181

community-based comprehensive

service centers

I: 53

consent and contldentiality

II: 377-378,410

III: 15,62-63

contraceptive sexvices, competence in

II: 377-378

JII: 21

counseling

III: 10, 14-15, 17-18,20-21,62

diagnostic skills

III: 15-22,23, 29,63

ethics of confidentiality

I: 59,62

III: 134-138, 140-141, 151-152

health insurance issues

I: 111

III: 50, 84,99, 104, 105, 108-110,

111, 116-117, 175

Medicaid participation

I: 111, 119

III: 50,99, 104, 105, 108-110, 111,

115, 116-117, 175

utilization of

I: 4, 10, 106-107

III: 8-11, 169, 188, 199

visit duration

III: 12, 13-14, 17,62

see also Pediatricians

Piagetian theory

H: 22

Police

II: 538,624

III: 146, 184

Policy issues and options

I: 44-87

II: 5,6, 27-29, 51-52, 102-103, 139-

141, 179, 183-186, 306-311,

417418,480488,5(M-567, 645-

648

III: 3,58,60,65-66,200-201, 256,

262-263

consent and confidentiality

III: 123, 148-153

insurance coverage

m: 117

school

I: 85-86,87

II: 66,67,70-71,76, 103-104

see also specific health problems and

issues

Political factors

I: 44

accident prevention

1: 89

community-based comprehensive

service centers

I: 50,51

consent and confidentiality

I: 62

fuearms

I: 80,81, 89

health education

I: 72

physician attitudes

III: 23

pregnancy prevention

II: 394-395

see also Public opinion

Postponing Sexual Involvement

program

II: 367

Poverty

I: 1,2, 113-115, 117

II: 95, 129, 158,248, 271,324,345,

347

III: 1-2, 159-178, 198, 199,200-201,

202-203,237,243,247, 287

access to services

I: 117

III: 169-171

Aid to Families With Dependent

Children

1: 19,55, 162

II: 323,348,350-351,401, 415-

416,617,664,679

III: 79,95-98, 100, 116, 152, 162,

173, 174, 175,225,229,253-

255

American Indians

I: 27

XII: 162, 174, 175, 192

child abuse

II: 4746

chronic physical diseases

I: 90

II: 158, 159

III: 168

clinical services

III: 31, 33

contraceptives

II: 389,410-411

III: 169, 243

delinquency

I: 102

II: 600-601,614,633

III: 169, 171

disabilities

III: 168

dropouts

II: 62,391

III: 55, 168

drug abuse

III: 169

employment

II: 87,98, 389-394,401,415-416

III: 165, 169, 170, 178

families

III: 159-161, 162, 169-170, 173-

174,243

Federal programs, general

III: 171-178

job training

II: 87,403-404

Ill: 251

minorities, general

I: 21,27, 102, 116, 123

III: 161, 162, 164, 179, 184, 185,

188, 189, 191

nutrition

II: 206,208,217

physician utilization

m: 11
II-754 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

policy options

I: 117

pregnancy and parenthood

II: 323,324,335,337-338, 345,

347,348,394,403-404, 407

III: 169, 176, 177,243

regional trends

III: 162-163, 165

research

I: 115, 117

risk factors, general

III: 159-160, 162, 167-169, 170

school influences

I: 86

II: 70,72,78,79-80,83,85, 87,

103-104

III: 46,55, 168-169

sexual activity and sexually

transmitted diseases

II: 263,268,323, 324,345

III: 169, 177

uninsured

III: 78-81, 83,94

urban areas

III: 165, 169, 170-171, 182, 185

see also Hopelessness; Medicaid;

Minorities

Preferred provider organizations

III: 84,88

Pregnancy and parenting

I: 11, 13, 16, 19,51,94-97,98

II: 38, 158,290, 323-328, 336-338,

340-418,675-676

III: 177, 183,214,237,254-255, 285

block grants for health services

I: 60

II: 400,414,415,679

III: 153, 177, 194,235-236

community-based programs

II: 358,368-372,414

comprehensive semices

II: 403,408,414

consent and contldentiality

I: 61

III: 129, 133, 137, 141, 142, 143,

144-145

counseling

I: 97

II: 401402,411

demographic factors

II: 348-356

demonstration projects, parenthood

and

II: 403406,411-412

drug abuse

II: 530,531

educational interventions

II: 342,344,349

employment programs

II: 389-390, 391-394,397,401,

415416

ethical issues

II: 357,376

Federal programs

II: 398,399,408-418

III: 153, 177, 178, 194,235-236

food programs

III: 178

health insurance

I: 29,97

II: 347-348,414

III: 84,90-93,98

Hispanics

I: 20-21

II: 351,354-356

Medicaid

II: 400,413-414

minorities

I: 20-21

II: 324,332-335,342, 351-356,

378,676

III: 183, 185, 186, 187

nutrition

II: 211-212

physician utilization

m: 9-1o

policy options

I: 94-98

poverty, parenthood and

II: 323,324, 335,337-338,345,

347,348,394,403-404, 407

III: 169, 176, 177,243

preventive interventions

II: 347-348, 356417

risk factors

II: 336,340-356

school-linked health centers

II: 356,357-372,400-401

III: 44,53-54,55,56

statistical programs

I: 98

II: 323-335

see aho Abortion; Contraception and

contraceptives

Pregnancy Discrimination Act of 1978

I: 97

II: 347,399-400

III: 90-91,92, 115, 117

Preventive health and education

measures

I: 25,32,46,55,64,77, 83, 161

II: 3-6,23,25,37

III: 250

accidental injuries

I: 88-90

II: 132-136, 140

III: 235, 244,245, 246, 262

chronic physical conditions

LI: 168-169, 176-177

delinquency

I: 23, 103

II: 586,620-625,642-644

III: 250, 251,258

demonstration pro@cts, general

I: 69,70,71-72

II: 243

dental and oral health

II: 240-245

design, general

I: 23-25, 120

II: 445446

drug abuse

I: 100-101

II: 85,462,534-544,545-546, 560-

565

III: 173,254

evaluation

I: 25,27

II: 133-134, 141,278-293

hopelessness

II: 689

insurance

I: 111

III: 85-86

mass media

II: 534,535,536,540,541, 543

mental health problems

II: 448477,481-482

minorities

III: 188,254

nutrition and fitness

II: 204-205,215,216-222

pregnancy and parenthood,

adolescents

II: 347-348,356417

safety equipment

I: 76,88-89

II: 130-131, 134-136

III: 252-253

sexual activity and diseases

I: 93-94,96-97

II: 272,275,277-295,298-304,

307-309,357-358

III: 44, 243

well-child care

III: 12

see aZso Counseling; Diagnosis;

Safety equipment; Screening

_ health care

III: 5-73, 176

American Academy of Pediatrics

II: 641

III: 12-13, 14,25, 28,52,62

defined

III: 7,62

drug abuse

II: 555-556

school-linked health centers

III: 44

sexually transmitted diseases

II: 277-295

statistical programs and data

I: 111

see also Physicians; Screening

Probation

II: 633,637
Index ● //-755

Professional associations

I: 108

II: 137, 243,244,463, 503-504,556-

557,673

III: 17-18, 25-27,52,76, 136-137

adolescent-specific

I: 31

IIX: 25-26, 27,28,52,62-63

consent and contldentiality guidelines

of

I: 57-58

III: 136-138

pediatrics

II: 641

III: 12-13, 14, 25, 28,52, 62, 102,

109, 136, 197

see also specific associations

Professional education

I: 30-31,62

III: 29, 57, 99

drug abuse

1: 101

II: 538,555-556,557-558

III: 19

evaluation

I: 30-31,62,63

III: 28-29, 33,57

Federal role

III: 29

health care personnel

I: 5,29, 30-31,46,48,53,57,

62-63,64,67, 108-109

II: 467,483,484-485

III: 190,202

multidisciplinary

I: 62

III: 29,57,64

policy options

I: 62-63

teachers

1: 27

II: 85

Project ALERT

II: 538-539

Project Redirection

II: 403404

Project Re-Education

II: 46344

Project SMART

II: 537-538

Project STAR

Ix: 540-541

Psychological and psychiatric services

I: 98-99

II: 454470 (paSSim), 484-485

commitment for

I: 58,60-61,62,99

II: 458459,471, 567

III: 130, 140, 144

comprehensive clinics

II: 453

III: 39

consent and contidentitity

III: 144, 147, 148

deficiencies in

I: 14, 31

diagnostic

III: 16-17

insurance

III: 86, 87

scteening

III: 31

specialists

III: 23, 25, 26, 63

utilization of services

II: 453462

see also Counseling

Public Health Service

I: 33

IL 246-247, 299

III: 176-177, 193-196,214-215,220-

221,229-244

Public Health Service Act

I: 60

II: 285,305, 345, 398, 399,408413,

671

III: 32,50,99, 132,153, 177,243-244

Public opinion

1: 51, 118

II: 3, 14

attitudes toward adolescents

III: 58

school-linked health centers

m: 50-51,55

Public/Private Ventures

II: 80-81, 391,406,408

Punishment

II: 71,604,605

Q

Quality of life

I: 2

II: 178

R

Racial and ethnic factors, see

Minorities

Rape

I: 1 9

II: 584,593,619,67 7

Recreation, see Sports and recreation

Referral to services

I: 4,53,63-64

II: 38-39,376,553-557,566, 627-629,

636-637

III: 10, 31-32,44,52,55-56, 175

see also Outreach services

Refugees

III: 186, 192

Regional trends

II: 520,615

III: 255

AIDS and other sexually transmitted

diseases

II: 263,272, 294-295

Medicaid eligibility

III: 98, 108, 116-117

minorities

III: 184, 199

poverty

III: 162-163, 165

rural residence

III: 196, 199

uninsured

III: 80-81

Regulations

comprehensive service centers

I: 52-54

consent and cordldentiality

I: 60

III: 123, 137, 152

correctional facilities and Medicaid

I: 104

environmental risks

I: 32,77-78

fiiarms

I: 79,80-82, 102, 103

pregnancy counseling

II: 411

private insurance

I: 47,54

III: 83,87,90-91,92,110, 112,115

safety equipment

I: 88-89

II: 134-136

Relatives, see Families; Parents and

parenting; Siblings

Religious influences and

organizations

II: 95-96, 342

Ill: 51,56, 190, 191, 192

Research

accidental injuries

1: 90

II: 139, 141

III: 252, 253-254

adolescent participation in design

I: 64-65, 128-129

advisory bodies

I: 64-65,73-74, 127-129

age v. competenu

I: 57,58

III: 123, 134-135, 138, 141-148,

150

AIDs drugs, clinical trials

II: 296-297, 309

child abuse

II: 4345

chronic physical diseases

I: 91

II: 171

contraceptives

II: 376-377,411

III: 153

delinquency
II-756 . Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

I: 106

II: 646-647

dental and oral health

I: 92

developmental processes

1: 72-74

II: 22

discretionary time

I: 85

II: 89,91

drug abuse

I: 102

II: 520-522,523,558-559, 561,

562,564-565,567

employment

III: 252

families

II: 37,51,52

Federal role in

I: 32-37,66,67,68,72-74, 81, 115,

117

f~earrns

I: 81

funding issues

I: 23,32,72-74,81

II: 141,298,303

hopelessness

I: 107

longitudinal studies

I: 23,25

III: 169, 171,254

mental health

I: 99, 100

II: 480,482,485-486

nutrition and fitness

I: 92

II: 211,221

poverty

I: 115, 117

preventive health care

I: 64

primary and comprehensive semices

1: 111

recreation

I: 81,87

risk-taking

II: 23-24

schools

I: 85,87

sexually transmitted diseases

I: 94

II: 264,266-267

see also Demonstration projects;

Evaluation issues; Longitudinal

studies

Residential treatment programs

1: 61

II: 46244,470,484,486,549-550,

557

III: 175,252

Respiratory diseases

I: 17,89

II: 151, 154, 157, 158, 159, 172

Retired Senior Volunteer Program

III: 172

Rhode Island

III: 43,82,97,103,105,107, 111,124

Risk factors

I: 1,2,44-45

II: 23-24,38, 129-131,202-209,240,

III: 34,55-56,64,235,254, 282-288

cancer

II: 176-177, 179

child abuse

II: 46A18

delinquency

II: 596-616, 646-(M7

drug abuse

II: 520-528,534,535,541, 562

environmental

I: 32,77-78

hopelessness as

I: 16, 105-106

II: 667-671,688

minorities, general

III: 179, 182-187

multiple problems

I: 22-23,25, 26,29

III: 61, 287

poverty-associated, general

III: 159-160, 162, 167-169, 170

pregnancy and panmthood

II: 336,340-356

sexual activity as

I: 11,96

II: 257,258,261,262,263-264,

271-272,277

suicide

II: 446448

Robert Wood Johnson Foundation

II: 472,477,673,676

III: 33,41,42,46,47,56, 170-171

Roe v. Wade

II: 330,347,397,398

III: 128-129

Role models

II: 37-38,279,347,389,390-391,402

III: 148, 171,203

see aZso Mentor influence; Peer

influence

Runaway and Homeless Youth Act

II: 671,682-683,685,688

III: 176, 229,254

Runaway Youth Act

III: 37

Runaways

I: 85, 106

H: 50,51,263,286,665-666, 671-

678,682-688

III: 37, 176, 193, 229,254

Rural areas

I: 2,27,30, 115, 116, 117, 118

II: 69, 128, 129,261,370,436,437,

601

III: 1, 165, 182, 196-200,201-202

Ryan White Comprehensive AIDS

Resources Emergency Act

II: 306

s

Safety equipment

1: 76,88-89

II: 130-131, 133

III: 252-253

Schall v. Martin

II: 645

School-Aged Service

II: 101-102

School/Community Program for

Sexual Risk Reduction

II: 370,372

School Development Program

II: 82

School Dropout Demonstration

Assistance Act

II: 86

School influences and services

I: 77,85-87

II: 3, 13, 15-16,59-87, 103-104

III: 61, 230,283

absenteeism

II: 67,119, 131-132,157, 158,175,

670

III: 54, 168

alcohol abuse interventions

II: 536-538

III: 47,54

apprenticeships

III: 252

attitudes of adolescents

I: 86

III: 43,52

chronic physical illness and

I: 10-11

II: 168, 175-176

consent and confidentiality

I: 31

III: 50-51,52

contraceptives

II: 386-387

III: 44,51,53-54,56

crime and delinquency

I: 86

II: 70,71, 104,609,621-622,624

III: 255

curriculum development

I: 25,26-27,72

II: 284,285,390,412,443, 536-

537,541

decisionmaking

I: 85-86,87

II: 66,67,70-71,357,358, 365-368

demography

II: 60,61,66

demonstration projects
Index . II-757

I: 87

II: 80-86

discretionary time

II: 94

driver education

I: 89

III: 252-253

drug abuse

II: 526,530,535,536-541, 544,

554-555,563

m: 47,54

evaluation issues

II: 81,85,358

III: 51,52-57,64

Federal programs

II: 78-87

financing

I: 31,51

m: 45,47-50

food programs

III: 178,246

funding

I: 87

II: 78,83,85, 86

III: 47-48, 50

health education

I: 71,72, 91

II: 216-217, 221-222, 244, 249,

272,275

homeless persons

II: 669-671,677, 678,684-685

insurance reimbursement

m: 50

legislation

I: 67

male-oriented

Ill 46,56

Medicaid

III: 46,48, 50,52

mental health

II: 443444,449-450,453,471-472

III: 4647

minorities

I: 86, 87

II: 67,69,70,78, 82, 103-104

III: 46, 196

nutrition

I: 91

II: 216-217,221-222

outreach

I: 31

III: 54,56

parent involvement

I: 87

II: 77-78, 85-86, 104

III: 50-51, 55,56

physical education

II: 206, 217, 218, 222

policy options

1: 85-86, 87

positive

I: 23

poverty

I: 86

II: 70,72,78,83,85,87, 103-104

III: 46,55, 168-169

pregnancy and parenthood

II: 356,357-372,400-401

HI: 53-54,55, 56

problems

I: 8-9

public opinion

m: 50-51,55

research

I: 85,87

school policies

II: 66,67,70-71,76, 103-104

screening

III: 52,55-56

sex education

I: 93-94,96-97

II: 272,275,280,285,356, 357-

372,395

III: 44,243

sexual activity interventions

II: 365-368

III: 51, 53-54,55,56,235

size factors, school/class

II: 66,67,69-70,72-73

social factors

II: 59,67

State programs

II: 60-61,80-83, 86,87

m: 47,49,50

teachers

II: 66-67,73-76,78,85, 104

III: 27,86-87

tracking, students

II: 68-69,70

transitions

I: 85, 86

II: 66-67,71-72, 104,444,445

urban areas

II: 69,73

utilization

III: 45-46,54,56

see also Dropouts; School-1inked

health centers

School-linked health centers

I: 31,47,49-54, 109-110

II: 82-83,378

m: 47-57

adolescent perspectives on

m: 43

contraceptives

II: 386-387

LII: 44,51,53-54,56

cost factors

III: 47-48,50, 56

counseling

III: 43-44,47,53,56

evaluations of

III: 52-55

I: 31,51

III: 45,47-50

limitations of

III: 55-57

mental illness

II: 472

parental and community attitudes

toward

m: 50-51

physician attitudes toward

III: 51-52

policy options

I: 4647,49-54

quality of care in

III: 55

services in

m: 434.4

sexual activity and outcomes

II: 277,295,386-388,389

State initiatives

III: 47,49,50

utilization of

III: 45-47,54,56

School Transition Environment

Project

II: 444,445

Screening

III: 12,235

AIDs

I: 62

III: 132

delinquency

II: 608

insurance

III: 85-86,88

Medicaid

I: 55,56

III: 1, 48, 99, 100, 101-104, 116,

117, 174

mental health problems

III: 31

pregnancy

1: 97

school-linked health centers

III: 52,55-56

sexually transmitted diseases

I: 57,60,61,62

III: 127-129, 132

Secondary Schools Basic Skills

Demonstration Assistance Act

H: 86

Self-help groups

II: 474-475,547-549, 557, 637

Sex differences, see Gender differences

Sex Respect Program

II: 367-368

Sexual activity

I: 2, 11,27,94-95,96

II: 18-20,38,42, 323-326,328,336,

342, 345,640,675-676

III: 61,235,243,262,263,285

age factors

II: 262,270,334,340-341, 342,343
II-758. Adolescent Heaith—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

attitudes of adolescents

II: 328,356,357, 358,367-368

attitudes of nonadolescents

I: 51

III: 23

black Americans

II: 262,263,268,271,324, 342,

351,352-353

child abuse

I: 8, 19

II: 43,46,48,49,676-677

III: 37

community services

II: 277,286-288, 358,360-372

consent and confidentiality

III: 127-129, 131, 132-134, 135,

137, 138

counseling

I: 53, 110

II: 368,387-388, 395

III: 21,44,51,53-54,56

drug abuse

II: 530,531

educational interventions

I: 93-94,96-97

II: 272,275,278-288,307-308,

357-372,395

III: 44,243

evaluation of intementions

I: 93-94,96-97

II: 277,278,281-295,308, 356-

357,358408

III: 243

females

II: 324,342-344, 352,353,354-

355,359,373,390,675-676

gender differences

II: 268,269,270,271,273-274,

306,326,640

health education

I: 96-97

homosexual

II: 42,258,261,262,285,286, 306,

309,665,676

III: 138

males

1: 93-94,96-97

II: 332,351,352,377,388 -389,418

III: 243,325,332

minorities

II: 263,268, 271, 272,279,280,

286,304,309, 351,352-356

III: 183, 185

peer influen%

II: 279,284,285,308,345, 353,

365-368,394,402

physician competence, counseling

m: 21-22

poverty and

II: 263,268,323, 324,345

III: 169, 177

preventive interventions, sexually

transmitted diseases and

I: 93-94,96-97

II: 272,275,277-295,298-304,

307-309,357-358

III: 44,243

as risk factor for sexually transmitted

diseases

1: 11,96

II: 257,258, 261,262,263-264,

271-272

school-linked health centexx

II: 365-368

III: 44,51,53-54,55,56,235

see also Contraception and

contraceptives; Pregnancy and

parenting

Sexually transmitted diseases

I: 9, 11, 12,89,93-94

II: 37,42,257-268,271-272, 275-294,

296-311,336, 373,640

III: 61,285

age factors

II: 262,270,334,340-341, 342,343

attitudes of adolescents

II: 273-274,275,284,294, 296,

304,308

CDC

II: 258,261,279,285,289, 295,

298,299-300,302,303, 304,

310

chancroid

II: 265,270

chlamydia

II: 264-265,268,306,640

clinical services

m: 35,37

community services

II: 277,286-288,358,360-372

condyloma acuminaturn

III: 265,269

consent and cotildentiality

I: 57,60, 61,62

III: 127-128, 132, 135, 137

demonstration projects

II: 297,303,304,305

diagnosis

II: 258,271, 342

III: 127-128

drugs for treatment

11: 296-297,309

educational interventions

1: 93-94,96-97

II: 272,275, 278-288, 307-308,

357-372,395

III: 243

family interventions, general

II: 279-280, 308

Federal programs

II: 258,280,298-306, 309-311

III: 233-235,239-241

gender differences

II: 268, 269, 270, 271, 273-274,

306,326,640

gonorrhea

II: 265,268-269,306

herpes

II: 265,269

knowledge about

I: 63-64

II: 272

minorities and

II: 263,268, 271,272,279,280,

286,304, 309, 351,352-356

III: 183, 185

morbidity data

I: 93,94

II: 257-271,326-337

pelvic i.nflammato~ disease

II: 270

physician competence in treating

III: 21,23, 2?)

policy options

I: 93-94

poverty

II: 263,268, 323, 324, 345

III: 169, 177

preventive interventions

I: 93-94,96-97

II: 272,275,277-295,298-304,

307-309,357-358

III: 44,243

research

I: 94

II: 264,266-267

screening

I: 57,60,61, 62

III: 127-129, 132

State-level activities

II: 258,276,280,284,293, 294,

306,309-310

statistical programs

II: 258-260,280,284,323-326, 378

syphilis

II: 265,269-270,277,287, 304,638

trichomoniasis

II: 265

urban i-u-ears

II: 261,268,272,304,306, 310

see also AIDS and HIV infection

Siblings

II: 440,441, 605,615

Skin diseases

acne

1: 11, 17, 108

II: 154, 179-181

III: 10, 20,61,63

diagnosis

III: 19-20

see also Acne

Smoking, see Tobacco use

Social factors

I: 2,76,78

II: 3-6, 13-17,25-26,27,28,36,

51-52,271
Index ● II-759

chronic diseases

II: 167-168, 175-176

competence

I: 46, 108-109

II: 43, 167-168

III: 125, 126-127, 131, 136, 140,

147-148

consent and confidentiality

III: 147-148

costs of health problems

I: 18-19

delinquency

II: 602-603,607-608,616, 622-

623,634,646

discretionary time

II: 89-90,91

dropouts

1: 9-10

drug abuse

II: 523,525,527,534,537-538,

539-540

health, defined

I: 4,5

hopelessness

II: 664

mental health problems

H: 441,442,448,474-475

pregnancy and parenthood

II: 337-338, 339-340, 345, 347-

348,401402

resiliency and

II: 616

m: 166

school-related

II: 59,67

statistical programs

I: 75-76

support

I: 23

see also Cultural factors; Families;

Mentor influence; Peer

influence

Social Security Act

I: 60

II: 138, 399,400,414415

III: 100, 153, 173-177, 194,229, 235

Social service agencies

II: 100-101

Society for Adolescent Medicine

1: 108

III: 25,27,28,52,62-63

Socioeconomic status

I: 1

II: 6, 158, 159, 160, 166

HI: 167-169

child abuse

II: 47+8

clinic utilization

ID: 32

consent and cordldentiality

ID: 144-145, 146-147

delinquency

II: 600-601,603,628,646

dropouts

II: 63

drug abuse

III: 169

II: 517-518

health insurance coverage

HI: 77-81

minorities

I: 21

III: 183

physician utilization

III: 10-11

pregnancy and parenthood

H: 335, 339, 349-352

utilization of semices

III: 10-12,46

see also Income; Poverty; Social

factors

South Carolina

II: 368,370, 372,396-397

III: 82, 97, 103, 105, 107, 111, 124

South Dakota

III: 82,97, 103, 105, 107, 111

Special education

III: 262

developmental disabilities

I: 7, 86

II: 215,585, 608-609, 614

III: 176, 186,229

Specialists

1: 108, 109

III: 10, 23, 25-29,63

adolescent-specific

I: 31

Ill: 25-26,27, 28,52, 62-63

dermatologists

II: 180

III: 19-20

Medicaid

m : 111

nutritionists

III: 22-23

psychologists and psychiatrists

III: 23, 25,26, 63

see also Pediatricians

Sports and recreation

I: 10,25, 74,81-82, 87

II: 88,95, 96, 217,623,682

III: 40, 56,225

drowning

II: 120-121,123-124,127, 128,530

injuries

II: 121, 124-126,213

nutrition

II: 212-213

policy options

I: 81-82, 85, 87

see also Discretionary time; Physical

fitness

Staffing

clinics

III: 37,39

community-based comprehensive

service centers

I: 50

III: 45, 55,56, 64

drug abuse services

II: 557-558

homeless shelters

II: 683-687

rural areas

I: 115

III: 199

school-linked health centers

III: 45, 55,56, 64

Standards

competency, informed consent

III: 125, 126-127, 131, 136, 140,

149-150

correctional facilities

I: 104

II: 641-642

III: 250

drug abuse treatment

I: 101

II: 556-557,558

ethics of contldentiality

I: 59,62

III: 134-138, 140-141, 151-152

homeless shelters

II: 664

Medicaid eligibility

I: 56, 104, 111-112, 116-117

II: 640,669

III: 65, 94,95-100, 105, 107, 108,

116-117, 170, 175,229

mental health care

II: 487

safety

11: 135, 139

testing, educational

II: 67-68, 103

State Comprehensive Mental Health

Services Plan Act

I: 99

II: 479

State-1evel programs and activities

access to services (model statute for)

1: 47,58-60

Aid to Families With Dependent

Children

I: 19,55

II: 323,348, 350-351,401,415-

416,617,664,679

III: 79,95-98, 100, 116, 152, 162,

173, 174, 175,225,229,253-

255

chronic physical conditions

II: 173

contraceptives

II: 378

coordination

I: 65
II-760. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services

III: 263

delinquency and comctions

II: 626,628,633,634,635

dental and oral health

II: 245

discretionary time, adolescents

II: 98

drug abuse programs

II: 543,552,553,557,566

Federal funding conditions

I: 47,52-53,60,61-62,65

11: 60-61,86,87, 101-103,310,

414,644,681-682

III: 65,250

foster care

II: 49,50,471

health insurance regulation

I: 47,54

III: 83,87,90-91,92,110,112, 115

hopelessness

II: 664,681-682

Medicaid issues

I: 52,56-57,60

II: 478

III: 50,65,94-117 (pd.nl), 152,

170, 174, 175, 199,229

mental health

II: 471,479

minorities

III: 191, 192

safety equipment, vehicles

I: 89

II: 130-131, 134-136

school-linked health centers

III: 47,49,50

schools

II: 60-61,80-83,86, 87

sex education

II: 358

sexually transmitted diseases

including AIDs

II: 258,276,280,284,293, 294,

306,309-310

see also Block grants; specific State

numes

Statistical programs and activities

I: 2, 16, 18-19, 102, 159-161

II: 5-6, 152-153

III: 254,262, 282

aboflion

I: 95

II: 325-326,329-331

accidental h~es

I: 80

II: 117-132, 140-141

age ag~gations

I: 159-160

child abuse

I: 8

H: 4345

chronic conditions

II: 150-161, 185

consent and cordldentiality

I: 75-76,94

delinquency

I: 106

II: 587-596,634,635-636, 646

III: 250

demonstration projects

I: 74-75

discretionary time

II: 89

drug abuse

II: 505-508,520-522

Federal

I: 32,66,67,74-76

II: 152-153

III: 235,262

funding

I: 74-75

HI: 224

health insurance

III: 77, 80,84

Hispanics

III: 185, 188

hopelessness

I: 107

II: 663,666-667,671-673

income

1: 160

local

I: 74-76

longitudinal studies

I: 23,25

III: 169, 171,254

Medicaid enrollment and

expenditures

III: 4,95,289

mental health

I: 100

II: 438,454-456,482

nutrition and fitness

I: 92

II: 194-195,202

political factors

I: 75

poverty

I: 117

III: 161-167,202

pregnancy

I: 98

II: 323-335,349,354,378

preventive interventions

I: 161

primary and comprehensive services

I: 111

III: 8-10

recreation

I: 87

rural areas

III: 196-197,202

sampling

I: 160

school factors

I: 63,80,87, 88,98

III: 41-48,254

sexual activity and sexually

transmitted diseases

II: 258-260,280,284,323-326, 378

social factors

I: 75-76

suicide

I: 76,97

II: 438439

see also Morbidity and mortality;

specific surveys

Stewart B. McKinney Homeless

Assistance Act

II: 671,679-681

III: 249,262

Student aid

II: 80

m: 190, 195

Student Community Service Program

III: 172

Substance abuse, see Alcohol abuse;

Drug abuse; Tobacco use

Suburban areas

II: 599

III: 35, 165, 169

Suicide

I: 2,8, 14, 19,63,76,97-98

II: 117,434,437-439,446-453, 468,

481-482,514,64 0

III: 59, 138, 183, 184, 198, 283,287

Summer programs

II: 79-80, 87, 391, 393

III: 251-252, 262

Summer Training and Education

Program

II: 80,391, 393

Supplemental Security Income

m : 100

Support Center for School-Based

Clinics of Center for Population

options

m: 41

Supreme Court

II: 398,640,643

III: 123; 125, 128-134, 140, 150,177,

243

Surgeon General

II: 184,200,201,336-337

Surveillance, Epidemiology, and End

Results Program

II: 153

Syphilis

II: 265,269-270,277, 287,304,640

T

Task Force on Pediatric Education

III: 29

Taxation

alcohol and tobacco

II: 543

disabilities, persons with
Index . II-761

II: 183-184

school funding, loczd

II: 61

Teachers

II: 78

attitudes

I: 86-87

II: 66-67,73-76, 104

education of

I: 27

II: 85,371,622-623

Technical assistance

1: 63

II: 310,479,644

III: 41, 192, 217

Teenage Parent Demonstration

program

H: 401

Teenage Pregnancy and Parenting

Program

II: 403

Teen Father Collaboration

II: 406

Teen outreach Program

II: 393

Telephone hot lines

II: 277,287,452,468

Television

II: 90-91, 208,287-288, 345,368

Tennessee

III: 82,97, 103, 105, 107, 111

‘Iesting, academic

II: 67-68, 103

Texas

II: 135,473

III: 41, 82, 97, 103, 105, 107, 111

Third-party payers, see Health

insurance; Medicaid; Medicare

Tobacco use

I: 14-15,99-101, 102

II: 500,508, 510, 513,527-528,529,

530,531,533, 536-538,539-

540,541,543,559

III: 54, 169, 240, 255,287

Torts

III: 124, 125, 139

Total Diet Study

II: 194

Tracking, students

II: 68-69,70

Transitions

school

I: 85, 86

II: 66-67,71-72, 104,444,445

Treatment, see Medical services and

treatments

Treatment Alternatives to Street Crime

H: 555

u

Uniform Crime Reports

II: 589,590,594

Uniform Minimum Drinking Age Act

II: 543

Universities and colleges

II: 16

III: 171, 193, 195, 198,230

student aid

III: 190

Urban areas

II: 14,98, 129, 353,436,437

American Indians in

I: 27

clinics

I: 26,52

III: 170-171

delinquency

1: 102, 115

II: 601,603,616,622-623

dropouts

I: 8-9

m: 55

minority groups

III: 182, 184, 185

poverty

III: 165, 169, 170-171, 182, 185

schools

II: 69,73

sexually transmitted diseases

including AIDS

II: 261,268,272,304, 306,310

U.S. Conference of Mayors

II: 564,666-667,671

Utah

II: 638

III: 50,82,97,103,105,107, 111,129

Utilization of services

accidental injuries

II: 118

chronic physical conditions

II: 169

drug abuse programs

II: 553

gender differences

III: 9-10,35, 146

hospital-based

III: 11-12,32, 34,87

Medicaid enrollment and

expenditunx

III: 4,95,96, 116, 175,289

mental health

I: 98-99

II: 454462

III: 87

minorities

III: 10-12,46, 179, 182-183, 188

physicians

I: 4, 10, 106-107

III: 8-11, 169, 188, 199

poor adolescents

1: 114

HI: 169

pregnancy and parenthood

H: 417

rural areas

III: 198-199

school-linked health centers

Ill: 45-47,54,56

socioeconomic status

III: 10-12,46

see also Access to services

v

Vaccines

III: 44, 145, 188, 235, 240

Vermont

II: 638

III: 82,97, 103, 105, 107, 111

Violence

I: 15, 16, 104

II: 37,41-42,43,440,441, 532,583,

586,591-596,619-620

III: 169, 184-185,250,287

against parents

II: 4142

fmarms

I: 79,80-82, 88,89, 102, 103

II: 5, 124,447,448,451,611-614,

615,647

rape

I: 19

II: 584,593,619,679

school size

II: 70

see also Child abuse and neglect;

Crimes and crirninals; Finm.rms

Virginia

III: 82,97, 103, 105, 107, 111

Vocational issues, see Employment and

unemployment; Job training and

aiding

Voluntary Cooperative Information

System

II: 326

Volunteers and volunteering

I: 74

II: 92-93,94, 101-103,452

III: 36, 37,38,39, 172-173, 191

ACTION

I: 35,65

II: 94, 102-103,563

III: 172-173,216,244

drug abuse treatment, participation in

II: 552,566-567

Volunteers in Service to America

I: 82

n: 101

III: 172, 244

w

Washington State

II: 284,621,640

III: 29, 82,97, 103, 105, 107, 111

Webster v. Reproductive Health

Services
II-762 . Adolescent Health—Volume Ii: Background and the Effectiveness of Selected Prevention and Treatment Services

II: 398

111: 129, 133

Well-child care

III: 12

West Virginia

III: 82,97, 103, 105, 107, 111

William T. Grant Foundation

II: 50, 100

III: 256

Wisconsin

III: 50,82, 97, 103, 105, 107, 111

World Health Organization

I: 4

H: 25,27

Wyoming

III: 82,97, 103, 105, 107,

111, 124, 129

X Y Z

Yale Child Welfare Program

II: 619

Yale-New Haven/Social ProblemSolving Project

II: 443,445

Young Americans Act of 1990

I: 65.67

II: 92-93

III: 200,246

Youth Incentive Entitlement Pilot

Projects

II: 391

Youth Opportunity Unlimited

program

II: 564

Youth Risk Behavior Surveillance

System

Young Unwed Fathers Project I: 75

II: 406 II: 194-195,220,505,506

Youth associations and organizations Youth service, see Community service;

I: 87 Discretionary time

U.S. GOVERNMENT PRINTING OFFICE : 1991 0 - 297-!346