Adolescent Health, Vol. III: Crosscutting

Issues in the Delivery of Health and Related

Services

June 1991

OTA-H-467

NTIS order #PB91-212183
Recommended Citation:

U.S. Congress, Office of Technology Assessment, Adolescent Health-Volume III: Crosscutting Issues in the Delivery of Health and Related Services, OTA-H-467 (Washington, DC:

U.S. Government Printing Office, June 1991).

For sale by the Superintendent of Documents

U.S. Government Printing Office, Washington, DC 20402-9325

(order form can be found in the back of this report)
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 1ong 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.

Volume II will be available later in 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.

w 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

Human

Anne C. Petersen, Ph.D.

Dean, College of Health&

Development

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

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. O’llA 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, Project Director

Jill Eden, Senior Analyst

Kerry B. Kemp, Analyst/Division Editor

Kelly Metcalf, Research Analystl

Kirsten Rowe, Analyst 2

Gloria Ruby, Senior Analyst

Pamela Simerly, Analyst

Andrea Soharz, Carnegie Detailee3

Urvi Thanawala, Research Assistant4

Paul Robertson, Research Assistants

Other Staff

James Havel, Carnegie Contractor6

Charlotte Clarke, Carnegie Contractor

Elizabeth Anglarill, Work Study Student8

Helima Croft, Summer Intern9

Jennifer Hart, Summer Intern10

Administrative Staff

Virginia Cwalina, Office Administrator

Carol Ann Guntow, P.C. Specialist

Carolyn Martin, Word Processor Specialist

Eileen Murphy, P.C. Specialist

lUntil July 1990

Trom (ktober 1988 to March 1990

3From December 1988 to Au~t 1990

4From June 1990

5From September 1990

6From April to Septcmber 1~

%om May to August 1990

@rem November 1989 to May 1990

%rom May 1990 to August 1990

IOprom June 1988 to Au~t 1988

v
Contractors

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

Trina Anglin, M. D., Ph. D., Cleveland Metropolitan General 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

Margaet 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 Corporation of New York and the Carnegie Council on Adolescent Development.

vi
Volume Ill

CROSSCUTTING ISSUES IN THE

DELlVERY OF HEALTH AND

RELATED SERVICES
Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Box A. Full Table of Contents for OTA’s Adolescent Health Report . . . . . . . . . . . . . . . . . 2

Box B. Summary of Major Policy Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Box C. Requesters of OTA’s Adolescent Health Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Chapter 15. Major Issues Pertaining to the Delivery of Primary and

Comprehensive Health Services to Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Chapter 16. Financial Access to Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Chapter 17. Consent and Confidentiality in Adolescent Health Care Decisionmaking . . . . . . . 123

Chapter 18. Issues in the Delivery of Services to Selected Groups of Adolescents . . . . . . . . . . 159

Chapter 19. The Role of Federal Agencies in Adolescent Health. . . . . . . . . . . . . . . . . . . . . . . . . 213

Appendix A. Glossary of Abbreviations and Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

Appendix B. Burden of Health Problems Among U.S. Adolescents . . . . . . . . . . . . . . . . . . . . . . . 282

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

Expenditures for Adolescents Ages 10 Through 18 . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

.,. W/l
INTRODUCTION

This is Volume III of OTA’s assessment, Adolescent Health. This volume addresses a number of

crosscutting issues in the delivery of health and

related services to adolescents ages 10 to 18. As

shown in box A, which lists the table of contents for

all three volumes of the assessment, the following

issues are discussed in this volume:l

●

●

●

●

●

Chapter 15: Major Issues Pertaining to the

Delivery of primary and Comprehensive

Health Services to Adolescents;

Chapter 16: Financial Access to Health Services;

Chapter 17: Consent and Confidentiality in

Adolescent Health Care Decisionmaking;

Chapter 18: Issues in the Delivery of Services

to Selected Groups of Adolescents; and

Chapter 19: The Role of Federal Agencies in

Adolescent Health.

Chapter 15 reviews research on the shortcomings

of the mainstream primary health care system with

respect to adolescents, including the scarcity of

specially trained providers. It also discusses recent

innovations to improve the delivery of health and

related services to adolescents. Prominent among

these innovations are community-based and schoollinked health centers, which at their best can

simultaneously address a number of barriers to

adolescents’ receipt of basic health services. Other

innovations, such as adolescent participation in the

design of services, can also help to meet the

demonstrated need for more user-friendly health

services for adolescents. Even should the rate of

these innovations be accelerated, the chapter makes

clear that increased and improved training of health

care providers is essential in order for adolescent

health services to be more accessible and effective.

Chapter 16 addresses issues in financial access to

health services. Financial access is key to any

discussion of adolescents’ access to health services,

yet one out of seven adolescents are without any

health insurance, and the percentage of adolescents

who are uninsured is growing. Even when adolescents have health insurance, available benefit packages may not meet adolescents’ special needs (e.g.,

their needs for preventive and early intervention

services; for dental, mental health, substance abuse

treatment, or for prenatal care; for services provided

by nonphysician health care professionals, or in

school settings). Medicaid’s Early and Periodic

Screening, Diagnosis, and Treatment (EPSDT) program theoretically provides the most generous and

comprehensive benefits package, but one out of

three poor adolescents does not have access to

Medicaid, and average EPSDT spending on adolescents appears to be quite low. The promise of

Medicaid in meeting the health care needs of the

country’s most disadvantaged adolescents appears

not to have been fulfilled.

Chapter 17 turns to a third major issue affecting

adolescents’ access to health services: requirements

for parental consent or notification. The chapter

summarizes the body of law that determines how the

authority for adolescent health care decisionmaking

is allocated-including the extent of parental involvement in adolescent health care decisionmaking. The chapter summarizes the common law rule,

the exceptions to the common law rule, the positions

of health care provider organizations on issues in

adolescent health care decisionmaking, and the

research literature on the capacity of adolescents to

make health care decisions on their own. Chapter 19

also provides a framework for conducting an analysis of the various interests that must be considered—

those of the state, of parents, of health care providers, and of adolescents—should change in the

existing situation be desired.

Chapter 18 addresses the health issues and

barriers to effective and appropriate health services

that are faced by selected groups of adolescents:

those living in poverty, members of racial or ethnic

minorities (black adolescents, Hispanic adolescents,

Asian adolescents, American Indian and Alaska

Native adolescents, Native Hawaiian adolescents),

and residents of rural areas. In addition, the chapter

reviews available knowledge on interventions designed to increase access to health services among

these groups of adolescents. Federal programs and

policies for poor adolescents, racial and ethnic

minority adolescents, and adolescents living in rural

areas are also assessed. The chapter takes on

l~e ~n~e ~~e~~ment is ~fig pub~sh~ ~ ~ee vol~es: ~ ad~tion to MS vol~e, he ~der GUI obti VOlUW14UWry and Po!lc)I OptiO?tS

(published in April 1991) and Volume II-Background and the Effectiveness of Selected Prevention and Treatment Services (to be published later in

1991).

-111-1 -
III-2 . Adolescent Health-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Box 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 1: Background on Adolescent Health

2. What Is Adolescent Health?

3. Parents’ and Families’ Influence on Adolescent Health

4. Schools and Discretionary Time

Part 11: 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 HI: 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

importance as one considers that the population of the systematic knowledge base on assisting these

the United States is becoming increasingly racially

—

adolescents is as yet underdeveloped.

and ethnically diverse, and that racial and ethnic

minority adolescents—as well as rural adolescents— Chapter 19 provides an overview of the Federal

are more likely than white adolescents to face the role in adolescent health. The chapter is based

health risks associated with living in poverty. Sadly, primarily on the results of an OTA survey of
Introduction ● III-3

Box B—Summary of Major Policy Options

OTA suggests a range of options that could be implemented in an effort to help improve adolescent health,

broadly defied. Three major options that OTA believes Congress may want to consider are:

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 services-for example, 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 examinedby OTA, a number of

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

It is important to note 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.

numerous Federal agencies identified by OTA as Although each chapter in this volume (and in

having a role or potential role in adolescent health.

The survey was followed by a meeting between U.S.

executive branch representatives and OTA staff and

advisors. The chapter concludes that funding for

adolescent health issues—including research and

services-is meager, that existing interagency coordination efforts are ineffective, and that Federal

leadership specific to adolescent health issues is

urgently needed.

Volume II) ends with a section on conclusions and

policy implications, specific legislative options

relevant to each of the issues discussed in Volume III

can be found in Volume I-Summary and Policy

Options of this assessment. 2 In addition, many of the

major policy options that were suggested by OTA’s

full analysis of adolescent health issues focus on

issues discussed in this volume. OTA’s major policy

options are briefly summarized in box B.

Zsee he back of this Report for ~ order fo~.
III-4 ● Adolescent Health-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

In order to provide context on the extent of a tures for adolescents. The many individuals who

number of adolescent health concerns, appendix B assisted OTA in the development of the three

in this Volume summarizes data from Volume II on volumes of this Report are listed in Appendix B of

the prevalence and incidence of the broad range of Volume I. The way OTA went about conducting the

health concerns found among adolescents. Appen- —. assessment-including lists of workshop particidix A is a glossary of terms and abbreviations, and

appendix C provides technical details on the Health

pants and members of-tie Youth Advisory Panel—is

Care Financing Administration’s method for esti- described in Appendix A of Volume I. The requestmating national Medicaid enrollment and expendi- ers of the assessment are listed in box C below.

Box C—Requesters of OTA's Adolescent Health Report

(with current committee chair or ranking minority assignment)

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.
Chapter 15

MAJOR ISSUES PERTAINING TO

THE DELIVERY OF PRIMARY AND

COMPREHENSIVE HEALTH

SERVICES TO ADOLESCENTS

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Utilization of Ambulatory Care by U.S. Adolescents . 8

Visits by Adolescents to Physicians . . . . . . . . . . . . 8

Adolescent Hospitalizations . . . . . . . . . . . . . . . . . . . 11

Guidelines for Screening and Well-Child Care

Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Health Care Professionals’ Interest in and Ability

To Care for Adolescents . . . . . . . . . . . . . . . . . . . . 12

Attitudes of pediatricians Toward Accepting

Adolescents Into Their Practices . . . . . . . . . . . . . 12

Time Spent With Adolescent Patients . . . . . . . . . . . 13

How Much Time Do Office-Based Physicians

Spend With Adolescent Patients? . . . . . . . . . . 13

How Much Anticipatory Guidance Do

Adolescent Patients Receive? . . . . . . . . . . . . . . 14

Physicians’ Attitudes Toward Confidential Health

Care for Adolescents . . . . . . . . . . . . . . . . . . . . . 15

Health Care Providers’ Competence in Diagnosing

and Treating Adolescents’ Specific Problems . . 15

How Effectively Do Physicians Recognize

Adolescent Problems? . . . . . . . . . . . . . . . . . . . . 15

How Do Health Care Professionals Perceive

Their Competence To Provide Health Care

to Adolescents? . . . . . . . . . . . . . . . . . . . . . . . . . . 20

What Personal Characteristics Do Effective

Adolescent Health Care Professionals Have? .23

Specialized Training in Adolescent Health Care.. 23

What Is the Availability of Specialists Trained

in Adolescent Health Care? . . . . . . . . . . . . . . . 23

What Are the Training Opportunities in

Adolescent Medicine? . . . . . . . . . . . . . . . . . . . . 26

Page

What Do Physicians Trained in Adolescent

Medicine Do? . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

How Effective Is Specialized Training in

Adolescent Health Care? . . . . . . . . . . . . . . . . . . 28

What Is the Federal Government’s Role in

Support of Trainingin Adolescent

Health Care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Innovations in the Delivery of Health and Related

Services to Adolescents . . . . . . . . . . . . . . . . . . . . . 29

Comprehensive Health Centers for Adolescents . . 30

Adolescent Health Care Clinics . . . . . . . . . . . . . . 31

Free Clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Multiservice Centers That Offer

Comprehensive Health and Other Services

to Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

School-Linked Health Centers . . . . . . . . . . . . . . . 41

Other Innovations in the Delivery of Health

Services to Adolescents . . . . . . . . . . . . . . . . . . . . . 57

Integrated Health Services . . . . . . . . . . . . . . . . . . . 57

Efforts To Involve Adolescents

in Health Services Planning and

Management ● . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Conclusions and Policy Implications . . . . . . . . . . . . . . 59

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Adolescents’ Need for Health Services . . . . . . . 59

The Adequacy of the Mainstream Health Care

System for Adolescents . . . . . . . . . . . . . . . . . . . 61

Innovations in the Delivery of Health and

Related Services to Adolescents . . . . . . . . . . . 64

Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Chapter 15 References . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Boxes

Box Page

15-A. A Community-Based and an HMO-Based

Adolescent Health Care Clinic . . . . . . . . . . . . . . 35

15-B. The Free Medical Clinic of Greater Cleveland. 37

15-C. The Ensley High School “Extra Help

Services Clinic”: A School-Linked Health

Center in Birmingham, Alabama . . . . . . . . . . . . 42

15-D. Adolescents’ Perspectives on Their Need for

a School-Linked Health Center . . . . . . . . . . . . . 43

15-E. State Initiatives in School-Linked Health

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

15-F. Obstacles in the Development and Maintenance

of Integrated Community Health Delivery

Programs as Identified by the Study Group

on Integrated Community Health Delivery

Programs of the 1986 Conference on Health

Futures of Adolescents ., . . . . . . . . . . . . . . . . . . . 58

15-G. Summary of Recommendations by the Youth

Advisory Panel for OTA’S Adolescent Health

Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Figures

Figure Page

15-1. Visits to Private Office-Based Physicians by

U.S. Adolescents Ages 10 to 18, by Physician

Specialty, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

15-2. Visits to private Office-Based Physicians by

U.S. Adolescents Ages 10 to 18, by Disposition,

1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

15-3. Visits to Private Office-Based Physicians by

U.S. Adolescents Ages 10 to 18, by Duration

of Visit, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Tables

Table Page

15-1. Visits to Private Office-Based Physicians by

U.S. Adolescents Ages 10 to 14 and 15 to 18,

by Sex, 1985 ● .*.......,...*.***.*.*.***,* 9

15-2. Visits to private Office-Based Physicians by

U.S. Adolescents Ages 10 to 18, by Diagnostic

Service and Sex, 1985 . . . . . . . . . . . . . . . . . . . . . 11

Table Page

15-3. Visits to Private Office-Based Physicians by

U.S. Adolescents Ages 10 to 18, by Nonmedication

Therapy Ordered or Provided, 1985 . . . . . . . . 11

15-4. Visits to Private Office-Based Physicians by

U.S. Adolescents Ages 10 to 18, by Patient’s

Race and Ethnicity, 1985 . . . . . . . . . . . . . . . . . . 13

15-5. Number and Percentage of Surveyed Health

Professionals Who Perceive Themselves To Be

Insufficiently Trained To Manage Adolescents’

Health Issues, by Respondents’ Professional

Discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

15-6. Number and Percentage of Surveyed Health

Professionals Who Want Additional Training

in Areas m Which They Reported Insufficient

Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

15-7. Estimates of the Number of Physicians

Specilizing in Adolescent Medicine ..,..... 25

15-8. Federal Funding for Interdisciplinary Training

Programs in Adolescent Health, Fiscal Years

1986-1990 ● . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

15-9. Percentages of On-Site School-Linked Health

Centers Which Offer Medical Services,

by Type of School, 1988-89 . . . . . . . . . . . . . ..44

15-10. Percentages of On-Site School-Linked Health

Centers Which Offer Counseling and Educational

Services, by Type of School, 1988-89.......44

15-11. Percentages of On-Site School-Linked Health

Centers Which Offer Family Planning Services,

by Type of School, 1988-89 . . . . . . . . . . . . . ..45

15-12. Race and Ethnicity of Students Using On-Site

School-Linked Health Centers, 1987-88.....46

15-13. Principal R-for Clinic Visits to 23

School-Linked Health Centers Funded by the

Robert Wood Johnson Foundation, 1988-89

and 1989-90 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

15-14. Funding Sources for On-Site School-Linked

Health Centers Responding to Center for

Population Options’ Surveys, 1985-86 to

1988-89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Chapter 15

MAJOR ISSUES PERTAINING TO THE DELIVERY OF PRIMARY AND

COMPREHENSIVE HEALTH SERVICES TO ADOLESCENTS

Introduction

This chapter addresses several important issues in

the delivery of primary health care services for

adolescents in the United States.l It begins by

presenting available data on adolescents’ visits to

private office-based physicians and then reviews a

number of questions related to physicians’ interest in

and ability to care for adolescents. How welcome are

adolescents in physicians’ practices? How much

time do office-based physicians spend with adolescent patients? Because adolescents may not have

some of the kinds of physical health problems that

typically bring younger or older individuals to the

doctor, some physicians have suggested that professional time spent with adolescents be used to assess

the presence of a variety of social and behavioral risk

factors and morbidities (e.g., quality of family life,

school performance, substance use, engagement in

sex), and to provide assistance to adolescents on

these issues (10). The need for appropriate attention

to such issues by health care professionals and others

who see adolescents is well documented in Volume

II of this Report, ‘‘Background and the Effectiveness

of Selected Prevention and Treatment Services. ’

(Also see app. B to this volume, “Burden of Health

Problems Among U.S. Adolescents.”) But are

primary care physicians and other health care

professionals who come into contact with adolescents able to recognize and treat adolescent health

problems? How competent are health care professionals in caring for adolescents?

The analysis in this chapter suggests that improvements in the training and education of physicians who see adolescents and the training of

additional specialists in adolescent health care are

needed. The analysis also cites evidence that the

mainstream model of health service delivery—

Photo credit: Benjamin Smith, Washington, DC

Adolescents are commonly regarded as the healthiest of

Americans, yet OTA’s analysis suggests that adolescents

do have health problems and problems gaining

access to services.

which relies chiefly on the provision of care by

private office-basedphysicians who wait for patients

to seek them out2-does not fully meet the needs of

U.S. adolescents. In recent years, several innovations in health service delivery have attempted to

meet the needs of adolescents. The most prominent

1A unified deftition of primary care that clearly distinguishes it from specialty care does not exist (262,263). An early defiition of primary care

that was published in 1973 included the following elements: f~st contact care, comprehensive care, coordinated or integrated care, and care that is

longitudinal over time rather than episodic (263). First contact care is the extent to which a patient contacts the source of care whenever he or she perceives

anew need for care. Coordination of care entails a medical 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. hngitudinality of care is the extent to which a provider serves as

a source of care over time regardless of the presenee or absence of a particular type of problem (263).

%e “waiting’ stance in health care delivery, in which health care providers physically remain in a service system and wait for patients to seek them

out, has been distinguished from the ‘‘seeking’ model, in which health care providers make themselves more accessible to potential patients (2 19,308).

-111-7-
III-8 ● Adolescent Health-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

of these efforts-adolescent health care clinics,

so-called ‘free” clinics, multiservice centers, schoollinked health centers (SLHCs), and efforts to involve

adolescents in health services planning and management—are described in this chapter. The chapter

concludes with a discussion of possibilities for

Federal action to improve the delivery of health

services to U.S. adolescents.

Utilization of Ambulatory Care

by U.S. Adolescents

Visits by Adolescents to Physicians

Data pertaining to the utilization of outpatient

services by U.S. adolescents are quite limited. The

1985 National Ambulatory Medical Care Survey

(NAMCS) conducted by the National Center for

Health Statistics (NCHS) in the U.S. Department of

Health and Human Services (DHHS) provides some

data on visits to non-Federal office-based physicians, but the reader should keep in mind that

NAMCS has numerous limitations. 3 The chief

limitation of NAMCS is that it is a survey of

physicians rather than of patients. Because many

racial and ethnic minorities and Medicaid recipients

do not get their health care from private office-based

physicians, their health care utilization is not accurately reflected in NAMCS data. Another limitation

of NAMCS is that it excludes ambulatory visits to

physicians in hospital-based outpatient departments;

family planning clinics; government-operated clinics for sexually transmitted diseases, and maternal

and child health; SLHCs; hospital emergency facilities; and other sources of care used by adolescents.

Further, at least some adolescents may not be willing

to seek a private physician’s care for certain

problems. One survey of suburban high school

students found that the majority would not go to a

private physician for their concerns about sexuality,

substance abuse, or emotional upset and also would

not be willing to seek care for these problems with

their parents’ knowledge (175)!

Information about physician contacts is collected

in another NCHS survey, the National Health

Interview Survey (NHIS) (287).5 NHIS is a continuing nationwide survey of households, in which data

about health status and some aspects of health

services utilization, including physician contacts,

are collected from a probability sample of the

civilian noninstitutionalized population residing in

the United States. The 1988 NHIS included a special

focus on the health status of children and adolescents

through age 17 (287), but information on children

and adolescents under age 17 was collected from a

proxy respondent (typically the mother). NHIS

requests and reports information not just about

office visits to physicians but about all physician

contacts, whether in person or by telephone, for

examination, diagnosis, treatment, or advice, although office and clinic visits are reported separately to some extent (287). With two exceptions—

the exclusion of physician contacts with hospital

inpatients and the exclusion of physician contacts

for mass screenings (e.g., in a trailer)-physician

contacts mentioned by NHIS respondents are not

restricted by type of setting or funding source. As in

NAMCS, a contact is considered to be a physician

contact if the service is provided directly by the

Ssee ch. 6, “chronic Physical Illnesses: Prevention and Services,” in VOL H. k~,NAMCS is a probability sample survey of office-based

physicians, conducted annually horn 1975 through 1981 and again in 1985 (286). ‘he focus of the 1985 NAMCS is on office visits made within the

coterminous United States (i.e., excluding Alaska and Hawaii) by ambulatory patients to nonfederally employed physicians who are principally engaged

in offke-based patient care practice, but not in the specialties of anesthesiology, pathology, or radiology. Tklephone contacts and nonoffice visits are

excluded from the NAMCS. The 1985 NAMCS physician universe included 276,430 doctors of medicine and 11,776 doctors of osteopathy; but the 1985

NAMCS eligible physician sample included 4,104 physicians, and only 2,879 physicians (70.2 percent of eligible sampled physicians, and 1 perczmt

of physicians in the survey universe) actually participated in the survey. Responding physicians were asked to complete a survey instrument following

the NAMCS designj for a single week in the survey year. The 1985 NAMCS responding sample physicians completed a total of 71,594 patient records.

Physicians are not requested to oversimple for any particular patient populations (e.g., adolescents). NAMCS includes visits to private physicians’

offices; non-hospital-bx@ free-standing clinics; gToups, partnerships; staff-model Mti *MUUICCo_tiow neigh~bd ~~cen~, ~

privately operated clinics (except family planning clinics) (286). For purposes of NAMCS, an ‘oflkx’ is defined as ‘premises identified by physicians

as locations for their ambulatory practices, customarily including consultatiorq ex aminatioq or treatment spaces the patients associate with a particular

physician” (286). ‘l%e 1985 survey desigq and comparisons of 1985 findings with those for 1975 to 1981, are described more fully in the NCHS

publication% The National Ambulatory Me&”cal Care Survey: Um”tedStates, 1975-81 and1985 Trena3 (286). However, as do many Federal publications,

that publication typically disaggregate data for ages under 15 and 15 to 24 (see app. C, “Issues Related to the Lack of Information About Adolescent

Health and Health and Related Services” in Vol. I of this Report).

A~e mW age of ~e~ re~ndenfi: was 15.4 years, 52 perwmt were fernale, and 95 percent were white. Most had ~dy aCCt?SS @ m~c~ cm; w

percent used a specific private physician. The sample included 649 students in grades 9 to 12.

5NHIS ~d~ it CoIIats on me health status of adole~nts are described more fully in ch. 6, “Chronic Physical Illnesses: Prevention and s-ices, ’

in vol. Ir.
Chapter 15—Major Issues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents ● III-9

Table 15-1-Visits to Private Office-Based Physicians by U.S. Adolescents Ages

10 to 14 and 15 to 18, by Sex, 1985

Number of Number of

visits in Percentage visits per person

Sex and age thousands distribution per yeara

Both sexes

Ages 10 to 18 . . . . . . . . . . . . . . . . . . . . .

10 to 14 years. . . . . . . . . . . . . . . . . . .

15 to 18 years. . . . . . . . . . . . . ., ... ,

Female

Ages 10 to 18 . . . . . . . . . . . . . . . . . . . . .

10 to 14 years . . . . . . . . . . . . . . . . . . .

15 to 18 years ., ... , , . . . . . . . . . . . .

Male

Ages 10 to 18 . . . . . . . . . . . . . . . . . . . . .

10 to 14 years. . . . . . . . . . . . . . . . . . .

15 to 18 years . . . . . . . . . . . . . . . . . . .

50,218

23,852

26,366

27,041

11,974

15,067

23,177

11,878

11,299

100.070

47.5

52.5

53.8

23.8

30.0

46.2

23.7

22.5

1.6

1.4

1.8

1.7

1.4

2.1

1.4

1.4

1.5

aRatesare b~~on ~timatw of the civilian, noninstitutional ized adolescent population, excluding Al*~ and Hawaii,

as of July 1, 1985.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control,

National Center for Health Statistics, urwublished data from the 1985 National Ambulator Medical Care

Survey, Hyattsville, MD, 1989. ‘

physician or by a nurse or other person acting under

a physician’s supervision.

NAMCS data show that the rate of visits to private

office-based physicians by U.S. adolescents ages 10

through 18 in 1985 was 1.6 visits per person per year

(see table 15-1)---far less than the nationwide

average of 2.7 visits for all ages (285,286,288).

Female adolescents made an average of 1.7 visits per

person that year, while male adolescents made an

average of 1.4 visits per person (288). Older female

adolescents (ages 15 to 18) made more visits per

person than either younger female adolescents (ages

10 to 14) or adolescent males of all ages. On average,

female adolescents ages 15 to 18 saw a private

office-based physician 2.1 times per year (288).

There were no significant utilization differences

between older and younger male adolescents (288).

Data from NHIS are not completely comparable

to those from NAMCS; however, the 1988 NHIS

also suggests that adolescents have among the

lowest rates of physician contacts of any age groups

in the United States.6 Except for females ages 15 to

17, who would be expected to have a higher number

of physician contacts due to pregnancies,7 adolescents ages 12 to 14 and 15 to 17 had the lowest rates

of visits among those under age 18.8

Figure 15-1 shows NAMCS data on the distribution of visits to private office-based physician

specialists who cared for adolescents in 1985 by

physician specialty. NAMCS found that more than

one-third of adolescent visits in 1985 were to general

and family practice physicians (288). Another onequarter of adolescent visits were to pediatricians.

Adolescents ages 15 to 18 were much more likely

than 10- to 14-year-olds to see dermatologists and

obstetrician/gynecologists (288). More than 9 percent of older adolescents’ visits were to dermatologists, as compared with 3.5 percent of the younger

adolescents’ visits. Visits to obstetrician/gynecologists accounted for 7.4 percent of older adolescents’

visits but only 1.1 percent of younger adolescents’

visits. These differences probably reflect the greater

proportion of older adolescents who seek treatment

6NHIS fo~d that ~rsons ages 18 to 24 had the lowest rate of physician Contacts.

TSee ch. 6, “~nic I%ysica,l Illness: Prevention and Semices, ‘‘ in Vol. II, for a discussion of reasons for visits to off~ce-based physicians.

WCHS did not separate visits fmm telephone contacts, or visits by place separately for 12-to 17-year-old adolescents, but for 5- to 17-year-olds in

the aggregate, the rate of visits to physicians’ ofices not located in a hospital, health maintenance organization (HMO), or clim.c was 1.9 per person

in 1988, lower than for all other age groups. Across all age groups, the number of office visits per person in 1988 was 3.2. Persons age 65 and over had

the highest rate (5.1 for 65- to 74-year-olds, and 5.7 for those age 75 and over), followed by persons under 5 years (4.1),45 to 64 (3.6), 25 to 44 (3.0),

and 18 to 24 (2.1) (287). Similarly the rate of viw”ts to physicians in hospitals (including emergency rooms, clinics, and doctor’s offices located in a

hospital (287)) (0.4 per person per year) and other sites (includes anyplace not classified into the other categories, including clinics and HMOS not located

in hospitals (287) (0.4 per person per year) was lower for 5- to 17-year-olds than for all other age gmmps (287). The rate of telephone contacts was also

lowest for 5- to 17-year-olds compared to the other age groups shown by NCHS (287).
`III-10 . Adolescent Health-1401ume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Figure 15-l-Visits to Private Office-Based Physicians

by U.S. Adolescents Ages 10 to 18, by Physician

Specialty, 1985a

Estimated number of visits = 50,218,000

Orthopedic

surgery

(7%) All other specialties (7%)

b.Dermatology (7%)

Pediatri

(23%)

ral surgery (3%)

nolaryngology

ry (3%)

d%Ophthalmology (5%)

Internal medicine (5%)

%Si$$gj Obstetrics and

gynecology (4%)

(2%)

General and family practice

(35%)

apermntag= may not add up to 100 kwcause of rounding.

SOURCE: U.S. Department of Health and Human Services, Public Health

8ervice, Centers for Disease Control, National Centerfor Health

Statistics, unpublished data from the 1985 Nationai Ambulatory

Medical Care Survey, Hyatwille, MD, 1989.

for acne and the higher rates of sexual activity and

pregnancy among older female adolescents.9

Another finding of NAMCS was that over half of

the U.S. adolescents visiting a private office-based

physician in 1985 had a diagnostic test or procedure

(288). Blood pressure checks, urinalysis, blood tests,

and other lab tests were the most common (see table

15-2).

According to NAMCS, more than one-fourth (28

percent) of the adolescents who visited private

office-based physicians in 1985 received some type

of nonmedication therapy (288). Ambulatory surgery and counseling (other than diet counseling,

family planning, or psychotherapy) were the most

common (see table 15-3).

Some type of followup was planned for most (82

percent) of the adolescents who visited a private

office-based physician in

percent) required a return

15-2). There were very few

care providers, however.

According to NAMCS,

1985; nearly half (47

visit (288) (see figure

referrals to other health

most adolescents (62

percent) spent between 6 and 15 minutes during the

course of a private office-based physician visit in

1985 (288) (see figure 15-3). Only 4 percent spent

more than half an hour. Half of all visits (49 percent)

took 10 minutes or less. The average length of a visit

was 14 minutes, slightly less than the average length

of a visit for persons of all ages (16.5 minutes (286)).

As noted earlier, NAMCS data have limited use in

examining utilization differences by race and ethnicity. Still, some interesting comparisons can be made.

NAMCS found that black adolescents visited private

office-based physicians in 1985 at about half the rate

of white adolescents (0.9 v. 1.7 visits per person)

(see table 15-4) (288). The majority (89.2 percent) of

visits to private office-based physicians were made

by white adolescents; black adolescents accounted

for 8.7 percent of visits and Hispanics, 7.3 percent.10

The 1988 NHIS report on adolescents, which

distinguished only between black and white adolescents, supported the NAMCS finding that nonwhite

adolescents have less physician contact than do

white adolescents (287). Black adolescents ages 12

to 17 averaged 2.2 physician contacts in 1988, as

compared with 3.6 physician contacts for white

adolescents ages 12 to 17 (287).11

An important consideration in evaluating utilization of—and, by inference, access to-eare among

adolescents from racial and ethnic minorities is that

differences in utilization may more accurately reflect socioeconomic status (and financial access)

than racial and ethnic background. 12 It is not

9S= Ch. tj, “ch.rotic Physical Illnesses: Prevention and Services, “ in Vol. II, for further discussion of chronic physical illnesses and ch. 10,

“Pregnancy and parenting: Prevention and Services,‘‘ in Vol. II, for information on pregnancy and parenting among adolescents.

I@emenK d. not add t. 1~ &auW individu~s co~d be id~til~ on the NAMCS patient record ss both black/white and fispanichon-fisp~c

(286). (Other racial categories are “Aswn/Patilc Islander’ and “AmericanIndian/Alaska Native” (286).) The racial/ethnic distribution of the NAMCS

adolescent patient population is almost identical to the all ages population in NAMCS: according to NAMCS, 90 percent of NAMCS patients were white,

and 10 percent were ‘‘black and other” in 1985 (and in the years 1975 through 1981) (286). Further breakdowns for all ages are not provided in NAMCS

publications (e.g., 286); they are available as unpublished data from NCHS, but often the numbers of nonwhite patients are too small to be statistically

reliable, especially if further disaggqated by age groups (288).

11A of J~y 1, 1988, approx~tel~r 81 ~rc~t of tie adolescent pOp~@On (ages 10 to 18) wss white (both Hispimic ~d non-Hispanic); 16 percent

was black (including Hispanic and non-Hispanic); and 10 percent was Hispanic (of any race).

%slles in f~ial access to health scrviczs arc discussed in ck 16,4 ‘Financial Access to Health Services,” in this volume. The relationship between

poverty and racial and ethnic background, and nonfbancial issues in delivery of health and related services to poor adolescents and racial and ethnic

minority adolescents, are discussed in ch. 18, “Issues in the Delivery of Setvices to Selected Groups of Adolescents,” in this volume.
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . 111-11

Table 15-2—Visits to Private Office-Based Physicians by U.S. Adolescents Ages 10 to 18,

by Diagnostic Service and Sex, 1985

Number of

visits in Female Male

Diagnostic service thousands Both sexessadolescents adolescents

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Blood pressure check . . . . . . . . . . . . . . . . . . . . . . . . . .

Urinalysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other lab test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hematology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Glucose test.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Visual acuity... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pelvic exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Blood chemistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Breast exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pap test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rectal exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22,751

12,463

7,130

5,887

5,044

4,232

4,083

3,932

4,379

2,813

2,014

1,809

1,228

1,118

45.3%

24.8

14.2

11.7

10.0

8.4

8.1

7.8

8.8

5.6

4.0

3.6

2.4

2.2

40.9%

28.7

17.0

14.1

11.4

10.9

7.8

7.2

7.2

10.4

3.4

6.5

4.5

3.5

50.4%

20.3

10.9

8.9

8.5

5.6

8.4

8.6

10.5

—

4.7

0.2—

0.7

apermntag= maynottotalto IOObecause some visits mayhave ineluded more than oneservi-.

SOURCE: U.S. Department of Health and Human Services, Public Health Serviee, Centers for Disease Control National Center for Health Statistics,

unpublished datafromthe 1985 National Ambulatory Med.kal Care Survey, Hyattsville,MD, 1989.

Table 15-3—Visits to Private Office-Based Physicians

by U.S. Adolescents Ages 10 to 18, by Nonmedication

Therapy Ordered or Provided, 1985

Number of visits

Nonmedication therapy in thousands Percentage a

None . . . . . . . . . . . . . . . . . . . .

Ambulatory surgery . . . . . . . .

Other Counseling . . . . . . . . . .

Physiotherapy, . . . . . . . . . . . .

Diet counseling . . . . . . . . . . .

Family planning . . . . . . . . . . .

Psychotherapy. . . . . . . . . . . .

Corrective lenses . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . .

36,016

4,406

4,293

1,935

1,460

1,070

998

842

789

71.7%

8.8

8.5

3.8

2.9

2.1

2.0

1.7

1.6

aperantag= maynottotal to lmbecmses ornevisits mayhaveinchdd

more than one therapy.

SOURCE: U.S.DepartmentofHealth and Human Services, PubiicHeaith

Service, Centers for Disease Control, National Centerfor Health

statistics, unpublished data from the 1985 National Ambulatory

Medical Care Survey, Hyattsville, MD, 1989.

possible to analyze NAMCS data by patient socioeconomic status, and the 1988 NHIS did not present

physician contact information by family income

level for adolescents. NHIS did, however, present

physician contact information by family income

level for all children and adolescents under age 18

combined. NHIS found that children and adolescents in families with incomes between $10,000 and

$19,999 were the least likely of all children and

adolescents to have had any physician contact (75.3

percent had at least one contact) and had the lowest

number of contacts per person per year (3.5) (287).

Children and adolescents in families with incomes

below $10,000 had slightly fewer physician contacts

(4.4) than those with incomes between $20,000 and

$34,999 (4.6), and even fewer than those with

incomes of $35,000 or more (5.2) (287a).

Adolescent Hospitalizatjons

Hospitalization is a fairly rare event for U.S

adolescents. NHIS found that only 2.2 percent of

12- to 14-year-olds and 4.7 percent of 15- to

17-year-olds (3.5 percent when hospitalizations for

infant delivery were excluded for 15- to 17-yearolds) were reported as having been hospitalized in

1988 (287).13 These were the next to the lowest rates

among all age groups shown in the NHIS report;

only 5- to 1 l-year-olds had a lower hospitalization

rate (287).14 15

To some extent, the black-white differences found

in physician contacts for ambulatory care are also

found with respect to hospitalizations. According to

the 1988 NHIS, 1.7 percent of black 12-to 14-yearls~~e NHIS def~tioq a ho~itiation (’ ‘hospital episode’ is ‘any continuous period of stay of 1 night or more in a hospital u ~ @atient exmpt

the period of stay of a well newborn infant” (287).

ld~e rates were 2.5 percent for 5- to 7-year-olds and 2.0 percent for 8- to 1 l-year-olds (287). Across ldl age fgOUpS, 5.4 pXat of PrWm rwrt~

having been hospitalized in 1988; after age 18, the rate increased with age to 14.2 percent for those 75 and over (287).

ls~e 1~ad@ ~mns for hospi~fition of 10- to l&yea-ol& are discussed in ch. 6, “Chronic Physical Illnesses: prevention ad Services, ” ill VOI.

II.
III-12 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Figure 15-2—Visits to Private Office-Based

Physicians by U.S. Adolescents Ages 10 to 18,

by Disposition, 1985a

Return if needed

(30%) //--F”\fO’’Ow:~$’anned

\

Telephone followup

planned (4%)

“Referred to other

~ ‘ physician (2%)

“ Admitted to hospital

Other (l%) (l%)

Return at specified time

(47%)

aperantagw may not add to 100 bWWSS of rounding.

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, Centers for Disease Control, National Centerfor Health

Statistics, unpublished dati~from the 1985 National Ambulatory

Medical Care Survey, Hyaltsville, MD, 1989.

olds and 3.5 percent of black 15- to 17-year-oldsl6

were reported hospitalized in 1988, as compared

with 2.3 percent of white l2- to 14-year-olds, and 3.6

percent of white 15- to 17-year-olds17 (287). However, the lower the family income, the more likely

children and adolescents are to be hospitalized,

according to NHIS data (287).18

Guidelines for Screening and Well-Child

Care Visits

Little is known about what health screening

periodicity is most appropriate and effective for

adolescents, especially those at high risk for the

common morbidities of adolescence. The American

Academy of Pediatrics recommends that, from ages

10 to 18, adolescents should be screened every 2

years (10). The U.S. Preventive Services Task Force

concluded that, from ages 7’ to 18, except for routine

pap smears for sexually active females ages 13 to 18

and a tetanus-diphtheria booster for all adolescents

between ages 14 and 16, the scheduling of additional

visits and the frequency of individual preventive

Figure 15-3-Visits to Private Office-Based

Physicians by U.S. Adolescents Ages 10 to 18,

by Duration of Visit, 1985a

Estimated number of visits = 50,218,000

“-’’’esnA’e3:::Ytes:Ytes (au%] / ’

6-10 min

31 minutes & over

~

O minute s

b ‘4 % )

k (3%)

[

4

/

1-5 minutes

‘v (14%)

(32%)

apermntag~ may not add to 100 because of rounding.

bRepresen~ offi~ ~sits in which there was nO faC9-to-fa@ contact

between the patient and the physician.

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, Centers for Disease Control, National Centerfor Health

Statistics, unpublished data from the 1985 National Ambulatory

Medical Care Survey, Hyattsville, MD, 1989.

services should be left to clinical discretion because

of lack of data and differing patient risk profiles

(291).

Many physicians subscribe to the recommendation by some (e.g., 174) that adolescents should visit

a physician for well-child care and anticipatory

guidance at least once a year (28). OTA has not

examined the efficacy of any recommended schedules for routine periodic screening of adolescents.19

Health Care Professionals’ Interest in

and Ability To Care for Adolescents20

Attitudes of Pediatricians Toward Accepting

Adolescents Into Their Practices

Since 1972, the American Academy of Pediatrics

has officially endorsed pediatric care to continue

until age 21 and even beyond 21 years for certain

l~ese fiWes exclude deliveries; wi~ deliveries, 5.8 percent of black 15- to 17-ye$r-ohh were reported hospi~~.

17~esefiwes exclude deliv~es; wi~ deliv~es, 4.5 perceIItOf wfite 15- @ lT-ye~-Ol@ ~d 5.8 percent c)f b~k Is- to l’7-ytxu-o1ds were r(?p(Xtd

hospitalized. Racial differences in pregnancy and birth rata are discussed more fully inch. 10, “Pregnancy and Parenting: Revention and Services,”

in vol. Il.

18&-.@~~gto ~s, 5.8 ~rwnt of c~~en~dadole~ents @er age 18 witi f~y incomes less w$lo,~ were hospitalized in 1988, COmpti

to 4.0 percent with family incomes between $10,OCK3 and $19,999, 3.4 percent with family incomes between $20,000 and $34,999, and 2.8 percent with

family incomes of $35,000 or more (287).

l~e cost-~Wtiveness of well-child-care visits for younger children wss emod by OTA in its 1988 report Healthy Children: Investing in the

Future (274a).

~Much of ~ss~tion descri~s evidence ~cm & interpret~ ss somew~t criticd of physici~’, i.npticuliu pediatricians’, intermt in ~d ability

to care for adolescents. A major reascln the chapter discusses pediatricians in particular is that almost all information has been collected from and by

pediatricians. Thus, this group has also taken the lead in emmining its own abilities to care for adolescents.
Chapter 15—Major Issues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-13

Table 15-4-Visits to Private Office-Based Physicians by U.S. Adolescents Ages

10 to 18, by Patient’s Race and Ethnicity, 1985

Number of Number of

visits in Percentage visits per person

Patient’s race and ethnicity thousands distribution per yeara

All visits . . . . . . . . . . . . . . . . . . . . . . . . . . 50,218 1 00.0% 1.6

Race

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44,812 89.2 1.7

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,365 8.7 0.9

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,040 2.1 1.1

Ethnicity

Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . 3,653 7.3 NA

Not Hispanic . . . . . . . . . . . . . . . . . . . . . . 46,564 92.7 NA

NA - Not available.

aRates are based on estjmates of the civilian noninstitutionalized population of the United States, exekfing Jksk3 and

Hawaii, as of July 1, 1990.

SOURCE: U.S. Department of Health and Human Services, Public Health Serviee, Centers for Disease Control,

National Center for Health Statistics, unpublished data from the 198!5 National Ambujato~ Medi~l Care

Survey, Hyattsville, MD, 1989.

young people with chronic illness or disability (15).

A study of Midwestern physicians conducted in

1980 to 1981 found, however, that only 40 percent

of pediatricians continued adolescent care to the age

of 18 (226). Pediatricians’ practice policies for

cutoff ages differed for accepting new patients into

their practices and continuing a professional relationship with established adolescent patients. Sixteen percent of pediatricians would not accept a new

patient into their practices who had reached the age

of 15, and 42 percent would not accept a new patient

who had reached the age of 16. For adolescent

patients already established in a pediatric practice, 7

percent of pediatricians would end their care by the

time the patient reached 15 years, and 20 percent by

the time the patient became 16 years old.

In general, the pediatricians participating in this

study who had low self-assessed competence in

handling traditional adolescent problems (especially

in contraceptive needs and emotional problems)

were more likely to use age cutoff policies than

others (226). However, insufficient training in adolescent medicine and discomfort with adolescents

were not usually given as reasons for pediatricians’

use of an adolescent age cutoff policy (12 and 7

percent of responses, respectively). The most frequent reason cited for an age cutoff policy was a

group practice’s preestablished decision (37 percent

of responses) rather than a decision made by an

individual pediatrician participating in the survey.

This study also reported that almost 90 percent of

pediatricians did not anticipate any further changes

in their practices’ age cutoff policies (226). More

recent information concerning physician age cutoff

policies is not available.

Midwestern physicians practicing general-family

medicine, obstetrics/gynecology, pediatrics, internal

medicine, and psychiatry have also been surveyed

by mail (207). In general, these physicians were only

moderately interested in adolescent health care, with

only 28 percent of the sample expressing a definite

interest. The return rate of this survey was only 34

percent; however, one can surmise that nonparticipating physicians were even less interested in

adolescent health care than were respondents.

Time Spent With Adolescent Patients

How Much Time Do Office-Based Physicians Spend

With Adolescent Patients?

As noted earlier, the 1985 NAMCS found that the

most common amount of time that private officebased physicians spent with adolescent patients was

between 6 and 10 minutes; the second most common

amount of time was between 11 and 15 minutes (see

figure 15-3).21 An earlier national study of pediatricians determined that, on average, the duration of

visits was 11.0 minutes with younger adolescents

(ages 10 to 14) and 11.6 minutes with older

adolescents (ages 15 to 19). Pediatricians spent an

z]It is ~tme~~g t. note titlen~ ofvisi~ t. ~hool-~~ he~th centers (SLHCS) by adolescents is substi~ly longer. me Robertwood Johnson

Foundation has found that more than 80 percent of the visits to the 23 SLHCS that it supported in the 1988-89 and 1989-90 school years lasted more

than 10 minutes and 46 pereent lasted more than 20 minutes (see section below entitled “Innovations in the Delivery of Health and Related Services

to Adolescents”).
III-14 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

average of approximately 1 minute more with

adolescents than they did with other noninfant

patients (115).

How Much Anticipatory Guidance Do Adolescent

Patients Receive?

An area of specific physician behavior that many

believe could enhance adolescents’ health is ‘anticipatory guidance, ’ or counseling about topics important for health and well-being. The American

Academy of Pediatrics recommends that pediatricians routinely address a range of topics with

adolescent patients (10).22 Clearly, helpful discussion can be time-consuming. It should be noted,

however, that very few pediatricians (fewer than 2

percent) stated that they had established age cutoffs

for adolescent patients because of excessive time

demands of this age group (226).

A direct observation study of office-based general

pediatricians found that they spent an average of

7 seconds on anticipatory guidance for adolescent

patients ages 13 to 18, 37 seconds for children ages

5 to 12, and 87 seconds for older infants (223). It

should be noted that the pediatricians observed in

this regional study contrasted with the physicians

included in the national sample because those in the

regional study averaged fewer minutes for total visit

time with adolescent patients (8.4 minutes). However, this study also determined that younger physicians and those in group practice were more likely to

spend more time with their patients in general, and

that the mean proportion of visit time spent addressing anticipatory guidance issues was greater (223).

The content of physician-provided adolescent

health counseling has been studied using three

different designs. A direct observation study of

pediatricians documented that 88 percent of anticipatory guidance time was divided between discussion of potential organic problems (54 percent) and

immunizations (34 percent). Nutritional issues accounted for 2 percent, and development accounted

for 4 percent of health counseling time. Behavioral

issues, sex education, and safety issues were not

addressed by this sample of pediatricians (223).

A second study surveyed a national sample of

pediatricians to explore their practices and attitudes

toward efforts to prevent adult heart disease. It found

that approximately 80 percent of pediatricians stated

that they routinely discussed cigarette smoking, 78

percent discussed exercise, and 48 percent routinely

discussed diet with their adolescent patients during

health maintenance visits (191).

The third study that explored physicians’ provision of health counseling to adolescents was a

questionnaire survey of college freshmen. Its findings appear to contradict what physicians have

stated to be their routine practices. The majority of

this study’s older adolescent respondents reported

that they had received no health counseling from

their physicians on the following subjects: cigarette

smoking (76 percent), alcohol/drug use (80/82

percent), depression/suicide (82/90 percent), stress

(69 percent), seat belt use (90 percent), contraception (81 percent), sexually transmitted diseases (79

percent), and heart disease prevention (81 percent).

General nutrition counseling was not recalled by 46

percent of college freshmen. In general, internists

were more likely to provide health counseling on

cigarette use, substance use, and heart disease

prevention than were pediatricians, and more likely

than family/general practitioners to discuss cigarette

use and alcohol use according to the students’

recollections. Both internists and pediatricians were

more likely to provide counseling on weight control

and nutrition than were family/general practitioners.

This study also found no correlation between the

level of counseling provided and college students’

reported involvement in health-compromising behaviors. The length of the doctor-patient relationship

did not seem to influence the likelihood of physicians’ provision of health counseling to their adolescent patients (130).

A 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 (170). The study is somewhat flawed in that both questions were asked

simultaneously; the results would be more valid if

the responses had been independent. In addition, the

study was conducted in Canada and may not apply

to the experience of U.S. adolescents. However,

~~e rmge of topics tit can pol~n~y be discussed by pediatricians is quite extensive (10), An offkial of the American Academy of Pediatrics

notes that in practice, physicians will generally lead with only a couple of basic questions (e.g., How are things going in school? How we things at home?

How are things going with friends?). If “red flags” are raised during responses to these questions, the physician will pursue with the more pointed

questions listed in the American Academy of Pediatrics’ guidelines (240).
Chapter 15—Major Issues Pertaining to the Delivetry of Primary & Comprehensive Health Services to Adolescents . ///-15

results of the study were consistent with previous

studies that found diverging interests of health care

providers and adolescents (see 170, 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, adolescents reported that discussion of issues

of interest to them took place considerably less

frequently than the adolescents desired.23 As discussed in chapter 6 of this Report,24 other studies

have found that adolescents and health care providers often disagree on what are the adolescents’ most

important health care needs.

Physicians’ Attitudes Toward Confidential

Health Care for Adolescents

Another important area of physician behavio r

regarding adolescent health care is patient confidentiality. Concerns about confidentiality may limi t

adolescents’ access to needed services.

25 A study in

Canada found that adolescents expressed a preference for seeking contraceptive services from family

planning clinics rather than from their family

physicians because they believed that their confidentiality would be broken and their parents informed (309).

Two separate studies have explored physicians’

attitudes toward confidential health care for adolescents.26 The first study was a national survey of all

physician members belonging to The Society for

Adolescent Medicine and a random sample of

pediatricians (166). This study found that 75 percent

of the surveyed physicians strongly supported patient confidentiality, especially around sexuality

issues and especially for adolescents who appeared

mature. Physicians who spent more than 20 percent

of their practice time with adolescent patients,

physicians who had formally declared their special

interest in adolescents through membership in The

Society for Adolescent Medicine, and younger

physicians (under age 44) were all more likely to

support confidential health care for adolescents

(166).

A more recent study, also conducted as a mail

survey of practicing physicians, was a regional

investigation of physicians’ attitudes toward using

deception to resolve difficult ethical problems (202).

The sample was composed of general practitioners,

surgeons, obstetricians, gynecologists, and internists. In this study, the majority of general practitioners, surgeons, and internists (61 percent overall)

stated that they would inform the mother of a

pregnant 15-year-old about her daughter’s pregnancy, despite the adolescent strongly stated desire

that the physician not break her confidence. The

hypothetical adolescent was planning to seek termination of her pregnancy, despite her parents’ disapproval. In contrast to other physician groups, the

majority of obstetrician-gynecologists (63 percent)

stated that they would withhold information about

this patient’s pregnancy from her mother. In addition, obstetrician-gynecologists were twice as likely

as physicians from other groups to cite respect for

confidentiality as their justification for not informing the adolescent’s mother. Physician age appeared

to be directly correlated with their decisions; the

older the physician, the more likely he or she was to

inform the parent of the adolescent’s pregnancy

(202). In Summary, it appears as though physicians

who have child- and adolescent-oriented training

backgrounds, physicians experienced in reproductive health care, and younger physicians are more

likely to honor adolescent patients’ requests for

confidential health care.

Health Care Providers’ Competence

in Diagnosing and Treating Adolescents’

Specific Problems

How Effectively Do Physicians Recognize

Adolescent Problems?

Avery small body of empirical work has explored

how well primary care physicians recognize specific

adolescent health problems. Most studies in this area

have focused on the identification of mental health

and substance abuse problems. Further, most studies

have been conducted by and among pediatricians.

L~IU order by level of interest the topics were: physical fimess, nutrition, gOW@ WXU~lY transmitted diseases, contraception acne, fear of cancer,

obesity, feelings of depression lack of cotildence. The discrepancies between adolescent interest and adolescent reports of physicians’ having discussed

the issue are given in ch. 6, “Chronic Physical Illnesses: Prevention and Services,” in Vol. II.

U* ‘~~c nysical Iktises: prevention and Sewices, ’ iU VOL H.

~For ~er discussion see Ch. 17, ‘‘Consent and Confidentiality in Adolescent Health Care Decisionmakm“ g,” in this volume.

MSW ch. 17, $ ‘Cement and Confidentiality in Adolescent Health Care Decisionmtig, ‘‘ in this volume for a discussion of professional ethical

standards relevant to consent and cotildentiality.
111-16. Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

The performance of physicians practicing internal

medicine or family practice is as yet untested. Little

research has explored physicians’ effectiveness in

diagnosing or managing other problems common

among adolescents.

Physicians’ Identification of Emotional and

Behavioral Problems--Primary care physicians

appear to have difficulty in identifying children who

have behavioral or emotional problems. Most of the

studies cited in this section were performed on

general pediatric populations or on preadolescent

children. Data relevant to adolescents are specified.

The identification of mental health problems

among children and adolescents is a controversial

issue. A scheduled national study of the prevalence

of mental health problems among children and

adolescents is still in a pilot-study phase. Until that

study is completed, comparisons of physician identification rates with overall prevalence rates based on

epidemiologic studies should be viewed cautiously.

The most recent studies suggest that between 18 and

22 percent of U.S. adolescents have mental health

problems requiring treatment.27 In contrast, a study

of pediatricians practices found that only 7.9

percent of 10- to 18-year-olds were judged to have

mental health problems (103). Several other studies

have found that psychiatric diagnoses made by

pediatricians in prepaid group practices (including

health maintenance organizations) ranked from

2 to 10 percent among the enrolled populations, and

between 3 and 12 percent for patients who actually

used the facility’s health care services (36,66,69, 124).

A study of seven primary care facilities found that

the proportion of children who were recognized as

having behavioral, educational, or social problems

varied between 5 and 15 percent by institution (265).

This study appeared to use broader categories of

problems than did other studies, which may explain

its higher rates.

Thus, epidemiologic studies using standardized

detailed assessment tools show a significantly higher

proportion of children as having behavioral and

emotional problems than do prevalence studies

based on pediatricians’ clinical assessments. However, this observation does not answer the question

of how well pediatricians identify children with

Photo credit: Zacchaeus Medical Clink, Washington, DC

Available evidence suggests that many primary care

physicians do not feel comfortable treating adolescents

and tend to underdiagnose certain types of problems

in adolescents.

emotional and behavioral problems. Two separate

studies specifically addressed this question. Each

study compared pediatricians’ reports with detailed,

comprehensive psychiatric assessments that were

made independently. The design of the first study

was based on a psychiatrist’s best estimate of a

DSM-III diagnosis28 in an individual child, synthesizing data from three sources: 1) direct interviews

of parents, 2) direct interviews of children, and 3)

standardized questionnaires (59). The children included in this study ranged between ages 6 and 17.

Adolescent-based data were not analyzed separately, but the study sample must have contained a

relatively large proportion of adolescents because its

mean age was approximately 14 years. This study

found very little correlation between pediatricians’

reports of psychiatric and behavioral problems and

assessments made by the psychiatrist and very little

27 SWch. II, ‘Men~ H4thproblems: pr~ention and Treatment,’ inVol. II, fora discussion of thepreva.lenee of adoleseentmental health probkns.

2$A DSM.~ dia~os~ is a dia~osis of a men~ &SOr&X based on the criteria put folih h the ATIleriCtUl psychhtic ASSOChtiOI1’S Diagnostic ad

Statistical Manual, 3rd edition (23a).
Chapter 15—Major lssues Pertaining to the Delivey of Primary & Comprehensive Health Services to Adolescents . III-17

correlation between pediatricians’ reports and independent reports by the children and their parents. In

addition, the study found, pediatricians underreported both major and less serious psychiatric

problems. Overall sensitivity 29 of pediatricians’

reports in this study was 38 percent using the

psychiatrist’s synthesis and judgment as the standard. For example, pediatricians identified only 7 (35

percent) of 20 depressed children.

The second study involved children ages 7 to 11

attending pediatric primary care clinics in a health

maintenance organization (71). Pediatricians’ judgments about the presence or absence of emotional

and behavioral problems were compared with scores

of two previously validated instruments: the “Child

Behavior Checklist,’ which is a well-known parental questionnaire that screens for social competence

and behavior problems, and the ‘‘Diagnostic Interview Schedule for Children, ’ a set of two structured

psychiatric interviews for children and their parents

that are designed for use in epidemiologic studies.

This study found that the standardized psychiatric

assessment identified twice as many children (1 1.8

percent) as having problems as the pediatricians did

(5.6 percent). Specific examples include pediatricians identifying one-third of the children independently diagnosed as having attention deficit disorder,

35 percent of the children with conduct disorder or

oppositional disorder, and 21 percent of the children

with anxiety disorder and phobias. Only one of the

five children diagnosed as having depression was

identified by a pediatrician. Overall, pediatricians

failed to identify 83 percent of children with

psychiatric problems. In contrast to the findings of

the previously cited study (59), this study found

pediatricians’ diagnoses to be highly specific; that

is, they correctly identified 84 percent of the

psychologically healthy children (71).

There are several reasons why primary care

physicians such as pediatricians may not identify

emotional and behavioral problems very effectively.

Short visits are a frequently mentioned barrier to the

identification of such problems (58,136). It is clearly

not possible to achieve knowledge and understanding of an individual’s social and psychological

functioning in brief amounts of time.

A second reason for primary care physicians’

tendency to underdiagnose behavioral and emotional problems may be that some adolescents and

their parents do not initiate discussion of emotional

and behavioral issues with their primary care physicians (58). However, a study conducted in 1%9

found that 12 percent of mothers attending a

pediatric outpatient department in an urban teaching

hospital generated spontaneous written concerns

about their children’s behavior or mental health

(264). The same study reported that even when these

concerns were written, physicians recorded their

recognition of less than half. Physicians were more

likely to document their awareness of mothers’

written concerns about their childrens somatic

problems (78 percent recognition rate) than their

concerns about behavioral issues (42 percent recognition rate).

The third major reason that may explain primary

care physicians’ tendency to underdiagnose behavioral and emotional problems is that many primary

care physicians have not had much formal education

and training in this area (136).

Physicians’ Identification of Substance Abuse

Problems30—Although physicians believe that drug

and alcohol use is a serious problem among adolescents and they report willingness to deal with

adolescents’ substance use problems, the available

evidence does not suggest that physicians, as a

group, are currently able to identify substance abuse

problems very effectively.

A recent national study of 617 primary care

practitioners conducted by the American Medical

Association (AMA) found that physicians appeared

willing to provide counseling for adolescents with

alcohol problems, and to refer them for specialized

substance abuse treatment (23). More than half (55

percent) of the surveyed physicians stated that the

misuse of alcohol among adolescents is a very

serious problem. Almost three-quarters (72 percent)

of the responding physicians reported having seen or

counseled at least one adolescent with an identified

alcohol problem in their medical practices; the most

common response was two adolescent patients.

One-third of physicians had counseled between 1

and 5 adolescent patients for alcohol problems, and

~~en~itiviv is one memwe of tie v~idiv (or awuacy) of a dia=ostic or screening test: the percentage Of all t.kw who actiy ~ve he -dibon

being tested for and who are correctly identifkd as positive by the test.

WS= Ch. 12, “Alcohol, Tobacco, and Drug Abuse: Prevention and sWiCt%, “ in Vol. II for a discussion of the prevalence of drug and alcohol abuse

among adolescents.
III-18 . Adolescent Health--Volume III: Crosscutting Issues in the Delivery of Health and Related Services

an additional 12 percent of physicians had counseled

6 to 10 adolescent patients for this problem. It should

be noted that the average percentage of patients

between ages 12 and 18 for this physician sample

was 13.4 percent. More than one-third (36 percent)

of the surveyed physicians’ practices contained less

than 10 percent adolescents, and only 15 percent of

practices contained at least one-quarter adolescent

patients. This published data set did not determine

the relationship between percentage of adolescent

patients in a practice and the likelihood of a

physician’s providing counseling for an alcohol

problem. In addition, this study did not explore

whether the physicians had actually independently

identified adolescent patients with alcohol problems

or had provided counseling for patients with previously known alcohol problems. Although this study

included physicians from several different primary

care specialties (family and general practice, pediatrics, internal medicine, obstetrics-gynecology), it

did not categorize response by specialty.

The large majority of physicians (73 percent) in

the AMA study stated that they had initiated

discussion about alcohol use with their adolescent

patients; fewer physicians (57 percent) had initiated

discussion concerning alcohol use with their adolescent patients’ parents. Almost 90 percent of surveyed physicians (89 percent) favored including

counseling and treatment for alcohol use as part of

their practices. The vast majority (99 percent) of

surveyed physicians stated, however, that they

would not treat adolescents with a serious alcohol

problem by themselves, but they would include

referral to a specialized treatment program for

problem drinkers.

Despite physicians’ willingness to treat minor

problems related to substance use and appropriately

refer more serious problems, it is probable that, as a

group, physicians do not identify substance abuse

problems very effectively. Supporting data are based

on studies conducted in teaching hospitals. Even

though these studies did not include office-based

physicians, it is not likely that their group performance would be better, given that practicing physicians are the products of teaching hospitals, and that

physician education and training in the area of

substance abuse is a recent phenomenon (1 10,161).

The first study was conducted at the Johns

Hopkins Hospital in Baltimore (187). Although it

concerned the diagnosis of alcoholism in adult

patients, the study’s findings probably reflect the

issues relevant for adolescent patients. The purpose

of this study was to determine how well physiciansin-training (i.e., residents) and physician faculty

detected alcoholism in hospitalized patients. The

large majority of patients were admitted to the

hospital for problems other than alcoholism. The

patients were screened independently for alcoholism

by structured interview and questionnaire. Physicians were interviewed about individual patients to

determine whether they had diagnosed any alcoholrelated problems, how their diagnoses were determined, and what treatment plans had been made. It

was found that house officers’ and faculty physicians’ detection rates varied between O and 66

percent depending on clinical specialty. In general,

faculty physicians performed no better than their

trainees, the resident physicians; in fact, the house

officers (residents) of some specialty services were

more successful than their faculty in identifying

alcohol problems. Overall, psychiatrists performed

better than other specialists; they correctly identified

two-thirds of patients with alcohol-related problems.

Internists successfully identified 35 to 52 percent of

patients, surgeons identified only 20 to 27 percent of

patients, and gynecologists were virtually unable to

identify any patient as having an alcohol problem;

their sensitivity was O to 7 percent (187).

A second study was conducted in the emergency

department of an urban teaching hospital (58). This

study reviewed the medical records of 346 motor

vehicle accident patients to determine the surveillance of alcohol intoxication by surgical resident

physicians. This study found that only 25 percent of

these patients were tested for blood alcohol concentration even though current textbooks recommended

routine testing of all trauma patients for alcohol use.

A State law that was enacted during the course of the

study allowed a hospital laboratory’s analysis of

patients’ blood to be used to establish probable cause

for drinking. This law did not affect the surgical

residents’ rates of deter-mining patients’ blood alcohol concentration levels. In addition, no patient was

referred by these surgical residents for further

evaluation or treatment of alcohol abuse (58). This

study’s findings of surgical residents’ inattention to

alcohol problems are similar to the earlier study’s

findings.

Two studies have attempted to assess physicians’

detection of substance abuse problems in an adolescent patient population. In a study by Oelberg and
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-19

Finkelstein of the patient records of hospitalized

adolescents, the majority of internal medicine and

obstetric/gynecologic records contained documentation of a history of smoking and alcohol use;

pediatric and surgical records did not contain such

documentation (204). However, very few records

from any specialty service contained information

concerning illicit drug use.

In a more recent study, 54 new adolescent patients

presenting for outpatient care in an urban teaching

hospital’s adolescent medicine program each completed a structured questionnaire designed especially to assess adolescent patients’ involvement

with drugs and alcohol (254). The responsible

medical clinicians independently judged the likelihoods of their individual patients as having substance abuse problems. Thirty-seven percent of

patients independently self-reported substance use

at sufficiently high levels to be considered abusers.

The sensitivity of medical providers’ judgments was

only 25 percent, and the positive predictive values

(concordance between medical provider and patient’s self-report on the presence of substance

abuse) was only 46 percent, slightly worse than

chance alone. In this study, as in others based on

adult patient samples, medical providers greatly

underestimated the presence of substance abuse

problems (254).

There are several reasons for physicians’ relatively poor performance in identifying substance

abuse problems. First, historically, medical schools

and residency training programs have not addressed

the issue of substance abuse. Although this situation

is changing, with both schools and individual

training programs now incorporating substance abuse

issues into their curricula, physicians who are

already in practice will not be exposed to this body

of knowledge. One study, conducted among medical

students and resident physicians in 1986-87, found

a strong relationship between trainees’ perceived

role responsibility regarding alcoholic patients, self-

-confidence in their skills, and their reported screening and referral practices (97). In particular, trainees

with higher levels of self-confidence in their skills

had enhanced perceptions of their role responsibilities for screening patients for alcoholism and for

providing interventions through referral. Physician

resistance to caring for patients with substance abuse

problems is thought to be related to their lack of

formal learning and preparation (136).

A second barrier to physician identification of

substance abuse problems is related to patient

attitudes. Probably a majority of patients with

substance abuse problems deny that they have such

a problem and resist evaluation and intervention

efforts (136). Adolescents may be particularly reluctant to admit substance use to a health professional

when a parentis present during the visit. One survey

of 54 substance-abusing adolescents found that 46

percent responded dishonestly to a physician’s

questions about alcohol or drug use, often because a

parent was present (96). Even well-meaning physicians, if they lack appropriate assessment skills, may

not be able to identify substance abuse problems.

The third major barrier to identification of substance abuse disorders is organizational. Assessment

of substance abuse disorders is time-consuming, and

in general, primary care practitioners may not be

adequately reimbursed for time spent with and on

behalf of patients with substance abuse problems

(136). In addition, it maybe difficult for physicians

to gain access to treatment resources for their

patients .31

Physicians’ Identification of Physical Problems--

For the most part, the ability of physicians to identify

physical problems in adolescents has not been

studied empirically (28). An example of a group of

physical problems that has received some study—

albeit minimally-is dermatological problems. Additionally, one study examined how well hospitalized adolescents are screened for a variety of

physical problems.

Primary Care Physicians’ Ability To Identify

Dermatological Problems--Primary care physicians’

identification of dermatological problems has been

studied minimally; their ability to manage such

problems has not been studied at all. Dermatological

problems are a leading reason for adolescent visits to

physicians. 32 However, dermatologists provide care

31s= Ch. 16, 1‘Financial Access to Health Services, ‘‘ in this volume, for a discussion of fucial issues in adolescents’ access to substance abuse

treatment and ch. 12, “Alcohol, Tobacco, and Drug Abuse: Prevention and Services, “ in Vol. II, for a discussion of other issues in gaining access to

substance abuse treatment services for adolescents.

SZS& Ch. 6, $ ‘ChrOniC Physical Illnesses: Prevention and Servic% ‘‘ in Vol. II, for a discussion of common physical problems in adolescence. Also

see “Health Care of MolesCents by Office-Based Physicians: National Ambulatory Medical Care Sumey” (2S4).
111-20. Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

for only 37 percent of dermatological problems

overall; the remainder are largely seen by primary

care physicians (132).

A study of 285 adult primary care providers

(family and general practitioners and internists)

found that, on the average, these physicians correctly

identified only 54 percent of 20 commonly seen or

serious dermatoses (dermatological problems) (2 18).

The majority of these common skin problems are

also seen in adolescent patients. Interestingly, acne,

the dermatosis most prevalent in adolescents, was

correctly identified by 94 percent of these primary

care physicians (218). A similarly designed study

evaluated how well pediatric residents are able to

identify 20 common skin disorders (217). This study

found that the residents’ average score was 53

percent; level of training, had little effect on test

score. Again, however, a relatively high percentage

of residents (68 percent) correctly identified acne

(217). However, these studies do not address whether

dermatological problems were identified in the

context of a visit not specifically related to dermatological problems.

No empirical study has addressed how effectively

primary care physicians actually manage skin problems. The documented difficulty in diagnosis may

imply that management is not optimal. It is not clear

how frequently primary care physicians refer patients to dermatologists or how they decide which

patients should be referred. Only 7 percent of

dermatologists’ patients overall are referred by other

physicians (132). One can infer from a readership

survey of a widely circulated journal, which pediatricians receive free of charge, that pediatricians

make selective referrals to dermatologists (68). A

majority of pediatricians (58 percent) responded that

they have referred patients for dermatological care.

This same survey found that approximately half (51

percent) of pediatricians ‘‘usually refer patients for

psoriasis. In contrast, the readership survey found

that patients with acne were referred only 13 percent

of the time by pediatricians (68). This lower rate of

referral may be consistent with pediatricians’ higher

rate of ability (68 percent) to diagnose acne accurately (217).

Physicians’ Collection of Information on Hospitalized Adolescents--A single study examined how

frequently physicians from different specialties collect complete data on hospitalized adolescent patients (204). This study found that no hospital

service, including pediatrics, internal medicine,

obstetrics and gynecology, and surgery, collected

complete historical information or documented

growth parameters consistently on their adolescent

patients.33

Different patterns of strengths and weaknesses

emerged for each specialty. The majority of records

contained past medical histories and family medical

histories. Pediatric records were more likely to

contain perinatal, immunization, school, and social

histories than were the medical records of other

specialties. Only records from the obstetric/

gynecologic service consistently recorded menstrual

histories in female adolescents.

This study also suggests that adolescent anemia

may be underdiagnosed (204). Complete blood

counts were recorded for almost all patients in all

specialties, so that the necessary laboratory data for

a diagnosis of anemia were present. Although this

study’s authors did not provide the reference hematologic parameters by which they regarded anemia to

be present, their personal chart review suggested that

37.6 percent of the hospitalized adolescents should

have been diagnosed as anemic. However, anemia

was actually documented as a problem in only 9.6

percent of the reviewed records.

How Do Health Care Professionals Perceive Their

Competence To Provide Health Care to

Adolescents?

Several recent studies have explored residents’

and medical students’ self-perceived interest and

clinical efficacy in caring for adolescents. Several

studies have phrased the question in terms of

perceived deficiencies in training.

Self-Perceived Competence of Physicians-A

1981 study examined the perceptions of pediatric

and internal medicine residents in a single teaching

institution (255). Findings were reported for residents at the conclusion of their 3-year training

programs. This study found that pediatric residents

were more likely than internal medicine residents to

consider various skills necessary to the practice of

adolescent medicine as important. Furthermore,

pediatric residents generally considered themselves

more skilled than did internal medicine residents for

33~ f~~ to docwent that a topic waa discusscd does not necessarily indicate that the topic was not discussed (275).
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-21

this same set of tasks. When reproductive health

issues were explored, however, both sets of residents

were less apt to consider themselves skilled in

providing specific contraceptive services (e.g., counseling, prescribing oral contraceptives, fitting patients for diaphragms, or inserting/removing intrauterine devices). The other major reproductive

health issue considered by this study concerned

counseling about and treatment for sexually transmitted diseases. In contrast to differences found in

self-perceived contraceptive counseling skills, the

large majority of both internal medicine and pediatric residents felt skilled in these two aspects of

patient care for sexually transmitted diseases.

This study also tapped residents’ willingness to

become personally involved in the evaluation of

adolescent patients with specific problems (255).

The majority of graduating internal medicine and

pediatric residents in the study planned to become

involved in adolescent patient care. However, patient age was an important determinin g factor. In

general, pediatric residents were more likely to refer

older adolescent patients (study example: age 19) for

evaluation of specific problems; conversely, internal

medicine residents were more likely to refer younger

adolescent patients (study example: age 15) for

evaluation. In addition, residents were more likely to

refer adolescents who presented with psychosocial

problems (study examples: contraception, alcohol

abuse, parental abuse) than with medical problems.

This study concluded that pediatric residents

considered themselves better prepared than internal

medicine residents for the care of adolescent patients. However, both groups of residents lacked

confidence in their counseling and contraceptive

skills. The study’s author commented that the very

problems for which many adolescents seek or need

care may be the problems that primary care physicians choose not to manage (255).

A similar study, conducted during 1984, surveyed

all residents enrolled in a single community teaching

hospital’s six training programs (107). The six

residency programs studied included family practice, internal medicine, pediatrics, emergency medicine, obstetrics/gynecology, and combined internal

medicine/pediatrics. The majority of surveyed residents expected to have clinical practice careers.

Many of this study’s findings were consistent with

the previously cited study’s findings: Residents

considered themselves relatively unskilled in the

areas of sexuality, handicaps, endocrine problems,

contraception, and psychosocial concerns. Residents from each training program identified specific

areas of relative strength and weakness. Internal

medicine residents were uncomfortable with gynecologic problems and contraception. Family practice

residents, although confident about contraceptive

and pregnancy issues, felt no more skilled than

residents from other specialty groups in managing

psychosocial issues. Emergency medicine residents

assessed their skill levels as relatively high in

managing adolescent crises and acute illnesses,

problems that are likely to present at an emergency

department. Residents in obstetrics/gynecology felt

confident only for problems and issues that are

classically considered within their expertise; they

felt uncomfortable with medical problems and

psychosocial problems other than sexual behavior

and pregnancy. In contrast, pediatric residents did

not feel skilled in gynecologic issues or in providing

contraceptive care.

Pediatricians practicing in Los Angeles County

were surveyed by mail (l%). Although these

pediatricians felt competent in managing general

medical issues of adolescence, they rated their

efficacy, comfort, and training experiences as somewhat lower for psychosocial issues, and as significantly lower for issues concerning sexual activity

and pelvic examination. They were also less likely

to regard these latter two areas as important to their

practices. However, more than one-third (37 percent) of these pediatricians declared their need for

greater expertise in gynecology and pelvic examination. In addition, 25 percent wanted more training

around psychosocial problems.

The Midwestern physicians practicing generalfamily medicine, obstetrics/gynecology, pediatrics,

internal medicine, and psychiatry who were surveyed by mail about their interest in adolescent

health care were also asked about their selfperceived competence in providing care to adolescents (207). Self-perceived competence varied by

specialty, with no specialty feeling competent to

address all problem areas included in this study. At

least 50 percent of general-family practitioners felt

competent to manage 8 of the 10 service areas listed

by the study, and at least 50 percent of pediatricians

felt competent to manage 5 areas. Internists, obstetricians-gynecologists, and psychiatrists had significantly narrower foci of perceived self-competence.

The majority of physicians from medical specialties
III-22 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

did not perceive themselves competent in counseling. No specialty felt particularly confident about

substance abuse issues, although approximately

two-thirds of general-family practitioners (65 percent) and psychiatrists (68 percent) felt competent in

this area. Approximately half of pediatricians (54

percent) and psychiatrists (50 percent) and only 41

percent of internists felt competent to address sexual

concerns with regard to (adolescents, although the

large majority of general-family practitioners (89

percent) and obstetrician-gynecologists (96 percent)

felt comfortable in this area. Consistent with this

finding were the low levels of self-perceived expertise in family planning perceived by physicians in

specialties other than general-family practice and

obstetrics-gynecology. In contrast, pediatricians (75

percent) and internists (62 percent) felt more prepared to address adolescent patients with chronic

illness than did general-family practitioners (54

percent).

This study also explored physicians’ perceived

training needs by determining their interests in

specific continuing medical education topics (207).

The most popular topics for hypothetical continuing

medical education included substance abuse, counseling, learning problems, and eating disorders. In

general, physicians desired further education in

areas where they already reported self-competence.

The exceptions to this observation included pediatricians and general-family practitioners. Greater proportions of pediatricians with lower self-perceived

competence v. positively rated competence desired

continuing education in counseling, substance abuse,

and family planning. At least 30 percent of pediatricians wanted to learn more about each of the 10

service topic areas listed on the survey. Similarly,

general-family practitioners who did not perceive

themselves as knowledgeable in chronic illness

desired more education in this area. Overall, more

than 30 percent of general-family practitioners were

interested in further education in 8 of the 10 listed

areas. The other specialists, including internists,

psychiatrists, and obstetrician-gynecologists, were

more focused in their interests in continuing medical

education in topics relevant to adolescent medicine

(207).

Robert Blum and his colleagues have also addressed the issue of self-perceived competence

among health care providers (40,41,42). A national

mail survey of primary care physicians, including

pediatricians, internists, and family practitioners,

assessed practicing physicians’ needs in adolescent

care (40,41). Areas of perceived training deficit

relevant to adolescent care varied by specialty. Of

the 19 problem areas listed in this study, at least 50

percent of all responding physicians reported having

received insufficient training in 10 areas. Eight of

these 10 areas of self-perceived weaknesses pertained to psychosocial, behavioral, and mental

health problems; more than 45 percent of physicians

felt deficient in these areas. The large majority of

internists (at least 74 percent) reported training

deficiencies for all 19 areas. In contrast, greater

proportions of family practitioners and pediatricians

perceived having received adequate training. There

were seven topic areas for which at least 50 percent

of family practitioners felt insufficiently trained to

handle, and similarly, eight topic areas for pediatricians. Six of the seven topic areas for family

practitioners, and six of the eight topic areas for

pediatricians, consisted of psychosocial, behavioral,

and mental health concerns.

Despite the high rates of acknowledged deficits

among these primary care physicians, relatively few

expressed a desire to upgrade their skills. Overall, no

more than 30 percent of physicians who had

self-identified deficiencies desired to increase their

proficiency in any of the 19 topic areas. Interest was

particularly low for internists; between O and 8

percent of those with self-perceived deficiency

wanted further training in any given topic relevant to

adolescent care. The percentage ranges for interested

pediatricians were 10 to 36 percent and for family

practitioners, 7 to 42 percent. However, this study

did not present data describing the overall interest of

physicians in attending educational courses relevant

to adolescent care.

Self-Perceived Competence of Nonphysician

Health Care Providers-Less is known about the

knowledge base of health care professionals who are

not physicians regarding adolescent care. The same

survey by Blum and his colleagues that was directed

to physicians (40,41) was also sent to professionals

in nursing, social work, psychology, and nutrition

(40,42).

The study drew representative samples from

national organizations or sections of organizations

that are youth-focused. Nutritionists were the only

group that was randomly selected from a general

organization that did not necessarily focus on

children or adolescents. However, 42 percent of
Chapter 15—Major Issues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents ● III-23

responding nutritionists described the population

group with which they primarily worked as being

younger than age 19 (40).

In general, many health professionals, across the

disciplines, felt inadequately trained to deal with

critical adolescent health problems (see table 15-5)

(42). More than 40 percent of the surveyed professionals in at least three of these five disciplines

reported significant shortcomings in their training

related to anorexia and bulimia, alcohol and drug

use, homosexuality (i.e., conflict about sexual orientation), and chronic illness. In contrast with physicians, however, professionals from nutrition, psychology, and social work appeared relatively enthusiastic about enhancing their knowledge on topic

areas for which they had self-identified deficiencies

(40). Yet, a sizable proportion of health professionals in each discipline reported that they would not

pursue continuing education or training to expand

their clinical competencies (see table 15-6) (42).

Physicians were the least interested among the

surveyed disciplines in improving their reported

training deficits (32 percent), followed by psychologists (40 percent).

What Personal Characteristics Do Effective

Adolescent Health Care Professionals Have?

Many observers believe that health care professionals’ ability to interact with adolescents is an

extremely important factor in initiating and maintaining adolescents’ use of health services. In

general, however, the subject of health care professionals’ ability to interact with adolescents—

regardless of the specific problem that an adolescent

may have—has received very little empirical investigation.

As discussed elsewhere in this Report,34 the issue

has received some attention with respect to providers’ abilities to maintain adolescent involvement in

treatment for sexually transmitted diseases. Attitudinal studies of adolescents that compared the importance of clinician gender with other clinician characteristics have suggested that clinician friendliness,

understanding, and willingness to take their time are

more important than gender (27, 165). Patients who

expressed satisfaction have been found to keep

future medical appointments more consistently than

patients who were dissatisfied (165), and clinicians

who were skilled in interacting with adolescents

promoted better patient compliance (27).

A study of residents explored the influences of

their own adolescent risk-taking experiences and

religious and political conservatism on their attitudes toward and their hypothetical professional

behavior regarding adolescent patients (95). In

general, more conservative residents, who also had

lower risk-taking scores, rated themselves as less

skilled in recognizing adolescent substance abuse,

less skilled in discussing sexually transmitted diseases with an adolescent patient, and less likely to

prescribe birth control pills to a sexually active

adolescent without parental consent, compared with

residents with higher risk-taking scores. This study

emphasizes the potential important influences that

individual physicians’ backgrounds have on their

professional behavior. These influences may become especially significant in controversial or

sensitive clinical situations.

Specialized Training in Adolescent Health Care

What Is the Availability of Specialists Trained in

Adolescent Health Care?

The majority of U.S. adolescents receive their

health and medical care from health care providers

who have not received subspecialty training in

adolescent health and who have not declared special

interest in adolescent health through memberships in

professional organizations devoted to this age group

(e.g., 83). Unfortunately, comprehensive data describing the numbers of adolescent health specialists, the nature of their training, and their activities

do not exist. There are some data on clinical

psychologists specializing in the care of adolescents,

and those data are summarized below. Otherwise,

this section is limited to a brief review of physician

specialists in adolescent medicine. (Data on nurses,

social workers, and nutritionists who specialize in

the care of adolescents are not available.35)

How Many Psychologists Specialize in the

Clinical Care of Adolescents?--Although the number is not known, many psychologists and other

~Sm ch. 9, “AIDS and Otier Sexually Transmitted Diseases: Prevention and %miccs,” h VO1. ~.

ls~e American Board of Examiners in Clinical Social Work (ABECSW) estimates that 80 percent of their 17,0W diplomats report that they serve

adolescents (43a) (adolescents are listed as one of four possible age groups in the ABECSW survey of diplomats), but the extent to which diplomats

have a primary or exclusive interest in adolescent care, or special training in adolescent care, has not been determined,
Table 15-5-Number and Percentage of Surveyed Health Professionals Who Perceive Themselves To Be Insufficiently Trained To Manage

Adolescents’ Health Issues, by Respondents’ Professional Discipline

NA. Not applicable.

SOURCE: Reprinted by permission of Elsevier Science Publishing Co., Inc. from “Knowfedge and Attitudes of Health Professionals Toward Adolescent Health Care,” by R. Blum and L. Bearinger,

Journal of Al&scent F/eatfh Care 11 (4):2S9-294. Copyright 1990 by The Society for Adolescent Medicine.

Table 15-6-Number and Percentage of Surveyed Health Professionals Who Want Additional Training in Areas in Which

They Reported Insufficient Traininga
Chapter 15—Major Issues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-25

health care providers (clinical social workers, nurses,

health educators, nutritionists) encounter and care

for adolescents in their clinical practices, in schools,

residential institutions, and other settings. The only

available data on psychologists who specialize in

adolescence comes from the membership files of the

American Psychological Association. In 1989,1,487

psychologists reported to the association that their

primary professional interest was adolescents; this

number represented 2.2 percent of the American

Psychological Association’s total membership and

4.4 percent of members who are clinical psychologists (24). Their interests included developmental

adolescence, clinical-adolescent therapy, and clinicaljuvenile delinquency.

How Many Physicians Specialize in Adolescent

Medicine? —Until recently, adolescent medicine

was not a certified medical subspecialty.36 Thus,

there are no definitive data on the number of

physicians specializing in adolescent medicine.

Nonetheless, statistics provided by The Society for

Adolescent Medicine (SAM), American Academy

of Pediatrics, AMA, and other membership societies

are useful indicators of the number of physicians

with a special interest in adolescent medicine (see

table 15-7).37 The available data make clear that the

number of physicians who dedicate their practices to

adolescent medicine is quite small.

SAM was established in 1968 and, as of 1989,

included 1,034 members from multiple disciplines

(including nonphysicians), although the vast majority (82 percent) are pediatricians (261).38 T h e

training backgrounds of physician members include

pediatrics (84 percent), family practice (7 percent),

internal medicine (5 percent), obstetrics-gynecology

(3 percent), and psychiatry (1 percent) (261).

The American Academy of Pediatrics formed a

Section on Adolescent Health in 1978, in response

to pediatrician members’ requests for a special

interest group. By 1989, this section was the third

largest of the academy’s 32 sections for practicing

Table 15-7—Estimates of the Number of Physicians

Specializing in Adolescent Medicine

Number of physicians

expressing interest in

Source of data adolescent medicinea

Primary care specialties

Society for Adolescent Medicine

1989 membership statistics. . . . . . . . . . . . . . 1,034

American Academy of Pediatrics’ Section

on Adolescent Health

1989 membership statistics. . . . . . . . . . . . . . 547b

American Medical Association

1988 Physician Masterfile. . . . . . . . . . . . . . . 1,420 total

Adolescent medicine is primary or

secondary specialty. . . . . . . . . . . . . . . . 1,261

Adolescent medicine is third

specialty. . . . . . . . . . . . . . . . . . . . . . . . . 159

Other specialties

North American Society of Pediatric and

Adolescent Gynecology . . . . . . . . . . . . . . . . 370

American Society for Adolescent

Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,500

aNOte that estimates overlap and cannot be summed.

b An estimated 500 of the 547 are also members of the Smiety for

Adolescent Medicine (64).

SOURCE: Office of Technology ksessment, 1991.

pediatricians and contained 547 members, or slightly

more than 2 percent of the American Academy of

Pediatrics’ total membership. The extent of overlap

between this group and SAM is not known, but it is

estimated that the vast majority (about 500) of the

American Academy of Pediatrics’ special section

are also members of SAM (64).

The AMA formally established adolescent medicine as a separate specialty in 1977 (33). The AMA’s

physician masterfile updates its information on

individual physicians (including nonmembers)

through a structured mail survey using a 4-year

rotating cycle, so that each responding physician

completes a questionnaire every 4 years. Of the

almost 800,000 physicians who listed a primary or

secondary specialty in the 1988 data set, only 1,261

selected adolescent medicine from the predesignated specialty categories (86). Of the 39,000

physicians who listed a third specialty, an additional

%A~ ~~ Repo~ went t. press, ~ application to fo~ly es~blish adolescent m~icine as a subspecialty of pediatrics was approved by the American

Board of Medical Specialties (152).

STSWclallsE me physic- who ~ve completed 1 (O 5 years of additional training in a SpCCld~ mea. such ~ning is not ~uir~ for medi~

Licensure, but physicians who have specialty training may be eligible to become certifkd by a specialty board. Even if they have not received specialty

training or been board-certitled, however, physicians may designate themselves specialists (275). In addition to offering a general eertificationj several

boards offer certflcates in subspecialty areas.

38Note a]50 tit more ~fom out of five physici~ @ained ~ adolescent medicine be~een 1974 and 1984 were pediatricians; the remainder were

internists, family practitioners, or other primary care specialists (220). Most reeently, of the 60 physicians in adolescent medicine fellowships in January

1990,47 had pediatric backgrounds, 6 had completed residencies in family practice, 3 were internists, and 2 had completed combined tr aining in internal

medicine and pediatrics (12 1).

292-872 0 - 91 - 2 QL 3
III-26 . Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

159 selected adolescent medicine. Overall, a total of

1,420 physicians in the AMA masterfile (0.2 percent

of all U.S. physicians) declared a formal interest in

adolescent medicine. Yet only about one-third (32

percent) of responding physicians practicing adolescent medicine perceived it to be their primary area of

practice.

The American Academy of Child and Adolescent

Psychiatry estimates that 5,000 child- and adolescenttrained psychiatrists are currently available in the

United States (276). The American Society for

Adolescent Psychiatry has 1,500 members, and the

North American Society for Pediatric and Adolescent Gynecology has 370 members (49,298).

Although many members of the American Academy of Family Physicians and the American College

of Physicians care for adolescent patients, how many

actually specialize in adolescent health is unknown.

Neither organization keeps track of members with a

special interest in adolescent medicine (189,256). It

should be noted, however, that subspecialization in

any particular age group is contrary to the discipline

of family practice, which emphasizes the importance

of comprehensive patient and family medical care(1).

What Are the Training Opportunities

in Adolescent Medicine?

Some physicians may get some general experience in adolescent health care while being trained in

primary care specialties such as pediatrics, family

practice, or internal medicine. Physicians who

specialize in adolescent medicine receive the most

intensive and advanced training in adolescent medicine as a medical subspecialty. Specialty training in

psychiatry or obstetrics/gynecology may also include experience in adolescent health care.

Primary Care Training—In January 1990, the

Pediatric Residency Review Committee of the

Accreditation Council for Graduate Medical Education significantly expanded its requirements for

pediatric residency training experience in adolescent

medicine (83). Accredited pediatric residencies must

now incorporate a structured adolescent medicine

experience that includes health maintenance examinations, family planning, sexually transmitted diseases, and gynecology (1).39 Experiences in chemical dependency treatment, sports medicine, health

needs of incarcerated youth, and college health

issues are also strongly recommended. The requirements further specify that a separate adolescent

medicine clinic is desirable. Exposure to adolescent

medicine must be both didactic and clinical and must

take place in inpatient and outpatient settings.

However, the training requirements do not specify

an age range for adolescent patients. Further, a

specific time duration for experience in adolescent

medicine is not required.

Accredited residency programs in family practice

are required to include a 4- to 5-month structured

educational experience in pediatrics, but there are no

specific requirements for exposure to adolescents

(4). Family practice residents may take an elective in

adolescent medicine in a department of pediatrics; it

is not known how many actually do. A recent survey

of family practice residency programs found that 40

percent of training programs included adolescence

as a specific component of the curriculum (250). Of

the 154 programs reporting the number of adolescent

patients that a trainee followed as part of his or her

‘‘practice,’ more than half (54 percent) estimated 20

patients or less. Only about 40 percent of the

responding family practice programs had either

trainees or faculty members with specifc interests in

adolescent medicine, and only 6 percent of responding programs offered at least 1 month’s dedicated

experience in adolescent medicine (250).

Although the guidelines for accredited residency

training programs in internal medicine stipulate that

residents should gain experience in caring for

adolescent patients, they do not call for any specific

curricula in adolescent medicine nor do they specify

any age range for adolescent patients or time

duration for experience in adolescent medicine (3).

Subspecialty Training—The majority of physicians who devote a significant portion of their time

to practicing adolescent medicine have received

subspecialty fellowship training (260).40 The first

fellowship program in adolescent medicine was

39A Smdy ~ 1978 feud tit ~m~ds (66 pement) of sweyed pedia~c~ be]iev~ their resid~cy training had not prepti them ad~ately fOr

the care of adolescents (16). Later, the residency experience in adolescent medicine appeans to have improved, so that pediatricians who had completed

their residencies after 1974 were less likely to rate their training as insufllcient in adolescent medicine, compared with pediatricians who had completed

their residencies during earlier years

@Subspecialty tr aining occurs afte~completionof a residency training program in a certified specialty. It is important to note that not all subspecialties,

including adolescent medicine, are certifkd by the American Board of Medical Specialties,
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents ● III-27

organized in 1956 at Children’s Hospital Medical

Center in Boston and since then an estimated 750

physicians have been trained in adolescent medicine

(121,222). Most adolescent medicine fellowship

programs accept trainees who have completed residencies in either pediatrics, internal medicine, or

family practice.

Training opportunities in adolescent medicine are

few in number and typically are located only in

teaching hospitals in major metropolitan areas (261).

As of January 1990, there were 39 adolescent

medicine physician fellowship programs in the

United States, with 60 active fellows (121).41 The

programs are small; 20 of the 39 fellowships train

only one fellow at a time, and most of the others have

the capacity to train only two.

Postdoctoral fellows in adolescent medicine are

distributed fairly evenly by gender: 46 percent of

fellows enrolled in training during 1988-89 were

women.

Adolescent medicine subspecialty training programs vary in curriculum and duration. Now that

adolescent medicine has been established as a

formal pediatric subspecialty, programs should become more uniform. Official curriculum standards

for fellowships in adolescent medicine will be

established. Currently, the fellowship training guidelines published by SAM are voluntary and no one

knows how many programs adhere to them. SAM

recommends that l-year adolescent fellowship programs emphasize clinical training; 2-year programs

provide additional skills in clinical research and/or

program administration in adolescent health care;

and 3-year programs enable the fellow to function as

an independent investigator (258). It is, therefore,

not surprising to find that physicians who have

completed l-year training programs are more likely

to be in full-time private practice with less time

devoted solely to adolescent medicine (220,221).

Surveys of physicians who have completed adolescent medicine fellowship programs have found that

2-year fellows are significantly more likely than

others to have full-time academic careers and to

devote 75 to 100 percent of their time to adolescent

medicine (both academic and clinical) (220,221).

Eight basic areas of skill and knowledge are

emphasized by the SAM program training guidePhoto credit: © Peter Byron, Mom’s Plains, NJ

Training opportunities in adolescent medicine are few in

number and typically are found only in teaching hospitals

in major metropolitan areas.

lines: interviewing skills, growth and development,

sexuality, medical problems, psychological and

social problems, preventive health care, academic

and research skills, and management and health care

delivery (258). The guidelines also stress that

training programs embody a team approach which

includes at a minimum a social worker, mental

health specialist, and nurse-all with established

experience in adolescent health care. A psychologist

and/or psychiatrist; nutritionist, nurse practitioner

and/or physicians’ assistant; teachers; and physical,

recreational, and occupational therapists are also

recommended.

The duration of adolescent medicine subspecialty

training has increased since the fellowships were

first established. Only 22 percent of those who

4 l[n addition, here were two programs in Canada ad one ti Puerto Rico.
III-28 ● Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

completed their training between 1974 and 1979

were in 2-year programs; the vast majority of

trainees, during that period, participated in l-year

fellowships (221). From 1979 through 1984, the

proportion of 2-year trainees increased to more than

one-third (34 percent) (221). The trend toward

longer training continues; in 1984, 35 percent of all

programs offered l-year fellowships; by 1990, 59

percent of all fellowships required 2 years of training

and only 8 percent allowed 1 year.

What Do Physicians Trained in Adolescent

Medicine Do?

Limited information is available concerning the

current activities of adolescent medicine specialists.

Recent data from a 1989 SAM membership survey

are useful, but, because it is chiefly pediatricians

who have elected to become members of SAM,

SAM data principally reflect the activities of pediatricians specializing in adolescent medicine and do

not include the family practitioners, internists,

psychiatrists, and others with a special interest in

adolescent health. Ninety percent of the respondents

to the 1989 SAM membership survey were physicians, and more than half (57 percent) of the

responding physician members had completed a

formal postdoctoral fellowship in adolescent medicine (260). Overall, SAM members (including

nonphysicians) tend to be involved in academic

medicine. That is, more than one-third (37 percent)

of SAMs members have a full-time appointment to

a university or medical school, and an additional 44

percent carry an adjunct or clinical appointment.

Only 30 percent of the 1989 SAM survey respondents devote all of their time to adolescent medicine

activities, including time involved in clinical work,

teaching, research, and administrative responsibilities.

The SAM survey also found that adolescent

medicine specialists were more likely to spend their

time in outpatient or office-based patient care than in

inpatient care. Eighty-seven percent of respondents

spent less than 25 percent of their time on inpatient

care (260).

l-low Effective Is Specialized Training

in Adolescent Health Care?

Only two published studies have attempted to

evaluate the effectiveness of specialized training in

adolescent medicine. Both have methodological

limitations. Only one included an objective evaluation of physicians’ skills (197). Neither included

ratings by adolescent patients of physicians’ skills.42

Neinstein and his colleagues assessed the impact

of an adolescent medicine rotation on the attitudes

and skills of advanced medical students and pediatric residents (197). Important findings included an

increased liking of adolescents by residents as well

as significantly improved pelvic examination skills

by trainees at the conclusion of the rotation, compared with prerotation scores, and with scores of

residents who did not select the rotation. These

changes appeared to persist across a l-year time

interval. The validity of this study’s findings may

have been limited by a potential subject-selection

bias. The adolescent medicine rotation was not

required, and residents were not assigned to it on a

random basis; residents could select it or another

rotation. The majority of residents, however, did

select the rotation. In addition, residents served as

their own controls and had two measurement points

prior to starting the rotation in adolescent medicine.

If this study’s findings are valid, it appears that

rotational experience through an adolescent medicine service can help both to modify trainees’

attitudes about adolescents and to enhance their

clinical skills.

Chastain and colleagues’ more recent study of a

national sample of pediatricians compared pediatricians who had formally declared their interest in

adolescent medicine through membership in the

American Academy of Pediatrics Section on Adolescent Health with other randomly selected pediatricians (60). Twenty-nine percent of the group with

formally declared interest in adolescent medicine

had elected to receive advanced training in adolescent medicine through postdoctoral fellowships;

overall, however, 50 percent of this group had

undergone formal training in adolescent medicine at

some point in their careers. About 30 percent of the

randomly selected pediatricians had also received

formal exposure to adolescent medicine teaching,

usually through residency experience. As would be

expected, the pediatricians with a formally declared

interest in adolescent medicine rated their selfperceived skills across the spectrum of common

adolescent problems as significantly higher than the

other pediatricians did. These differences were

dz~ ~ ~revlou~ ~mdy, OTA feud that pati~~’ ratigs were a valid indicator of some MP@.S Of qd~ of cue (275).
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents ● III-29

especially pronounced in their self-perceived abilities to diagnose and manage psychosocial problems,

substance abuse, eating disorders, and sexually

transmitted infections; to perform pelvic examinations; and to provide contraceptive counseling.

When Chastain and colleagues examined training

issues across time, the following findings emerged

(60). Even though the percentage of pediatricians

who have received formal training in adolescent

medicine has increased over the past two decades,

only slightly more than one-third (35 percent) of all

pediatricians participating in the survey had received formal instruction in adolescent medicine as

part of their residency during the decade 1976 to

1985, 7 years of which followed the Task Force on

Pediatric Education’s 1978 recommendation that all

pediatric training routinely include training in adolescent medicine (16). Among pediatricians without

a designated formal interest in adolescent medicine,

those who had graduated from medical school since

1976 felt less adequately trained than did those who

had graduated during the preceding decade, 1966 to

1975. Each successive cohort of these more recent

graduates, however, felt more competent than did

their older colleagues in several classical areas of

adolescent medicine, including substance abuse,

sexually transmitted diseases, pelvic examinations,

and contraceptive counseling. However, the trend of

heightened self-perceived efficacy for more recent

pediatric graduates was not sustained for some

content areas of adolescent medicine, including

general medical problems, general psychosocial

problems, sports medicine and orthopedic problems,

and eating disorders (60).

What Is the Federal Government’s Role in Support

of Training in Adolescent Health Care?

The Federal Government began to support interdisciplinary training programs in adolescent health

in 1968, but its role in training and education for

adolescent health care specialists has been very

limited. The Bureau of Maternal and Child Health in

the Health Resources and Services Administration

of DHHS currently funds six interdisciplinary training programs in adolescent health, a reduction from

nine programs in fiscal year 1981 (212). The

programs are located in metropolitan medical centers in Baltimore, Birmingham (Alabama), CincinTable 15-8-Federal Funding for Interdisciplinary

Training Programs in Adolescent Health,

Fiscal Years 1986-90

Fiscal year Total funding

1986 . . . . . . . . . . . . . . . . . . . . . . . . . $1,644,000

1987 . . . . . . . . . . . . . . . . . . . . . . . . . 1,677,000

1988 , . . . . . . . . . . . . . . . . . . . . . . . . 1,700,000

1989 . . . . . . . . . . . . . . . . . . . . . . . . . 1,776,000

1990 . . . . . . . . . . . . . . . . . . . . . . . . . 1,779,000

SOURCE: J. Papai, Chief, Researeh and Training Branch, Bureau of

Maternal and Child Health, Health Resourcws and Serviees

Administration, Public Health Servka, U.S. Department of

Health and Human Serviees, Roekville, MD, Sept. 16, 1990.

nati, Minneapolis, Seattle, and San Francisco. The

programs are noteworthy for their multidisciplinary

and comprehensive approaches to training; trainees

include not only physicians but also psychologists,

social workers, nurses, nutritionists, and others.

From 1979 through 1990, these programs trained

625 individuals. Total funding for the programs was

$1.8 million in 1990 and has not changed substantially in the last 5 years (see table 15-8) (212).

In general, little is known about past participants

in the federally funded interdisciplinary programs

and the role the trainees eventually play in providing

health care to adolescents. A 1987-88 survey of

trainees from these programs found that most (85

percent) were employed in adolescent health services in settings that included universities (26 percent), hospitals (24 percent), self-employment (8

percent), social services agencies (8 percent), mental

health agencies (8 percent), and public health

departments and community health programs (13

percent) (258).43 Most graduates were employed in

the States in which they were trained.

There has been no explicit Federal support of

training in adolescent health for health professionals, such as family practitioners, pediatricians,

internists, psychologists, nurse practitioners, and

others, who are already actively involved in adolescent health care and who may seek advanced

training.

Innovations in the Delivery of Health and

Related Services to Adolescents

Efforts to improve the delivery of health and

related services to adolescents have spawned several

innovations. One innovation is comprehensive

dj~s sumey WM conducted h 1987 and 1988 by the Division of Adolescent Medicine, Child Development Center, University of Washington ~d

was targeted to 283 individuals who had completed their traiting in the previous 5 years. The response rate was 55 pereent.
111-30. Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

health centers for adolescents. Comprehensive

health centers for adolescents take a variety of

organizational forms, ranging from communitybased adolescent health care clinics to school-linked

health centers (SLHCs). Another innovation, which

might be considered an alternative to the provision

of comprehensive services at a single site, is to use

case management and other methods to integrate

services in the community for adolescents. A third

innovation, and one used by OTA in the preparation

of this assessment, is for organizations involved in

the delivery of services to seek adolescents’ advice

on how to become more responsive to their needs.

Photo credit: Katherine Criss, New York, NY

Comprehensive Health Centers for Adolescents

Comprehensive health centers for adolescents

typically offer adolescents a variety of health and

related services in a single site and have a team of

staff members who are knowledgeable about and

committed to helping adolescents (192). Such centers, which take a variety of forms described further

below, are an alternative to the traditional model of

health care delivery that typically takes place in

physicians’ offices.

Many of the comprehensive programs described

below were developed in response to specific

communities’ needs, so their organizational structures and the services they offer vary widely. Some

of the programs developed their structural foundations de novo (independently); others incorporated

their services into the functioning of existing organizations.

Nonetheless, each described program is responsive to the specific needs of adolescents (e.g., for free

care or use of sliding-fee scales, evening and

weekend hours of operation, and confidentiality of

services).44

Staff members who work incomprehensive health

programs for adolescents generally choose to work

there because they are committed to and enjoy

helping adolescents. They are knowledgeable about

adolescent development, behavior, and health and

social problems. They frequently perceive themselves as advocates for their adolescent clients and

may actually serve as formal case managers to work

together with individual adolescents to coordinate

Comprehensive health centers for adolescents attempt to

provide services that address the range of problems many

adolescents face. Such services include care for acute

physical illnesses, general medical exams, reproductive

health care, mental health counseling, family counseling,

vocational training, recreational opportunity, and

child care services.

their programs of care (292). This set of personal

attributes of staff members may be one of the most

cogent characteristics that separates comprehensive

care programs from more traditional health services.

Very little formal evaluation of comprehensive

care programs for adolescents has been conducted.

Although the staff who operate these programs are

convinced that their approaches are successful,

limited funding, budgetary constraints, and other

factors (e.g., diversity of mission) have precluded

objective assessments of how effectively comprehensive health centers for adolescents are accomplishing their missions. More than a decade ago, the

Institute of Medicine’s Conference on Adolescent

Behavior and Health urged that model programs be

evaluated because the assumptions that have been

made about preferred program structure are not

grounded in empirical data (192). Impressions of

highly visible programs may be regarded as documented fact, so that opportunities may be missed to

determine which approaches work most effectively

for different groups of adolescents.

Most types of comprehensive health care programs for adolescents share the same problem of

survival: financial support for these programs is

frequently difficult to secure, and finding sources of

~F~c~ ~emtit impede ad,~lescents’ a~-ess to health services are discussed in ch. 16, “Financial ACCESS to Health Services, ’ h this vohune.

Laws pertaining to consent and confidentiality are discussed inch. 17, “Consent and Confidentiality in Adolescent H.dth Care Decisionmaking, ” in

this volume.
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-31

income and funding is an ongoing challenge. In

general, hospital-based programs supported by teaching hospitals are an exception to concerns about a

stable source of funding. As discussed further below,

however, hospital-based programs face other problems that may impede the delivery of appropriate

care to adolescents.

The comprehensive programs described below

include adolescent health care clinics, a free clinic,

a multiservice center, and SLHCs. The programs

described are examples of more widespread models

of innovative attempts to deliver health and related

services to adolescents. In general, little information

is available concerning similar programs that have

been established in various communities across the

United States. The number of such programs is

known to be quite low, however.

Adolescent Health Care Clinics

Some hospitals, at least one health maintenance

organization (HMO), and several groups of physicians acting on their own at the request of their

community have established programs of medical

care specifically for adolescents. The precise number of adolescent health care clinics of this type is

not known. Hospital-based adolescent health care

clinics are more widespread than programs initiated

by groups of physicians, and hospitals with residency training programs are probably more likely to

have developed such programs than hospitals without residency programs. The HMO-based and community-based adolescent health care clinics were

initiated by faculty or graduates of nearby adolescent medicine training programs. In addition to

providing clinical services, many of the hospitalbased programs also serve as training sites for young

physicians (176). Given the fact that teaching

hospitals and their affiliated community health

centers are frequently located in socioeconomically

depressed neighborhoods, it is likely that a large

proportion of adolescents who receive their health

and medical care from such programs come from

poor or near-poor families.45

There is no formal prototype for adolescent health

care clinics. The majority of hospital-, HMO-, and

community-based adolescent health care clinics,

however, probably conform to the following general

description:

●

●

●

●

*

●

—

They are able to provide primary and secondary

level care for adolescents with a variety of

problems.

They have a nuclear cadre of staff organized by

a physician who specializes in the field of

adolescent medicine and who is likely to hold

a faculty appointment at a local medical school.

They schedule adolescents’ visits for a broad

array of concerns, usually by appointment.

Although they may use a “team” approach, a

physician or nurse practitioner (working under

a physician’s supervision) is the focal provider,

directs management of the patients’ needs, and

decides when referral resources are indicated.

The focus of these programs, given their

institutional locations and the source of their

leadership, is primarily on adolescents’ physical health, but the programs also attempt to

identify and to provide intervention for adolescents with mental health problems, Identification of adolescents at risk for mental health

problems is usually accomplished through screening. That is, a psychosocial profile is completed

for every patient seen for the frost time,

regardless of the presenting problem. This

screening may take place by interview or by

questionnaire. The majority of programs have

developed independent strategies to conduct

these assessments. Screening interviews may

be done by the primary medical clinician

(physician or nurse practitioner), a nurse who

coordinates the program, or a social worker.

Depending on the issues that are disclosed by

patients or their families, the physician or nurse

practitioner may decide to ask other professional personnel to become involved in the care

of an individual patient, depending on institutional resources. For example, a patient could

be referred to a mental health professional

(psychiatrist, psychologist, or clinical social

worker), a substance abuse counselor, a vocational counselor, or a nutritionist.

There are usually close working relationships

with other medical and surgical subspecialty

programs, so that adolescents can easily be

referred for specific problems that may require

assessment or management that is beyond the

purview of an adolescent medicine practitioner.

.$5 For ~ discu~S1on of tie he~th probl~s of adoie~ents living in poor and near-poorfamilies, see ch. 18, ‘‘Issues in the Delivery of Services to Selected

Groups of Adohxents,” in this volume.
III-32 . Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

● These programs may also have ties with other

agencies, so that occasional patients may be

referred to independent institutions, especially

if internal resources (e.g., mental health resources) are limited.

Although no programmatic data are available, it is

suspected that the majority of hospital- and communitybased adolescent health care clinics, although they

encourage parental involvement, provide confidential care to adolescents for their reproductive health

needs. The costs for such confidential services may

be compensated by public moneys (e.g., family

planning funds under Title X of the Public Health

Service Act, Medicaid funds, and local revenues), or

may be borne by a larger institution that is committed to providing a full array of adolescent-oriented

services. Some institutions arrange for their adolescent patients to pay for their own care using a

sliding-scale fee structure.

Issues Concerning Hospital-Based Adolescent

Health Care Clinics-When evaluating the effectiveness of most of the adolescent health care clinics

set in the organizational structure of much larger

institutions, it is important to bear in mind three

major issues. One issue is that adolescents may have

limited access to these programs. Hospital-based

clinics are frequently located in inner-city areas that

require skill in negotiating a city’s public transportation system or access to an automobile. Adolescents

and families of adolescents who live in more socially

prosperous areas may be reluctant to use health care

facilities that are known to serve impoverished

populations or are in areas perceived as unsafe.

Access may also be limited by a program’s placement within a large complex of buildings. Finding

one’s way in a hospital can be intimidating. The

registration process for institution-bound adolescent

health care programs may be constrainedly the rules

of the larger institution and may not be ‘‘user-

-friendly. ’ Thus, for example, an institution may not

permit appointments to be scheduled in the late

afternoon or early evening, times that are desirable

for adolescent patients to prevent interference with

school attendance. The institution may require that

all patients register for their clinical care in a

centralized area, prior to proceeding to patient care

areas. In addition to the potential for time spent

waiting in line, such a practice may violate standards

for discreet provision of confidential care for sensitive health care problems. Adolescents may be

required to disclose the purpose for their visits in

front of other patients who have also been waiting in

line. Such internal bureaucratic obstacles may in fact

limit adolescents’ perceived access to these specialized programs.

A second issue confronting hospital-based adolescent health care clinics is related to their mission

to provide training to young professionals such as

medical students, resident physicians, and nursing,

psychology, and social work students. The goals of

teaching trainees how to engage and work with

adolescent patients and how to evaluate and manage

adolescents health and medical problems are extremely important. It is difficult for clinicians to

develop these skills without practical experience.

There is inherent tension, however, between the two

goals of providing comprehensive yet efficient

evaluation and treatment services, and teaching

trainees. Overall, less experienced physicians and

medical students are not able to work as quickly as

experienced physicians. In addition, trainees require

individual supervision for each patient that they see,

during the time of the actual visits. These facts may

mean that patient flow is apt to be slower for less

experienced clinicians. In addition, continuity of

patient care may be compromised in a teaching

setting. That is, consistent clinical care across time

for an individual patient (longitudinality of care) is

difficult to arrange when a physician trainee is

assigned to see a patient at a particular visit. In

general, residents and medical students may be

assigned to an adolescent health care clinic for one

to two sessions, or for no longer than a month’s

block of time, before they are rotated to a different

clinical experience. Although no known study has

measured actual quality of interpersonal interaction

between provider and adolescent patient, or overall

quality of patient care vis-à-vis clinician’s experience

level, it is hypothesized that clinicians who are more

experienced in working with adolescent patients

perform better than do less experienced clinicians.

One measure of quality of the interaction between

adolescent patients and clinician is based on patient

satisfaction with the visit. A small study conducted

in an adolescent health care clinic found that 75

percent of surveyed adolescent patients who had

been seen by a senior physician trainee (postdoctoral

fellow in adolescent medicine) were satisfied with

their visits, and that only 39 percent of patients who

have been seen by a resident or medical student were

satisfied (165). This finding suggests that adolescent

patient care programs in teaching institutions need to
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents ● III-33

develop interfactional strategies that help to compensate for trainees weaknesses during the learning

process. It also suggests that more attention should

be focused on developing structured curricula that

can teach trainees the interfactional and knowledgebased skills that are essential for working with

adolescents.

A final issue that concerns hospital-based adolescent health care clinics is evidence for their effectiveness. How successful are such clinics in identifying adolescents’ problems, in providing interventions, and in improving the health status of their

adolescent patients? Relatively little information is

available to answer these questions. Recently, however, formal evaluation of a foundation-supported

national demonstration program has explored these

issues.

In 1982, the Robert Wood Johnson Foundation

awarded twenty 4-year grants to teaching hospitals

working in concert with 54 community-based agencies as part of its Program To Consolidate Health

Services for High-Risk Young People (84,157,158,

267). The overall goal of this national program was

to improve the health status of adolescents and

young adults who lived in communities served by

the individual funded projects. The four program

objectives were as follows: 1) to increase health

services to youth at risk for serious socioeconomic

and medical problems, 2) to train health professionals in the care of youth, 3) to consolidate health

services into comprehensive care centers, and 4) to

secure long-term financial support for adolescent

health services (157,158). Formal evaluation of this

national program consisted of a longitudinal (twowave) survey conducted over a 12-month interval of

a cohort of youths receiving clinical services from

seven of the funded sites and from three that

included adolescents as part of their service populations but offered neither specialized services for this

age group nor training programs in adolescent

medicine. The funded and nonfunded clinics were

similar in that they were all located in major public

medical centers in their respective cities and were

accessible to indigent patients (84).

Overall, more than 2,000 adolescent 13- to

18-year-old patients were interviewed twice and had

their medical records reviewed as part of the

evaluation process (84,267). The adolescents served

by these clinical programs were at risk for serious

health and behavior problems, as documented during the first wave of interviews. For example, 23

percent had a chronic illness, 79 percent were

sexually active, 47 percent of interviewed adolescent females had been pregnant, 20 percent of the

patients had had significant recent depressive symptoms, 25 percent engaged in illicit substance use, and

26 percent had been in physical fights (267).

Two important findings emerged from this evaluation (84). One was that adolescents attending the

funded clinical service programs that were specifically geared toward adolescents were significantly

more likely to disclose behavioral and lifestyle

problems to their clinical providers than were

adolescents attending the comparison programs

(84). Consequently, larger proportions of adolescents attending the specialized adolescent programs

received care (usually on site, but occasionally

through referral) for these specific problems than did

adolescents attending the comparison programs. In

general, the funded adolescent health care programs

demonstrated more extensive documentation of

health problems, including behavioral and lifestyle

concerns, than did the general programs. However,

adolescents in both funded and nonfunded clinics

were more likely to inform their medical providers

of clear-cut medical problems (e.g., asthma, injury,

sexually transmitted diseases) and of need for

contraception than of other behavioral and lifestyle

problems.

A second important finding of this evaluation was

that despite their better identification and treatment

capabilities for adolescent problems, the funded

adolescent health care programs were not able to

effect greater improvement in selected health problems, including persistent depressive symptoms,

unmet contraceptive needs, and heavy alcohol or

drug use, than the comparison programs (84). At the

time of their second interviews, relatively similar

smaller percentages of adolescents attending each

type of program reported having depressive symptoms and unmet contraceptive needs than reported

these problems at their initial interviews. Regardless

of program type, however, virtually no changes in

self-reported heavy alcohol or drug use occurred

across the year interval between interviews (84).

Earls and his colleagues have suggested three

reasons for the failure of the specialized adolescentoriented programs to demonstrate differences in

health outcomes for adolescents. First, the followup

period of 12 months may have been too short an
III-34 ● Adolescent Health-Volume III: Crosscutting Issues in the Delivery of Health and Related Services

interval. Second, more time may be needed to test

the impact of specialized primary health care for

adolescents, given the newness of this field. Third,

it may be inherently difficult for medical clinics

alone to improve the behavioral and lifestyle problems of adolescents who attend these clinical programs because the adolescents’ difficulties are so

deeply embedded in the socioeconomic contexts of

their environments (84).

It is a useful exercise to discuss adolescent health

care clinics in the context of the attributes outlined

by Schorr in her discussion of “interventions that

work’ for high-risk adolescents (246). Schorr based

her conclusions about the nature of successful

interventions on case studies of selected intervention

programs. In Schorr’s view, successful intervention

programs offer a broad spectrum of services, cross

traditional professional and bureaucratic boundaries, and remain flexible in approaches to problem

solving. Successful programs also view the adolescent in the context of family, and the family in the

context of its environment. In addition to their

professional skills, staff members affiliated with

successful programs possess commitment to and

caring and respect for their clients. Structurally,

successful programs’ services are coherent and easy

to use. Such programs attempt to reduce the possible

barriers that clients may face in attempting to utilize

offered services. If necessary, program staff circumvent traditional professional and bureaucratic limitations, in order to meet the needs of their clients.

Schorr Summarized the necessary characteristics of

successful intervention programs as intensity and

comprehensiveness of services, and flexibility and

respectful commitment by staff (246).

Many adolescent health care clinics situated in

teaching or community hospitals certainly strive to

attain many of the functions and characteristics that

Schorr outlined. Overall, their professional staff

could be described as skilled and committed. Trainees who rotate through these programs as part of

their learning experiences, however, may lack either

the necessary background knowledge or the commitment to and caring about adolescents that appear so

important to a successful program. Clinic staff may

attempt to compensate for their trainees’ weaknesses, but this issue requires continuous monitoring. It is possible that hospital-based adolescent

health care clinics are not able to provide sufficient

breadth or intensity of services for their patients, no

matter how hard they try, given their structural

limitations. In general, they operate on the campuses

of large institutions. Patients may be seen for

medical issues on a regular basis on site; although

quarterly visits would not be considered unusual,

relatively few adolescents are seen by medical

clinicians as frequently as every week or every

month on an ongoing basis. Mental health professionals may establish weekly or even twice weekly

appointments with their adolescent clients. However, neither the medical nor the mental health

interventions may provide adequate intensity of

service for certain adolescents. After all, 2 hours a

week of professional time, no matter how skilled,

cannot realistically be expected to countermand the

influences of the events taking place in the remaining 166 hours of the week of an adolescent who is

experiencing major behavioral and lifestyle problems. Finally, adolescent health care clinics usually

function in the context of the bureaucracy of a larger

institution. Although program staff may successfully negotiate with the institution’s administration

for policies that lower barriers to care (e.g., issues

requiring the need for parental consent and payment

for services), they are still frequently constrained by

institutional rules, and by the large imposing buildings in which their clinical space is often located.

Community- and HMO-Based Adolescent

Health Care Clinics--In some suburban communities, health care professionals trained in adolescent

health care have developed special adolescent health

care centers that are not formally affiliated with

hospitals. Two examples are described in box 15-A.

One center was developed in response to community

concerns by adolescent medicine faculty physicians

based at a teaching hospital in a suburban Long

Island, New York, community (92,175). Another,

the Teen and Young Adult Health Center, is part of

the Kaiser Permanence HMO, and is situated at

Kaiser’s Granada Hills, California, location (135,146).

Free Clinics

Free clinics developed approximately two decades ago in this country in response to the needs of

substance-using youth, many of whom were alienated from society at large and were unable or

unwilling to receive medical care from traditional

sources. Free clinics do not set eligibility requirements or charge fees for service, although they do

accept donations from their clients. In general, free

clinic services are provided by volunteers, with

agency activities coordinated by a core of paid staff.
Chapter 15—Major Issues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-35

Box 15-A—A Community-Based and an HMO-Based Adolescent Health Care Clinic

In recent years, health care professionals trained in adolescent health care have developed adolescent health

care programs that are not formally affiliated with hospitals. Two examples, both in suburban communities, are

described below.

A Community-Based Adolescent Health Care Clinic in Long Island, NY

A comprehensive adolescent health care service that was developed for a suburban Long Island community

by adolescent medicine faculty physicians based at a teaching hospital is described by Fisher, Marks, and Trieller

(92). This program was established in 1980 in response to the request of a group of civic leaders living in a middle- to

upper-class suburb. A survey of the community’s junior and senior high school students was conducted as part of

program planning. In general, although significant proportions of students disclosed regular illicit substance use (20

percent), sexual activity (24 percent), and concern about a self-perceived weight problem (38 percent), very few

students (1 percent, 4 percent, and 10 percent, respectively) had actually sought care for these matters. Despite their

ready access to private office-based physicians (90 percent had a specific doctor, and 93 percent had visited a doctor

within the previous year), the majority of students stated that they would not choose to use a private physician for

reproductive health care, substance abuse, or emotional problems, and furthermore, that they would not be willing

to seek care for these problems with their parents’ knowledge (175). Thus, even in a middle-class community that

is well-supplied by private physicians, adolescents perceived the need for an alternative resource for their

reproductive health care and other sensitive problems.

The Long Island community-based adolescent health clinic is located in a building shared with a substance

abuse counseling agency. It is staffed by a nurse coordinator (who also is a master’s prepared counselor), and

pediatricians specializing in adolescent medicine. The nurse coordinator performs basic medical and psychological

counseling, as well as program administration and outreach. Although confidential health care is provided for

sexuality-related matters, adolescents younger than age 18 must have parental consent in order to receive care for

other problems.

Funding for the program comes primarily from the New York State Department of Health but also from local

funding sources. Although adolescent patients were seen free of charge during the first 2 years of the program’s

operation (92), fees were later instituted at the request of the State funding agency after a survey of registered patients

was conducted. The majority of these patients affirmed that they would be personally able and willing to pay for

services without help from their parents (93). From 1982 until recently, adolescents were charged no more than

$25.00 for an initial visit and $15.00 for a followup visit. Patients were asked to pay as much as they could at the

times of their visits; no bills were sent home. The overall collection rate, based on total accrued charges, has been

73 percent. Only 16 percent of patients have not been able to pay even a portion of their bills (92). Recently,

however, a cut in State funding has caused the program to curtail its operations to approximately half-time for the

nurse coordinator and to 6 hours a week of physician time. In addition, the program has raised its fee schedule to

$40.00 for a first visit and $25.00 for a followup visit (91a). No information is available concerning the effect of

the increased fees on collection rates.

Eighty-two percent of the first 1,000 adolescents and young adults who registered for clinical care over the first

6 years of the program’s operation were female. Almost three-quarters (72 percent) of the initial visits by adolescents

residing in this middle-class suburban community were for reproductive health care, including contraception,

pregnancy determination, and sexually transmitted infections. Over time, 67 percent were for reproductive health

care. An additional 27 percent of visits were for other medical problems and for preventive care (e.g.,

immunizations, nutrition concerns, dermatologic and orthopedic problems). Only 6 percent of visits were for

emotional concerns or substance abuse (92), despite the overall higher community prevalence rates of these

problems that had been reported in the student survey preceding the opening of the program (175). Data reported

from the Long Island program indicate that it has filled a void in the reproductive health care needs of adolescents.

The Kaiser Permanence Teen and Young Adult Health Center in Granola Hills, CA

The philosophy of the Kaiser Teen and Young Adult Health Center is based on that of the adolescent medicine

program in the Children’s Hospital Medical Center in Los Angeles (147), The Kaiser Teen and Young Adult Center

attempts to have its multidisciplinary staff, many of whom have been specifically trained to work with adolescents,

work in an interdisciplinary manner to meet the diverse needs of their adolescent clients. An innovative feature

Continued on next page
///-36 . Adolescent Health-Volume III: Crosscutting issues in the Delivery of Health and Related Services

Box 15-A—A Community-Based and an HMO-Based Adolescent Health Care Clinic-Continued

of the Teen and Young Adult Health Centers’ approach is the use of a team of “Teen Advisors. The rationale for

having a special adolescent program within the HMO is to deliver health services to adolescents in a proactive and

preventive, rather than a reactive, manner (146). In that spirit the Center also produces and distributes its own

newsletter, The Kaiser Advisor.

Staff and Services-The Center staff consists of a multidisciplinary team of professionals, including doctors

in adolescent medicine and obstetrics-gynecology, health educators, a part-time social worker, a part-time

psychiatrist, and a full-time project coodinator. Adolescents served at the Center are interviewed by their health

cam providers to identify potential or existing problems of depression, suicide, unwanted pregnancy, substance

abuse, eating disorders, and other problems. In addition to this compressive psychosocial assessment the Center

provides comprehensive health services, which they have defined to include:

● Primary medical care (general health care; routine physicals and health assessment treatment for acute and

chronic illnesses; routine gynecological care; family planning services; pregnancy testing, diagnosis and

referral; STD [sexually transmitted disease] diagnosis and treatment; contraceptive decisionmaking and

education);

● Obstetrical care for adolescents (prenatal care, postpartum care, prenatal education, childbirth classes,

parenting classes, nutrition counseling, and social services assistance and counseling);

. Health education services (printed materials, audio-visual programs, interactive health education computer

programs, other group and individual health educational activities); and

. Social and psychological services (counseling and education regarding grief, family problems, substance

abuse, sexual concerns, relationships, pregnancy, depression, and low self-esteem) (146).

In order to help expand the network of referrals to and frkom the Center and coordinate services with other

departments, the Center project coordinator and physicians hold outreach meetings with other Kaiser Permanence

departments on an ongoing basis (146)

Teen Avisors--The "Teen Advisors” area group of volunteers, ages 15 to 20, who meet regularly at the

Center, and attempt to help the Center better serve its adolescent clients by acting as a sounding board for the Center

staff. The Teen Advisors review films and educational materials, and advise the Center’s staff on how to work

effectively with teenagers (134,135).

Program Effectiveness-No information on the effectiveness of Kaiser’s Teen and Young Adult Health

Center has yet been published, but an evaluation to determine “if the current Center model provides cost-effective,

comprehensive physical and psychosocial health care services to adolescents and young adults in a manner that

fulfills their needs and expectations, maintains and enhances their health, and encourages thereto continue as health

plan members in the future” (146) is under way.

SOURCE: Office of ‘Rcbnolo# Awmwmxlg 1991.

Today, it is estimated that roughly 80 free clinics solutions to their communities’ health care problems

exist across the United States (1 12). Such clinics are (see box 15-B).

more likely to be found on the west coast than in the

Northeast or Midwest. Because free clinics developed in response to the needs of their home

communities, they tend to serve different ethnic

populations. For example, free clinics in the Southwest tend to be oriented toward Hispanic groups, and

free clinics in some parts of California are apt to

serve Southeast Asian refugees. In general, free

clinics can offer only a finite range of health

services, given their budget and staffing constraints.

They can offer a relatively fast and partial solution

to a community’s otherwise unmet health care

needs, but the directors of free clinics do not view

them as being able to provide comprehensive

Little published information is available that

describes the characteristics of adolescents who use

free clinics. Also, very few published studies have

compared the characteristics of adolescents who use

free clinics with those who use other sites for their

health and medical care.

Multiservice Centers That Offer Comprehensive

Health and Other Services to Adolescents

Multiservice centers for adolescents operate on a

model of adolescent health care delivery that recognizes adolescents’ broad and varying need for

services beyond traditional medical care. One multi-
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-37

Box 15-B—The Free Medical Clinic of Greater Cleveland

The Free Medical Clinic of Greater Cleveland is the third largest free clinic in the country in terms of budget

and patient flow. The Free Clinic opened in 1970 to provide services to patients of all ages. Thus, many of its services

are available to patients other than adolescents. In 1987, the Free Clinic provided medical services to almost 14,000

people. Visits by adolescents accounted for more than a quarter (29 percent) of all patient visits. More than 75

percent of all adolescent visits for medical services were for contraception, pregnancy testing, and treatment for

sexually transmitted diseases (STDs). In 1989, the Free Clinic joined with a large tertiary care facility to establish

an adolescent clinic. This and other Free Clinic services used by adolescents are described further below.

Overview-Since 1970, the Free Clinic has offered acute ambulatory medical care and drug and mental health

treatment to patients of all ages. These two programs were enhanced by a hot line and a patient advocacy service

that helped to direct patients to other community resources if the Free Clinic was unable to provide direct assistance.

Several other programs were added over the next 7 years: an emergency dental service, a runaway shelter, a

hypertension clinic, and a legal service. Recently, the Free Clinic established an anonymous human

immunodeficiency virus (HIV) testing program and a medical monitoring project, which provides long-term

continuity of care for individuals who are HIV-positive but lack clinically apparent symptoms.

The Free Clinic owns its current physical facilities. Five years after it opened, the Free Clinic was evicted from

its original site and moved to its current location at the border of the cities of Cleveland and East Cleveland. The

clinic’s current location is close to the campus of Case Western Reserve University, Cleveland’s largest private

university. Several years after moving to its present location, the Free Clinic was able to purchase and to renovate

its building and facilities through a grant based on a 9:1 Stat-to-private match from the State of Ohio.

Services Used by Adolescents--In the fall of 1989, the Free Clinic established an adolescent clinic in

partnership with Rainbow Babies and Children’s Hospital, a large tertiary care facility located approximately 1 mile

from the clinic. Physician staffing is provided by the hospital, and the Free Clinic supplies the physical space, staff

coordination, laboratory, and medical and pharmaceutical supplies. Patient care statistics for this specifc program

mirror the Free Clinic’s general statistics for adolescents. Half of patients seen in the adolescent clinic are females

seeking contraceptive services or pregnancy testing. Another 26 percent of adolescents are seeking treatment of an

STD. Various programs offered by the Free Clinic are utilized by adolescents. Safe Space is the Free Clinic’s

runaway shelter and is located next door. It provides services consistent with the regulations of the National Youth

Runaway Act (Public Law 93-415) to almost 600 minors a year.l It is one of the very few runaway shelters in the

country that is able to offer medical and legal services to its adolescent clients. Approximately 30 percent of

adolescents seeking refuge at Safe Space request or are perceived to need medical care, which is available to them

at the Free Clinic. Common reasons given by adolescents for needing medical care include documentation of

physical abuse and reproductive health concerns. Safe Space retains its own attorney on salary in order to represent

its adolescent clients to the judicial system. The attorney handles approximately 30 to 40 cases each month.

Other Free Clinic services used by adolescents include ambulatory medical care and general counseling and

outpatient drug abuse treatment services. The Free Clinic sponsors the Adolescent Sexual Offender Project and an

Incest Survivors’ Group. For general issues, master’s prepared mental health professionals include adolescents as

part of their individual caseloads. The Adolescent Sexual Offender Project, which started in 1986, is largely funded

through a contract with the county’s Juvenile Court. It has a capacity of 20 clients and includes family members

in its treatment services. The Free Clinic’s dental service is very small and provides emergency an for less than

100 patients a year. Very few adolescents use this service.

Staff-The Free Clinic’s staff includes 42 paid employees and more than 400 volunteers. In the medical

services division, five paid coordinator provide supervision as well as direct patient care. The physician medical

director provides direct patient care and supervises one to four family practice residents per month. Licensed

medical volunteers at the practitioner level include 30 physicians, 22 dentists, 6 nurse practitioners, and 6 physician

assistants. In addition, 80 to 90 medical students volunteer at the Free Clinic each year.

The mental health staff consists of four part-time counselors for the Adolescent Sexual Offenders’ Project and

4.5 full-time master’s prepared counselors to provide general mental health and substance abuse treatment services.

Approximately 50 volunteer therapists also maintain active caseloads of clients.

IS= Ch 14, “Hom~kj~~s: prWeIItiOII and Services,” in Vol. II, for a discussion of Federal law ~to homeless and nmaway

adolescents.

Continued on next page
III-38 . Adolescent Health---Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Box 15-B—The Free Medical Clinic of Greater Cleveland-Continued

Legal services are staffed by 15 volunteer attorneys, who provide advice and referral by telephone.

Budget and Funding--The Free Clinic’s annual budget, including operation of its runaway shelter, is $1.2

million. The funding mix is 60 percent public and 40 percent private moneys.

The largest proportions of public moneys are from the Ohio State Department of Health for STD control and

HIV testing and from the County Drug Board. Federal funds for family planning services made available under from

Title X of the U.S. Public Health Service Act help to support the Free Clinic’s family planning program.2 The Free

Clinic does not bill Medicaid or private insurance companies for patients who maybe eligible for these benefits.

Private resources come from foundations, corporations, individual contributions, and other sources. The

privately funded portion of the budget is generally less restricted than the portion from categorical government

grants and contracts. One observer has noted that it is highly unusual for integrated health services programs to have

such a high proportion of unrestricted funds available and that such unrestricted support is important to the

long-term viability of integrated programs (128a). Foundation grants have remained quite stable since the Free

Clinic’s inception and support its general operating costs. This arrangement is quite unusual, given that foundations

frequently prefer to support demonstration projects. Corporate contributions are assuming an increasingly important

role in the overall budget, as the Free Clinic’s Board of Trustees becomes more active in fundraising. Although

individual contributions made up 37 percent of the 1990 budget’s private resources, such contributions are regarded

as the budget’s least stable section. The Free Clinic’s annual individual fundraising campaign goal is partially

determined by its anticipated budget deficit; the funds generated through individual fundraising are used to offset

these expenses. In addition the Free Clinic’s staff sponsor at least one special fundraising event each year (e.g., rock

concert) that raises approximately $25,000. The Free Clinic also operates a Thrift Store, which breaks even

financially each year.

Volunteers are important to the Free Clinic. The Free Clinic’s overall monetary budget is enhanced by 80

percent, and its personnel budget is doubled, by the almost $1 million of service time that its volunteers contribute.

Personnel costs absorb approximately 75 percent of the Free Clinic’s operating budget. Seventeen percent of

nonpersonnel costs pay for medical supplies, laboratory fees, and other general operating costs.

The budgetary goals of the Free Clinic are to develop a diverse funding base, so as to allow services to continue

despite possible interruption of individual funding sources, and to enhance the proportion of funding from stable

corporate contributions. The Free Clinic considers itself fortunate to have had a relatively stable external funding

base over the past decade, through continuation of its multiple grants and contracts.

Strengths--The Free Medical Clinic of Greater Cleveland has been able to grow over the 2 decades of its

existence for several reasons. It has enjoyed consistent, strong leadership. There have only been three directors

during this time period It has been recognized as an important community resource, as witnessed by its ability to

attract and maintain a strong and varied public and private funding base. It has become a popular organization for

volunteers, many of whom have continued their involvement with the Free Clinic for several years. It is located close

to a university and its medical school, which allows many students to volunteer. It has retained its organizational

identity and original mission.

Weaknesses-In some ways, the weaknesses of the Free Clinic represent the converse sides of its strengths.

For example, the paid staff consist of only a few positions, each of which carries supervisory and direct service

responsibilities. Staff turnover can be especially troublesome. The Free Clinic may find it difficult to recruit certain

paid staff positions because salary levels are significantly below those of other local health care institutions.

Consequently, individuals who are attracted to working at the Free Clinic are frequently young adults with a strong

altruistic commitment and a sense of social advocacy.

Conclusion--There has been no formal evaluation of the ability of the Free Clinic to meet the needs of

adolescents and others in the community. The current director of the Free Clinic has stated that it serves as a

“bandaid,” a short-term and incomplete solution to the community’s problem of providing financial access to

health and medical care for all its citizens, including individuals who perceive themselves as alienated from

mainstream society and who are not willing to seek care from its traditional sources.

2T~~e x of ~~bfic H~tlis~i~ Act is discussed in ch, 10, “Pregnancy and P~Qt@: Prevention and &Xvic@,” ill Vol. ~.

SOURCE: M. Hiller, Executive Director, The Pree Medical Clinic of Gmat.er Clevelai@ information provided in an intemiew conducted for

OTA by ‘llina ktglinj M.D., Ph.D. Dimtor of Adolesccmt Medicine, Cleveland MctmpoManHo6pitaljC&&@ Ox Apr. 16,1990.
Chapter 15—Major Issues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-39

service center known as ‘‘The Door’ is frequently

described as the prototype of an integrated, comprehensive service model for adolescents. This section

describes its programs in detail.

The Door is an independent, community-based

facility in New York City that offers comprehensive

health and medical care, mental health and drug

treatment, educational, legal, social services, recreational, creative arts, and employment training services for youth up to age 21. It opened in 1972,

following more than a year of planning and development activities by a multidisciplinary group of

professionals who were concerned about the physical health, mental health, and social issues of youth

living in New York City. The Door’s initial quarters

were donated as free space, and for its first 7 months

of operation, its staff were unpaid volunteers.

Originally, the Door was begun as a model substance

abuse prevention program (101). However, the Door

was adopted as a model project by the International

Center for Integrative Studies to demonstrate an

integrated human services approach to the wellbeing of adolescents. The center seeks to promote

interdisciplinary communication and cooperation

among the humanities, and the behavioral, social,

and life sciences (280).

The Door is currently located in a renovated

building in lower Manhattan. It serves approximately 7,000 adolescents annually and reports

approximately 70,000 visits a year (101,128). About

75 percent of the adolescents who use the Door for

their physical health and mental health care do not

have health insurance coverage, either public or

private. An estimated 22 percent of adolescents who

use the Door are covered by Medicaid, and an

estimated 3 percent have private third-party insurance coverage (10 1). No more than 7 percent of the

Door’s operating budget is recovered from Medicaid; although a sliding-scale payment system is

operational, out-of-pocket payments by the Door’s

clients are negligible (128). The Door’s annual

budget is supported by more than 80 funding

sources, including Federal, State, and local public

agencies, as well as private foundations, corporations, and individuals.

The Door’s staff consists of approximately 70

full-time-equivalent paid positions and more than 75

volunteers. The staff is divided into three interdisciplinary working teams, which meet regularly to

review the needs and progress of their adolescent

clients. Staff members include physicians, nurse

practitioners, nurses, family planning counselors,

health educators, nutritionists, pharmacists, 1aboratory technicians, medical assistants, psychiatrists,

psychologists, social workers, lawyers, teachers,

vocational rehabilitation counselors, job developers,

youth workers, and physical education instructors

and artists from the creative, visual, performing, and

martial arts (101). These staff members provide a

wide spectrum of services for the adolescent clients

of the Door. Important to the Door’s philosophy is

its combination of case management and interdisciplinary teamwork. Following a comprehensive indepth assessment, each adolescent client is assigned

to a primary counselor, who will coordinate care and

assure continuity and quality of care throughout the

client’s involvement with the Door. The primary

counselor works closely with the interdisciplinary

therapeutic team built around each client with acute

or broad-ranging problems.

The Door’s Adolescent Health Center offers

general medical services; a prenatal, young parents,

and child health program for the young children of

adolescent parents, including on-site nursery services; a health care program that offers ongoing

continuity of care to youth who have no regular

source of health care or who have chronic diseases

such as asthma, diabetes and hypertension; family

planning and sex counseling services; and a nutrition

counseling service. The approximately 3,500 adolescents enrolled in the Adolescent Health Center

make about 18,000 total visits per year.

The Door’s Psychiatric Services provide diagnostic assessment and therapy using a number of

treatment modalities, including crisis intervention,

individual and group psychotherapy, individual and

group drug and alcohol counseling, pharmacotherapy, couples and family counseling, milieu therapy,

and art and recreational therapy. Many of the

adolescents seen in the Door’s Psychiatric Services

have problems related to the use of substances. The

Door’s Drug and Alcohol Education Services provide information and education about substance use

and treatment resources. In addition to helping

adolescents on-site, the Door has an active outreach

program for students enrolled in schools, and for

adolescents who congregate on the streets and in

parks.

The Door’s Social Service Program provides

social crisis intervention and supportive counseling
111-40. Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

for adolescents with emergency needs for shelter,

food, and clothing, including adolescents who have

run away. Social services staff help young people to

develop more constructive communication and working relationships with their families. They facilitate

mobilizing other agencies’ resources for their youthful clients.

The Door supports three separate counseling

services which help adolescents to address educational, vocational, and legal issues. The Educational

Counseling Services Program offers educational

evaluation and diagnosis, counseling for adolescents

who are truant from or who have quit school,

tutoring, remediation for youth with learning disabilities, and help with the admissions process to

college. The Learning Center Program provides both

ongoing assistance to adolescents having difficulties

at school and an alternative education program for

students who have quit school. The Door’s Vocational Counseling Services provide work readiness

evaluation, vocational testing, career counseling,

vocational training, job shadowing, and job placement. The Legal Counseling Services Program

offers legal advice, representation on civil and

criminal cases, and assistance in dealing with public

agencies and in receiving public benefits. The

program helps to divert appropriate clients from the

justice system to the Door’s Mental Health Counseling Services. It also advocates for legal reform

concerning minors.

The Door’s Creative and Performing Arts Workshops Program allows adolescents to try a wide

range of possible career choices and creative expressions, to learn to work cooperatively, to learn

work-related skills, and to develop pride in their

skills. The creative workshops are perceived as

valuable vocational and life training experiences and

include a variety of classes in dance, theater, music,

fine arts, crafts, photography, silkscreen, sculpture,

pottery, jewelrymaking, and plastic arts. The Door’s

Recreation and Physical Education Program, which

includes classes, games, and team formation in a

variety of activities such as gymnastics, martial arts,

wrestling, weight lifting, aerobics, and ball sports,

emphasizes working cooperatively with peers and

gaining a respect for good health. The Door also

sponsors recreational and educational field trips as

part of its overall program of constructive adolescentoriented activities.

The Door’s Food Services Program prepares a

free, nutritious evening meal for adolescents, many

of whom otherwise would not receive adequate

nourishment. This program also helps adolescents to

learn how to plan and prepare nutritious meals, with

particular attention to hygiene and the use of

institutional equipment.

Other programs at the Door focus on long-term

issues. For example, the Mental Health, Drug and

Alcohol Treatment Program provides long-term

treatment for adolescents with serious problems in

these areas. The program uses a combined case

management and interdisciplinary team approach to

plan, implement, and monitor individualized treatment, using the Door’s many resources. Adolescents

become involved with a therapeutic milieu but

continue to live outside the Door.

The Door has grown from a small program staffed

primarily by volunteers into a large, complex

organization. However, it has retained the elements

that define the service characteristics of an integrated community health delivery program. It offers

comprehensive services at a single site. It interacts

with other community agencies through referral

networks and tracks youngsters who are referred to

another agency for care. It performs multiproblem

needs assessments for individual adolescent clients.

The Door’s service model is based on the concept of

an interdisciplinary team that meets regularly to

coordinate the efforts of its individual providers.

Finally, the Door is committed to case management,

so that each adolescent client has a single, primary

contact person to coordinate programmatic elements. As part of this model, a single, unified record

is maintained for each adolescent (34).

Staff members are flexible in their roles and serve

as advocates for their clients. Through the case

management approach, the Door has continued to

make it easy for its adolescent clients to use its

facilities. In addition, its afternoon and evening

hours of operation were established for the convenience of its clients, so that adolescents who attend

school do not need to miss classes to participate in

the Door’s programs.

Even though the Door is frequently cited as the

model health program for adolescents, it should be

understood that it probably cannot be replicated

exactly in the majority of communities in the United

States. But its underlying principles of care can

clearly be adopted by other communities. As dis-
Chapter 15—Major Issues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . ///-41

cussed by Jellinek (127), the Door had certain

advantages during its formative period. First, its

parent organization, the International Center for

Integrative Studies, provided extremely high caliber

technical expertise, which has allowed the Door to

develop its unique management structure and professional staff mix in the context of its organizational goals. Second, its placement in New York

City has given the Door access to a large and diverse

pool of professional talent, and consequently, the

ability to be selective in its choice of staff members.

The Door’s location in New York City gives it

another advantage relative to other communities.

Because New York has a superior public transportation system linking all boroughs, and because

adolescents in New York usually learn to navigate it

independently at an early age, access to the Door’s

single, stationary site is not a problem. In contrast,

public transportation systems in the majority of

other cities are not as well-developed or convenient

to use as New York’s is, so that a single location of

services may not be as accessible.

School-Linked Health Centers

The SLHC model for providing comprehensive

health services to adolescents has received considerable attention and has the potential to reach many

medically undeserved adolescents because of its

capacity to be replicated in many communities. The

first SLHC opened in West Dallas, Texas, in 1970

and offered a variety of services previously unavailable in a school setting, focusing principally on

general primary care. In 1973, the first SLHC to

emphasize reproductive health services (along with

primary health care services) was established at the

St. Paul High School Clinic in Minnesota (142). Box

15-C describes a typical SLHC in Birmingham,

Alabama.

The number of SLHCs in this country has grown

dramatically in recent years, particularly in the latter

half of the 1980s.46 Unfortunately, it is impossible to

develop a good estimate of the number of adolescents who have access to an SLHC for several

reasons. First, there is no national, comprehensive

source of information on the number of operating

SLHCs. This situation stems in part from the

dynamic nature of the school-linked health care

movement. Also, there are varying definitions of

Photo credit: © Randall Hagadom, Titusville, NJ

There is as yet little systematic evidence that school-linked

or community-based comprehensive service centers for

adolescents improve health outcomes, but there is clear

evidence that such centers can improve adolescents’

access to the health and related services that are most

likely to be needed by adolescents.

what constitutes an SLHC. OTA uses the term

SLHC to refer to any school health center for

students (and sometimes the family members of

students and school dropouts) that provides a wide

range of medical and counseling services and is

located on or near school grounds and is associated

with the school. But some researchers confine their

work to centers based on school grounds and others

consider a school with an on-site, part-time nurse

practitioner, to have an SLHC. A number of States

have recently undertaken initiatives in school-linked

health care, some with programs that go far beyond

traditional, primary health care (e.g., New Jersey

includes job training and employment services in its

program).

Almost all the data on SLHCs that are available

are collected and disseminated by two groups: the

Center for Population Options’ (CPO) Support

Center for School-Based Clinics and the Robert

Wood Johnson Foundation’s School-Based Adolescent Health Care Program. Both programs are

actively engaged in supporting and promoting the

SLHC model of health care for adolescents. Data

from other sources is extremely limited.

CPO, which surveys SLHCs annually, limits its

research to SLHCs operating on school grounds (i.e.,

~At lat 39 new ~fic~ owned d- 1987 done, when my comm~ties ~CeiVed fi@from tie ROb@ Wd Johnson Foundation’s Mtiod

School-Based Adolescent Health Care Frogram.
III-42 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Box IS-C-The Ensley High School “Extra Help Services Clinic”:

A School-Linked Health Center in Birmingham, Alabama

The Ensley High School school-linked health center-named m a vote by students as the “Extra Help Services

Clinic’’--in Birmingham, Alabama was established in 1987. The Jefferson County Department of Health

established the center with financial support from the Robert Wood Johnson Foundation’s School-Based

Adolescent Health Care Program.

A community advisory committee, composed of local clergy, legislators, school officials, parents, adolescents,

and health officials, played a significant role in the health center’s planning and development and continues to

monitor the health center’s performance. With input from discussions at several public forums and a planning survey

of the school’s faculty, students, and their parents, the advisory committee determinedthe scope of the center’s

services. The planning survey found that one out of three Ensley High School students had not seen a doctor in

2 or more years and that treatment for minor injuries and illness was most frequently requested by parents, closely

followed by athletic and employment physicals, alcohol and drug abuse counseling, and treatment for sexually

transmitted diseases. Although the county health department has final responsibility for the health center, the

advisory commit@ also approves any changes in its procedures and services.

The Ensley High School health center provides physical exams; acute care; care for chronic conditions, such

as diabetes and high blood pressure; immunizations;dental, vision, and hearing screening; lab tests; nutrition

counseling, including an exercise and weight management program; reproductive health care, including pap smears,

birth control education and referral, and treatment for sexually transmitted diseases; prenatal care and parenting

education; individual, group, and family therapy; and vouchers for prescription drugs for those students who cannot

afford them.

The Jefferson County Department of Health provides a number of services not available at the school health

center, including contraception, specialized lab tests, surgery, and long-term mental health counseling. Although

the se services are provided off-site, the health center staff continue to manage cases referred outside the center and

follow up students to ensure that all of them get the services to which they are referred.

In the 1988-89 school year, more than 70 percent of Ensley High School’s students were enrolled to receive

the school health center’s services with their parents’ permission. Of the visits to the health center that year, 45

percent were for acute illness, 15 percent for psychosocial services, 9 percent for physical exams, 9 percent for

reproductive health care, 4 percent for prenatal care, 3 percent for chronic conditions, and 2 percent for sexually

transmitted disease treatment. More than half of the patient visits to the center last over 20 minutes. Supporters of

the clinic emphasize that the compassionate care and personal attention provided by health center staff go beyond

the services represented by the statistics. School faculty support has been especially important to the center’s

success; faculty account for approximately 45 percent of referrals to the health center.

The Ensley High School health center is open Monday through Friday, 7:30 a.m. to 4:30 p.m., and is staffed

by a full-time family nurse practitioner, registered nurse, and receptionist A pediatrician, social worker, nutritionist,

and mental health counselor are part-time staff.

SOURCE: Jefferson County Department of Health, “Witness to the Possible: Ensley High School Health Center,” Birmingham, AL, no date.

school-based clinics)47 and appears to omit a number CPO served senior high school students and are

of the State programs (e.g., New Jersey and New located in low-income neighborhoods of large cit-

 ies 49 York). In 1990, CPO reported that, in the 1988-89 . CPO’s data suggest that a minimum of 233,600

school year, it surveyed 153 on-site SLHCs in 96 U.S. adolescents, less than 1 percent of the country’s

communities in 32 States (1 17).48 Ninety-five 31 million adolescents overall, have access to an

schools responded. Most of the SLHCs surveyed by on-site SLHC.50 Although this estimate falls short of

dl’c~ ~Iw t. broaden me scow (Jf its smq to include off-site SLHCS in its future research however, data from on-site and off-site SLHCS fil

be anatyzed separately (296).

@~ere ~e 35,786 mid~e, j~or hi- and senior high schools nationwide; the overwhelming majority of ~h~ls do not have an SLHC.

dsIn 1988, only 15 of tie 120 existing on-site SLHCS were in junior high or middle schools.

-s number was calculated by multiplying the number of on-site SLHCS suxveyed by CPO in 1988-89 (i.e., 153 times average enrollment of schools

with surveyed SLHCS in 1988-89 (i.e , 1,527) (153 X 1,527 = 233,631).
Chapter 15—Major Issues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-43

—.

Box 15-D—Adolescents' Perspectives on Their Need for a School-Linked Health Center

One way of assessing the need for school-linked health centers (SLHCs) is to ask adolescents whether they

need and will use the services if implemented Although many programs have conducted needs assessments as part

of planning activities for the development of SLHCs, few programs have published their findings. One health needs

assessment, which was conducted in a Rhode Island public high school in preparation for the opening of a school

health clinic, found that the majority of students expressed a willingness to use the specified clinical services. In

addition, students who acknowledged problems or behavior in defined areas, including depression, history of

suicidal intention or attempt, obesity, and sexual activity (but not substance use), were significantly more interested

in using relevant clinical services than students who did not report such concerns or behaviors (227).

The State of New Jersey Department of Human Services surveyed approximately 3,600 high school students

to determine their knowledge about and frequency of use of established helping resources (237a). It found that

although the majority of students could identify helping resources for problems with school, work, their families,

health, sexually transmitted infections, finding a job, and depression, there were significant gaps between knowing

about helping resources and actually using them. The largest gaps were for help with health services and personal

problems. This survey also found that students were most likely to identify the school as a helping resource,

regardless of the type of problem. In addition, the large majority of students who had actually sought help from the

school were satisfied with the help they had received. Based on these findings, the State Department of Human

Services recommended that New Jersey’s School-Based Youth Services Program should provide both health

information and staff to help students with personal problems (237a).

A study of SLHCs in New York City public schools found that 38 percent of interviewed students reported

that they would not have sought help for a problem addressed by the SLHC if no clinic had existed (304).

SOURCE: OffIce of ‘Rdnology Assessmen~ 1991.

the actual number, it is obvious that the overwhelm- examinations, laboratory and pregnancy tests, pre

ing majority of U.S. adolescents do not have access

to an SLHC.

Services Provided by SLHCs5l—Data on the

services provided by the on-site SLHCs surveyed by

CPO are presented below. Although all SLHCs aim

to provide a wide range of health care services, what

they 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. Several surveys that have asked adolescents

about their needs for a school health center are

summarized in box 15-D.

Medical Services-In 1988-89, 90 percent or

more of the on-site SLHCs surveyed by CPO

provided general primary health care, assessment

and referrals to community health care services,

diagnosis and treatment of minor injuries, diagnosis

and treatment of sexually transmitted diseases,

general as well as sports and employment physical

scriptions for medication, and referrals for prenatal

care (see table 15-9). A slightly smaller proportion

(80 to 89 percent) of SLHCs also provided assessment

referral to private physicians, chronic illness management, gynecological examinations, and immunizations. Services at junior high/middle schools and

senior high schools are generally similar, although it

appears that junior high/middle schools are less

likely to provide referrals to community health care

or private physicians.

Counseling/Educational Services----Common counseling/educational services include health and nutrition education, sexuality counseling, pregnancy

counseling, mental health and psychosocial counseling, and weight reduction programs, Most SLHCs

responding to the CPO survey provided all those

services considered to be counseling or education

(see table 15-10). The services least likely to be

delivered were job counseling, parenting education,

and drug/alcohol counseling. Less than half the

s I D;ita ~rescnl~ here on We scmlces provided by SLHCS are drawn from a 1988-89 survey of on-site SLHCS conducted by the Center for population

options (CPOJ ( 1 17) Ninety-five of the 153 on-site SLHCS known by CPO to be operating during the 1988-89 school year participated-a 62-pement

response rate, The respondents represented 27 of the 32 States in which SLHCS were located and 56 of the 96 communities. Participating schools included

senior high schools, junior high/middle schools, vocational schools, and schools going tlom kindergarten ~hrough wade 12 ( 11 7). The definition of the

service categories ( 1 e , medical, counselingjeducation, and family planning) are CPO’S.
III-44 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Table 15-9—Percentages of On-Site School-Linked Health Centers Which Offer Medical Services,

by Type of School, 1988-89a

Type of School

Senior high Junior high/middle Ail schools

Medical service (n= 76) (n= 11) (N= 95)

Diagnosis/treatment of minor injuries. . . . . . . . . . . . . . . . . . . . . . . . . 99% 1 00% 98%

General primary health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 100 97

laboratory tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 100 97

Physical exams for sports/work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 100 97

General physicals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 100 96

Pregnancy tests ... , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 91 93

Prescribe medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 100 92

Referral for prenatal care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 100 91

Assessment/referral to community health care. . . . . . . . . . . . . . . . . 93 55 90

Diagnosis/treatment of sexually transmitted diseases . . . . . . . . . . . 92 82 90

Gynecological exams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 91 88

Chronic illness management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 100 87

Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 100 87

Assessment/referral to private physician. . . . . . . . . . . . . . . . . . . . . . 90 55 85

Dispense medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 82 74

EPSDT screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 55 48

Pediatric care for infants of adolescents . . . . . . . . . . . . . . . . . . . . . . 38 18 38

Prenatal care (on-site) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 18 36

Dental services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 55 31

aData present~ in this table are drawn from a 1990 survey ccmductect by the Center for Population Options (CPO). Ninety-five of the 153 on-site SLHCS (i.e.,

school-basedclinics) known by CPOI:O be operating during the 1988-89 school year participated-a 62-percent response rate. The respondents represented

270f the 32 States in which SLHCs wore located and 56 of the 96 communities. Participating schools included senior high schoois, junior higtimiddle schoois,

vocational schools, and schools going from kindergarten through grade 12.

bEpsDT is M~”@id’S Earty and Periodic Screening, Diagnosis, W?d Treatment program.

SOURCE: H.J. Hyche-Williams and C. Waszak, “School-Based Clinics: Update 1990” (Washington, DC: Center for Population Options, 1990).

Table 15-10-Percentages of On-Site School-Linked Health Centers Which Offer Counseling and Educational

Services, by Type of School, 1988-89a

Type of school

Senior high Junior high/middle All Schools

Counseling/educational service (n= 76) (n= 11) (N= 95)

Health education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nutrition education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sexuality counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pregnancy counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mental health and psychosocial counseling . . . . . . . . . . . . . . . . . . . .

Weight reduction programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sex education in classroom setting . . . . . . . . . . . . . . . . . . . . . . . . . .

Family counseling with students and parents . . . . . . . . . . . . . . . . . .

Drug and substance abuse programs, . . . . . . . . . . . . . . . . . . . . . . . .

Parenting education , ... , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Job counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100%

100

97

92

91

91

87

83

63

65

32

100%

100

91

91

82

82

73

73

73

46

9

100%

99

96

91

91

90

85

82

66

62

30

aData present~ in thista~e are drawn from a 19gOsu~eya~uct~ by the Center for population Options (CPO). Ninety-five of the 153 on-site SLHCS (i.e.,

school-based clinics) known by CPOto be operating during the 1988-89school year participat- 62-percent response rate. The respondents represented

270f the 32 States in which SLHCs were located and 56 of the 96 communities. Participating schmls included senior high schools, junior higtVmiddle schools,

vocational schoois, and schoois going from kindergarten through grade 12.

SOURCE: H.J. Hyche-WNiams and C. Waszak, “School-8ased Clinics: Update 1990” (Washington, DC: Center for Population Options, 1990).

surveyed SLHCs provided a structured HIV preven- table 15-1 1). Other common services include examition program in the classroom or on-site clinic (1 17). nations, followup, and referrals for birth control

methods. In 1988-89,21 percent of surveyed SLHCs

Family Planning Services—Almost all on-site dispensed contraceptives, a decline from 28 percent

SLHCs surveyed by CPO provided counseling on in 1985-86. More than half (54 percent) of the

birth control methods in 1988-89, although 3 of 11 surveyed SLHCs provided written prescriptions for

responding junior high/middle schools did not (see birth control methods.
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-45

Table 15-1 l—Percentages of On-Site School-Linked Health Centers Which Offer Family Planning Services,

by Type of School, 1988-89”

Type of school

Senior high Junior high/middle All schools

Family planning service (n= 76) (n= 11) (N= 95)

Counseling on birth control methods . . . . . . . . . . . . . . . . . . . . . . . . . 97% 73% 94%

Followup for birth control methods . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 55 78

Referrals for birth control methods and exam . . . . . . . . . . . . . . . . . . 72 46 71

Examinations for birth control methods . . . . . . . . . . . . . . . . . . . . . . . 72 55 70

Writing prescriptions for birth control methods . . . . . . . . . . . . . . . . . . 55 55 54

Dispensing birth control methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 27 21

aData presented in this table are drawn f rom a 1 ggo survey conducted by the Center for Population Options (CPO). Ninety-five of the 153 On-Site SLHCS (i.e.,

school-basedcli nies) known by CPOto be operating during the 1988-89 school year participated-a 62-percent response rate. The respondents represented

270f the 32 States in which SLHCs were located and 58 of the 96 communities. Participating schools indudedsenior high sehmls, junior higtVm iddle schools,

vocational schools, and schools going from kindergarten through grade 12.

SOURCE: H.J. liyche-Williams and C. Waszak, “School-Based Clinics: Update 1990” (Washington, DC: Center for Population Options, 1990).

Sponsoring Agencies and Administrative Arrangements of SLHCs-The majority of SLHCs

maintain organizational and administrative independence from their school system, although an

increasing number are administered by community

school districts (143). The designers of the frost

SLHCs intended that the centers remain fiscally and

administratively independent of the schools that

housed them in order to ensure patient confidentiality and encourage students’ trust in clinic staff. In the

1985-86 school year, only 4 percent of the on-site

SLHCs surveyed by CPO were sponsored by school

districts; by 1988-89, 19 percent of them were

administered by school districts (1 17,143). Some

SLHCs report that school district sponsorship works

well because it facilitates integration of school

health services and eliminates a level of bureaucracy

(55). According to CPO, SLHCs that are not

sponsored by school districts are most commonly

sponsored by public health departments (33 percent

in 1988-89), community clinics (18 percent), and

hospitals (18 percent) (1 17). Twelve percent of

school-based SLHCs were sponsored by other entities. Many agencies operate more than one SLHC

site.

In 1988-89,91 percent of the SLHCs participating

in the CPO survey were located inside a main school

building serving an average enrollment of 1,527

students (with a range of315 to 10,000) (1 17), More

than half were open during the summer and almost

one-quarter were open on holidays. Ninety percent

were open either before or after regular school hours.

Staffing of SLHCs---SLHCs are usually staffed

by nurse practitioners, physician assistants, and

physicians to provide the majority of clinical care,

and counselors or social workers to address mental

health, substance use, and family issues (142,167).

The training of physicians who staff SLHCs is more

likely to be pediatrics than obstetrics and gynecology (184). Other specialized personnel include

dental hygienists, nutritionists, dentists, and psychologists (184).

Most SLHCs try to employ staff with special

expertise in adolescent health care. Although bilingual or bicultural staff may more effectively meet

the needs of minority adolescents, and some funding

agencies have made a special effort to hire them for

SLHCs (28), as a general matter their numbers and

availability are seriously limited (184).52

Eighty-two percent of the on-site SLHCs responding to CPO’s survey employ a school nurse (1 17). In

44 percent of these schools, the school nurse is part

of the clinic staff, performin g such functions as

delivering direct services, providing case management, participating in clinic staff meetings and case

conferences, and serving on clinic advisory boards.

In the majority of schools, however, the school nurse

operates independently of the school clinic although

she may refer students to the SLHC for further care

(117).

Demographics and Utilization of SLHCs--It is

well-documented that many adolescents in schools

that have SLHCs use the centers and that a large

proportion of adolescents in schools with an SLHC

Szsee ch. Ig, “ISSUeS in tie Delivery of Services to Selected (%oups Of Adolescents, ” in this volume for a discussion of the special health care needs

of minority adolescents.
III-46 ● Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

either have no other regular source of care or rely on

a local emergency room for their medical care

(156,168,184).53 Nationwide, the average SLHC

serves 59 students and has 183 visits per month,

according to CPO (143). In 1987-88, almost half (48

percent) of the students who were eligible to use the

services of on-site SLHCs surveyed by CPO enrolled to receive the center’s services (143). Eighty

percent of enrolled students used the centers’

services at least once during the school year (143).

Schools with SLHCs are typically located in

low-income communities where access to health

care is limited and lack of health insurance is

common. Overall, approximately 55 percent of

students enrolled in SLHCs surveyed by CPO had no

other source of primary health care during 1988; in

some programs this was true for almost 100 percent

of clinic enrollees (168). Thirty-four percent of

enrolled students were uninsured in 1988, more than

twice the 15 percent national rate of adolescents

without health insurance, according to CPO (150,

168).54 Another indicator of the poverty of the communities in which the SLHCs surveyed by CPO are

located is that 30 percent of enrolled students in 1988

had Medicaid coverage—three times the national

average of adolescents with Medicaid coverage (150,

168). In 1988, only 36 percent of students enrolled in

an SLHC had private health insurance (168).

The health needs of middle-class adolescents

suggest the potential value of SLHCs in less

impoverished areas (175,184). One study of middleclass adolescents residing in a suburban area found

that almost half had unmet health needs that could be

met by an SLHC or similar facility (175).

Although some schools with SLHCs serve predominantly white students, the large majority of

students who currently use SLHCs are black or

Hispanic (see table 15-12).55 56 Some SLHCs have

been relatively successful in attracting male stuTable 15-12—Race and Ethnicity of Students Using

On-Site School-Linked Health Centers, 1987-88a

Percentage of school

population enrolled

in clinic

Race and ethnicity (N= 130)

Black . . . . . . . . . . . . . . . . . . . . . . . . . . 59%

White . . . . . . . . . . . . . . . . . . . . . . . . . 25%

Hispanic. . . . . . . . . . . . . . . . . . . . . . . 12%

Other . . . . . . . . . . . . . . . . . . . . . . . . . . 4%

aData presented in this table are drawn from a survey of on-site SLHCS (i.e.,

school-&aseddinics) conducted byths Center for Population Options (CPO).

SOURCE: D. Kirby, C. Waszak, and J. Ziegler, “Assessment of Six

School-Based Clinics: Services, Impact, Potential” (Washington, DC: Center for Population Options, 1989).

dents; in 1988-89, 44 percent of SLHC patients in

schools surveyed by CPO were male (1 17). One

study found that SLHCs were more successful at

attracting males than neighborhood or hospitalbased clinics (84). Centers that offer and promote

sports physicals are reported to be particularly

successfully in attracting male students (184).

Why Adolescents Use SLHCs--On average, 46

percent of visits to Robert Wood Johnson Foundation SLHCs lasted more than 20 minutes in the

1988-89 school year (156). The primary diagnoses

of adolescents who visited 23 SLHCs sponsored by

the Robert Wood Johnson Foundation in the 1988-

89 and 1989-90 school years are detailed in table

15-13. 57 More than 80 percent of visits were for

return patients. The leading primary diagnoses were

acute illness or injury (26 percent), mental health

problems (21 percent), and physical exams and other

preventive services such as immunizations and

vision and hearing testing (24 percent) .58 Reproductive health care accounted for 12 percent. Anecdotal

reports from a variety of SLHC staff indicate a high

prevalence of depression, sexual abuse, and parental

drug use (184).

Mental health problems are often discovered in

visits by adolescents visiting the health center for

SJ~ emergenqmom is the most (OSUY site for acute care and is omy appropriate for serious emergencies. Emergency rooms do not provide preventive

medical care, health education or ongoing support for emotional and psychological problems and other chronic conditions.

~See ch. 16, ‘ ‘Financial Access to Health Se~iC=, ‘‘ in this volume for further details on health insurance, Medicaid, and financial barriers to care.

55~e Ro&fi Wmd Jo~on Fo~~dation fo~d titr~~ ad ehnic minority students amounted for more than thftX?-CpIiIlf3rS Of the visits tO the

23 SLHCS it supports (156).

56Most c~cs Sene o~y theu student populatio~ but some we ~W open to ~pouts (16 ~rwn[), children of students (16 percent), other ftiiy

members of students (11 percent), and adolescents in the broader community (143).

sTIn vol. II, see ch. 5, ‘‘Acidental Injuries: Prevention ~d SWiCeS, ” for a description of adolescents’ accidental tijuries, ch. 6, ‘‘Chronic Physical

KUnesses: Prevention and Services,” for a review of physical problems among adolescents, and ch. 11, ‘ “Mental Health Problems: Prevention and

Services, ’ for details on adolescent mental health problems.

58~ese dla~oses ~present tie pnnclp~ re~(]n for tie visit ~d do not ~flect otier services that my have been provided.
Chapter 15—Major Issues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-47

Table 15-13-Principal Reason for Clinic Visits to 23

School-Linked Health Centers Funded by the Robert

Wood Johnson Foundation, 1988-89 and 1989-90

Percentage of visits

Principal reason 1988-89” 1989-90 b

Acute illness/accidents . . . . . . . . . . . . . . 25°/0 26%

Mental health related . . . . . . . . . . . . . . . 20 21

Other, including immunizations,

vision, and hearing testing . . . . . . . . . 13 12

Reproductive health . . . . . . . . . . . . . . . . 13 12

Physical examinations . . . . . . . . . . . . . . 12 12

Chronic disease management . . . . . . . . 5 4

Acne, other dermatology . . . . . . . . . . . . 4 4

Nutrition, including eating disorders . . . 3 3

Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . <1 1

Drug and alcohol abuse . . . . . . . . . . . . . Cl 1

where were 49,3T7 total visits m the 1988-89 school year.

bhere were 58,148 total visits in the 1989-90 school year,

SOURCE: J. Lear, Co-Director, School-Based Adolescent Health Care

Program, Robert Wood Johnson Foundation, Washington, DC,

unpublished data on student utilization of SLHCS, October 1990,

some other complaint (184). While drug and alcohol

counseling are available at many SLHCs, the

number of visits to the Robert Wood Johnson

Foundation sites for substance abuse problems was

negligible.

Financing Issues for SLHCs-Financing is a

critical determinant of SLHCs’ hours of operation,

scope of services, and long-term viability. Current

programs owe much of their existence to private

foundation support, Recently, some State and local

health departments, as well as school districts

themselves, have begun to provide substantial financial support to local SLHCs. There is evidence that

some programs have been able to receive Medicaid

and private health insurance reimbursement for their

eligible students, although the level of third-party

revenues supporting SLHCs appears to be minimal.

Costs and Sources of Funding—The average

operating budget for the on-site SLHCs surveyed by

CPO was $143,827 in 1988-89 (1 17). In 1987-88,

SLHC budgets ranged from $100,000 to $313,000,

depending largely on clinic hours (143). It has been

estimated that SLHCs cost between $50 and $150

per student per year (184). One study found that the

average cost of a routine physical examin ation at a

SLHC was considerably less than the cost of one

performed in a private physician office in the same

community: $11.25 v. $45 (25 1). Considering the

lost wages of parents who may accompany their

children for the visit to a private physician increases

the difference even further.

SLHCs are funded by a variety of public and

private sources (e.g., see table 15-14). Most of the

on-site SLHCs responding to CPO’s survey are

subsidized by at least two sources; more than half

have three sources or more (143). In fact, program

staff must often devote significant time to securing

financial support, making fundraising itself a costly

program activity (1 84). Foundation grants, although

time-limited, have been key to the startup, development, and growth of SLHCs. Foundations typically

provide seed moneys for startup with the expectation

and intention that the successful project will garner

more stable and long-term resources (87). As shown

in table 15-14, 26 percent of the 1988-89 operating

budgets of 79 SLHCs surveyed by CPO was derived

from foundation grants; the percentage was lower

than it had been in previous years, when foundation

support accounted for as much as 41 percent of

SLHC budgets (55,56). A significant percentage of

foundation support for SLHCs comes from the

Robert Wood Johnson Foundation’s School-Based

Adolescent Health Care Program, whose funding

will end in 1993. It is not clear whether other moneys

will be available to compensate. Continued changes

in funding may create problems for SLHCs, because

changes in grants sometimes necessitate changes in

program content that are disruptive to program

operations and confusing to students.

While the share of SLHC funding from foundations has been declining in recent years, the share of

State funding of SLHCs has recently increased

dramatically (see table 15-14). The increased share

of State funding reflects a number of State initiatives

supporting SLHCs (see box 15-E). In 1985-86, State

health departments contributed 16 percent of funds

for the operating budgets of SLHCs surveyed by

CPO and city/county governments contributed virtually nothing; in 1988-89, State health departments

contributed 28 percent of funds for surveyed SLHCs'

operating budgets and city/county governments

contributed 19 percent (55,1 17).59 School systems

often provide in-kind contributions of space, utili59co~ni~ health centers provide health services to residents of low-income and rural communities or neighborhoods which have been desi~t~

medically underserved areas (87). The centers provide primary health services, including preventive, medical, dental, and mental health services. Public

or private nonprofit organiza tions may receive grants to establish a community hcdh center. A network of SLHCs has been established by a community

health center in at least one State (87).
III-48 . Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Table 15-14--Funding Sources for On-Site School-Linked Health Centers Responding

to the Center for Population Options’ Surveys, 1985-86 to 1988-891

Percentage of total operating budget

1985-86 1986-87 1987-86 1988-89

Funding source (N= 61) (N= 45) (N= 92) (N= 79)

Public sources

Maternal and child health block grantsb. . . . . . . . . . . . . . . . .

EPSDTC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Title Xd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Title Axe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

School district . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Community health center . . . . . . . . . . . . . . . . . . . . . . . . . . . .

State health department. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

City/county . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total public support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27%.

14—

3

2—

2

16—

—

14%

2

2

NA

1 —

NA

19

19—

16%

2

2

0.4

—

3

6

19

16

2

l l %

b

2

3

—

<1

2

4

28

19

NA

64% 57% 66.4% 70%

Private sources

Foundation grants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31% 41% 31% 26%

Private health insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . — 0.1 0.1 2

Patient fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 0.4 0.3 <1

Other privatef . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 2 NA

Total private support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36% 43.5% 33.4% 29%.

Total funding

Estimated total funding (all centers )...... . . . . . . . . . . . . . . NA $9,200,000 NA $11,362,000

Average operating budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA $ 120,991 NA $ 143,827

Range in operating budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA $10,000 to $414,900 NA NA

NA-Notavaitable.

at)ata presented in twistable aredrawn from surveys of on-site SLHCs(i.e., school-hasecfclinics) conducted bythe Center for Population Options (cpO).

%aternal and child health block grants,authorizadbyTitl eVofthe Sodal Security Ac~arelntendedto reduce infant mortality, reducetheinddence of

preventable disease andhandicapping cxmctitionsa mongchildren, andincreasetheavaitabitity ofprenata~delivery andpostpartum caretolow-income

mothers. In fiscal year 1988, the U.S. Department of Health and Human Services’ Bureau of Maternal and Child Health distributed $444.3 m ill ion to States

as maternal and child health block grants. Twenty-three centers reeeived a portion of this funding in grants ranging from $8,260 to $135,727, and totaling

more than $1.3 million. Similar data for earlier years are not available.

CEpSDT is Medieaid’s Eady and Periodie Screening, Diagnosis, and Treatment program.

%itle X of the Public Health Serviee Act isa Federal program administered by the U.S. Department of Health and Human Services. It provides Federal funds

for public or private nonprofit entitias that offer family planning services. The fiscal year 1990 appropriation was $141 million.

~itle XX of the Public Health Service Act is a Federal program administered by the U.S. Department of Health and Human Services. It provides Federal funds

for demonstration projects to encourage adolescents to postpone sexual activity and demonstration projects that provide comprehensive health and sodal

servims for pregnant or parenting adolescents. Annual authorizations were $9.5 million through 1992.

~his includes donations from private corporations and nonprofit organizations.

SOURCE: 1985-86 and 1987-88 data: Center for Population Options, “SBCS: Update 1989,” Clink News 5 (4):7, Washington, DC, 1989.

1986-87 data: S. Lovic+ and R. Stern, “School-Based Clinics: 1988 Update” (Washington, DC: Center for Population Optionsr 1968).

1988-89 data: H. Hyche-Williams and C. Waszak, “School-Based Clinics: Update 1990” (Washington, DC: Center for Population Options, 1990).

ties, and maintenance, but they seldom have suffi- decreased (see table 15-14).60 In the 1988-89 school

cient financial resources to provide substantial fiscal year, 11 percent of SLHCs’ operating budgets were

support. In 1988-89, local school districts provided supported by Federal maternal and child health

2 percent of the operating budgets of SLHCs block grants, a drop from 27 percent in 1985-86.6162

surveyed by CPO (1 17). The 1988-89 share of Federal support provided by

As local funding and the number of SLHCs have Medicaid’s Early and Periodic Screening, Diagnoincreased, the relative share of Federal support has sis, and Treatment (EPSDT) program, other Med-

@Av@ble da~ make it difficult to determine whether the overall level of FederaI funding has changed. The majority of Federal dollars for SLHCS

has come through maternal and child health block grants. Complete data on how these block grants are allocated is not available.

61 Twenty-~ee of ~i@~-one s~~cs re5Wnding to a 1989 cm s~ey reported receivfig mdd md child health block gr~t tidstht year: th&

ranged from $8,260 to $135,727 and totaled $1,338,419 (2%).

6zFede~ ~te~~d c~d he~[hb]~k gr~ts were comoli&t~ ~der Title V of the social Swurity Act in 1981 ~d cm be u5ed to provide SeIVi(XS

to a wider range of individuals than Medicaid because of more generous eligibility rules (87). Another advantage of maternal and child health grants

is that SLHCS can use existing Title V personnel in public health depmtrnents as staff if the health department is willing to use the SLI-IC as one of its

sites (87).
Chapter 15—Major Issues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents ● 111-49

Box 15-E—State Initiatives in School-Linked Health Care

A number of States have implemented initiatives in comprehensive school-linked health care. Although privately

funded school-linked health centers (SLHCs) have existed for some time, State efforts to authorize and appropriate funds

for SLHCs are fairly recent.. At least nine States, five of which are described below, have begun to establish programs or

demonstration projects in school-linked health care.l

New Jersey

In 1987, the New Jersey State Department of Health Services provided 29 grants to public and nonprofit organizations

to establish SLHCs in local communities as part of its School-Based Youth Services Program (SBYSP). Funding for New

Jersey’s SBYSP comes from a $6.5-million set-aside in the State budget. Grants of $250,000 are awarded to school districts

that formulate plans for SLHCs. Participating communities must be willing to provide 25 percent of the cost incurred by

the center either through direct funding or the use of community facilities (270). The SBYSP requires that the SLHCs offer

certain core services, including job training and employment services, health screening and referrals, and mental health

and family counseling services. Depending on the community’s needs, some centers provide additional services, such as

programs for adolescent dropouts, classes in parenting skills for adolescent parents, child care, transportation, nutrition

counseling, and a 24-hour crisis hotline. The SBYSP emphasizes coordination among parents, communities, and schools

in the provision of adolescent health-related services (270). In addition, the program encourages the involvement of

students in assessing the needs of adolescents, in order to help identify and address the many problems facing adolescents

(63).

Kentucky

Kentucky’s initiative in SLHCs is modeled on New Jersey’s approach of providing comprehensive services.

Kentucky established a task force in 1990 to determine the specific guidelines for their $9.5-million program to fund 125

to 150 youth and family resource centers. State officials plan to implement the program in July 1991. Only school districts

in which at least 20 percent of the student body is eligible for the Federal School Lunch Program can participate. Each

eligible district will receive between $30,000 to $90,000 to establish a center and may subcontract with outside

organizations (90).

Iowa

Iowa began a pilot demonstration in September 1990 that established four SLHCs, which are also modeled after New

Jersey’s SBYSP. Iowa’s program, established by State legislation, is funded entirely by private foundations and is

coordinated by the Child and Family Policy Center, a nonprofit organization. The State may consider legislation that

authorizes funding for the SLHCs, after evaluating the current program (37).

Florida

In Florida, the State Department of Health and Rehabilitative Services and State Department of Education are jointly

coordinating a program designed to supplement current school health services. Initial funding for the program is $2.9

million for fiscal year 1991 and $9.6 million per annum thereafter. Florida’s program offers grants to local school districts

and county public health organizations to develop programs based on one of the following four models: a school health

improvement project which provides expanded health screening services and coordinates health services with parents and

the community; student support services teams consisting of a psychologist, social worker, and nurse to provide mental

health services, alcohol and drug abuse counseling, care for sexually transmitted diseases, and pregnancy consultation to

serve the local elementary, middle, and high schools; fill-service schools program that will allow the State Department

of Human Services to provide health, economic, and social services to both adolescents and parents on school grounds;

and locally designed programs that are designed to meet the specific needs of a community (94).

New York

New York State’s Department of Health in cooperation with the State Departments of Education and Social Services,

has conducted School Health Demonstration programs since 1982 and currently funds 115 elementary, middle, and high

school clinics (81). The program targets low-income and high-risk youth and provides primary care, preventive care, and

health education for students and parents (304). The Departments of Education and Social Services also fund a Community

Schools Project at 10 demonstration schools. These schools are required to be open at night, weekends, and during the

summer, and offer a broad range of social, medical, recreational, and other human services(81).

lme nine states are New Jersey, Kentucky, Iow% Flon@ New York Connecticut, Illinois, Mkhig- ad *gon.

SOURCE: Mice of ‘Ikdnology Assessmen6 1991.
111-50. Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

icaid funds, Title X of the Public Health Service Act,

and Title XX of the Public Health Service Act was

6 percent, a drop from 19 percent in 1985-86.63 64

Medicaid and Private Health Insurance-To

date, reimbursement from Medicaid or private

health insurers has played a very limited role in the

financing of SLHCs. In fact, five States (Arkansas,

the District of Columbia, Florida, Utah, and Wisconsin) explicitly prohibit Medicaid reimbursement for

physician services provided in school settings (178).

At least one State (Colorado) has a Physician-OnSite Rule, which requires that a physician be on the

premises at the time a service is provided for it to be

eligible for Medicaid reimbursement (273). Such

regulations preclude Medicaid coverage of most

SLHC services because SLHCs typically rely on

nonphysician providers (with part-time physician

supervision) to minimize cost.

Half of the SLHCs surveyed by Palfrey et al.

reported efforts to collect Medicaid payments in

1990 and one-third tried to collect private insurance

(21 1). But CPO reported that Medicaid and private

health insurance together covered only approximately 7 percent of the 1988-89 costs of SLHCs that

it surveyed (1 17). There is no information available

on how well Medicaid or private health insurance

payments reimburse the actual cost of covered

services (including the administrative costs related

to billing).

The principal obstacles to collecting third-party

revenues cited by SLHCs are that students do not

know their family’s insurance status, costs and

paperwork are involved in billing Medicaid and

private insurance, payment for services is sometimes

refused by third parties, and providers are concerned

about breaching confidentiality (87,211). Furthermore, many students in schools with health centers

are not eligible for third-party coverage because they

are uninsured (143,156,184).65 Many low-income

students with private health insurance coverage

belong to HMOs, which by design usually refuse

coverage for nonemergency services provided outside the health plan (21 1,273).

Many SLHC programs cite significant administrative obstacles in trying to become Medicaid

providers (21 1). Palfrey’s survey found that SLHCs

operated by community agencies with billing expertise are the most likely to try to collect Medicaid and

private insurance reimbursement (211). Several of

the surveyed centers had a Medicaid eligibility

worker on-site to facilitate eligibility (especially for

pregnant students) (211). School-sponsored centers

responding to Palfrey’s survey did not bill Medicaid

or private health insurance at all, perhaps because

they lacked the necessary administrative systems

and experience (21 1).

It is not clear how much incentive grant-supported

SLHCs have had to pursue third-party financing;

only half of centers surveyed by Palfrey (52 percent)

even attempted to identify their students’ Medicaid

status in 1990 (21 1). The Denver school-based

clinics studied the implications of billing third

parties and found that it would cost more to bill for

services than would be captured through available

third-party sources (273). Some adolescents are

particularly sensitive to questions asked about eligibility for health coverage and may turn away from

available services rather than respond (101). And,

there may be reason to question the wisdom of

relying on third-party payment in a model of

adolescent health care designed with several critical

goals in mind: easy access, an atmosphere of trust

and confidentiality, and low administrative overhead (101 ,21 1). Third-party billing could undermine

these goals.66 67

Parental and Community Attitudes Toward

SLHCs--Nearly 90 percent of SLHCs responding to

CPO’s survey in 1990 required parental consent

61Ti~e x of the pubfic Health S~wiW Act was es~bhshed by the Family Planning Services and Population Research Act of 1978. Title X provides

Federal funds for public or private nonprofit entitles that offer family planning services. The Title X program is administered by the U.S. Department

of Health and Human Services. The Title X family planning clinics are required to serve adolescents (87). For further discussion, see ch. 10, “Pregnancy

and Parenting: Prevention and Services, ” in Vol. II.

~T1fle ~of tie ~blic H~th Sewice Act Wm es~blish~ by the Adoles&nt Ftiy Life Act of 1981. Title XX provides Federal funds for

demonstration projects to encourage adolescents to postpone sexual activity and demonstration projects to provide comprehensive services for pregnant

and parenting adolescents. For fiuther discussion see ch. 10, “Pregnancy and Parenting: Prevention and Services, ” in Vol. II.

bssee ch. 16, ‘‘F~ci~ Access to Health SWiCeS, “ in this volume for further discussion of adolescents without Medicaid or private health insurance.

66For emple, some Smte Medic,aid pmgTaros wnd each Medicaid recipient family a monthly itemized 1ist of the services that family members hve

received (87). Most private insurers send subscribers an explanation of benefits for every reimbursed service.

b7See ch, 16 { ‘Fi~ci~ Access to Health SelWiCeS, ’ and ch. 17, ‘‘Consent and Cotildentiality in Adolescent Health Care Decisionrnaking, ’ in this

volume.
Chapter 15—Major issues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents ● III-51

before students could use their services (1 17),

although many surveyed clinics offered emergency

services (57 percent), family planning (43 percent),

and treatment for sexually transmitted diseases (47

percent) without parental consent if the law permits

(117). Overall about half of parents gave permission

for their adolescents to receive services from SLHCs

responding to the CPO survey in 1987-88 (168);

schools whose centers have been established for at

least 1 year tend to have higher enrollment rates (56).

The issue that has engendered the most intense

parental and community concern about SLHCs is

how the centers manage issues of sexuality and

reproductive health. A great deal of media attention

has been directed towards SLHCs because of their

family planning services (81). Considerable controversy has occurred in some communities during the

planning and early implementation phases of SLHCs,

and experience shows that successful SLHCs closely

involve community representatives (184). Most

SLHCs have advisory boards that include parents,

members from local health departments, private

sector physicians, church organizations, and youth

service organizations ( 184).

Opposition to the establishment of local SLHCs

usually focuses on pregnancy prevention activities

and the fears that such activities will lead to

increased sexual activity among students. The National Conference of Catholic Bishops, for example,

is opposed to SLHCs that distribute contraception or

provide abortion services on the grounds that such

SLHCs are both: 1) “morally objectionable” because, in the view of the Bishops, they encourage

premarital sex, and 2) ‘‘open to question even on

practical [i.e., effectiveness] grounds” (193). However, the National Conference statement on SLHCs

recognized that the basic health care needs of young

people are not being adequately addressed and

suggested that SLHCs ‘ ‘that clearly separate themselves from the agenda of contraceptive advocates

may provide part of an effective response to the

health needs of young people” (193).68

Concern that SLHCs have the effect of increasing

sexual activity or abortions among adolescents is not

borne out by existing research (131,143,194,316).

More research has been conducted on the issue of

whether the presence of SLHCs increases sexual

activity rates among adolescents than on whether

abortions are encouraged (e.g., 143,3 16).

Physician Attitudes Toward SLHCs-Organizations of health care professionals can have considerable impact on any attempts to modify existing

health care delivery systems; thus, the attitudes of

physicians and other health care professionals toward SLHCs may be important. OTA is aware of six

published sources of information about health care

professionals’ attitudes toward SLHCs. These include a survey of pediatricians (8) and the positions

of five physician groups (7,8,17,21 ,259).

Pediatricians appear divided in their attitudes

towards SLHCs. In 1987, the American Academy of

Pediatrics included questions about SLHCs in its

national survey of a random sample of its membership and found that pediatricians opinions were

roughly equally divided between those supporting

the concept, those who were neutral, and those

expressing negative attitudes (8). Those holding

negative opinions cited concerns over disruption of

continuity of care, lack of cost-effectiveness relative

to office-based care, duplication of existing services,

and inappropriateness for adolescents with other

sources of health care. Nonetheless, almost 60

percent of the surveyed pediatricians believed that

SLHCs should dispense contraceptives to adolescents, and slightly more than half thought that

parental consent should not be required for dispensing contraceptives. Overall, the survey found

that pediatricians specializing in adolescent medicine and pediatricians who did not provide direct

patient care held more positive attitudes towards

SLHCs than did other pediatricians (8). What

proportion of the pediatricians participating in the

survey actually practiced in communities with an

68A ~Y,stemtic ~ffofi that attempted t. obtain informed citizen opinion on the issue of SLHCS was conducted by the Jefferson Center for NCW

Democratic Processes at the request of the State of Minnesota Senate Health and Human Services Committee (126). The Jefferson Center convened eight

groups at the local Ievcl, representatwes of which went on to debate at the statewide level. All groups were presented with testimony from opponents

and proponents of SLHCS. Of the clght local groups, one voted in opposition to clinics, three voted for alternatives, and four voted in favor. Individuals

at the local level were more likely to be split on the issue of SLHCS, however, with 43 percent supporting clinics, 7 percent opposing, and 50 percent

supporting altemativcs. However, when citizens were selected to go to the statewide meeting, they were selected to be representative of opposing views.

Thus, It is not surprising that citizens participating at the State level voted 13 to 11 to favor SLHCS at a modest level (i.e., in support of SLHCS that did

not distribute contraceptives or provide abortion counseling), with 11 members opposing any introduction of SLHCS ( 126). However, this decision

should be considered cautiously, because, from the outset, citizens were asked to consider the usefulness of SLHCS in preventing ‘ ‘teen pregnancy, AIDS,

and other sexually transmitted diseases (126), not as a meam of providing basic heatth services to adolescmts.
III-52 . Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

SLHC or had had personal experience with an SLHC

is not clear.

Community physicians are commonly thought to

oppose SLHCs because the clinics are viewed as

competitors for patients (259). In fact, however,

community physicians may not lose patient visits to

SLHCs; there is some evidence that many adolescents are unwilling to visit their private physician for

concerns about sexuality, substance abuse, or emotional upset and also would not be willing to seek

care for these problems with their parents’ knowledge (175). In addition, most SLHCs established to

date have been located in medically underserved

communities, and many of the adolescents who use

SLHCs lack private health insurance or Medicaid

coverage (143,156,184). Also, SLHC health screening may identify patients with health problems that

require referral to a physician for more detailed

assessment or continuing management (203). Most

surveyed SLHCs refer students to community health

care (90 percent) and to private physicians (85

percent) for further care (117). Findings from one

evaluation of a school health demonstration project

suggest that nurse practitioners working within

SLHCs can establish successful referral relationships with community physicians (180,203).

Five physician groups have published positions

relative to SLHCs: the American Academy of

Family Physicians, the American Medical Association (AMA), The Society for Adolescent Medicine

(SAM), the American Academy of Pediatrics (AAP),

and the American College of Obstetricians and

Gynecologists. In general, these positions can be

characterized as partially supportive of SLHCs but

more supportive of providing access to care through

an individual office-based physician, who is seen as

better able to provide continuous, comprehensive

care.

The American Academy of Family Physicians

‘‘supports the selective implementation of schoolbased health clinic programs only in areas where the

health care needs of the school age population are

not being met’ and urges that all clinics be staffed

by family physicians (7). The academy also notes,

however, that because of issues of confidentiality,

consent, and compliance, adolescents may derive

special benefits from access to care through schoolbased health clinics.

In 1987, the AMA adopted a resolution to study

the efficacy of school-based health clinics, and its

Council on Scientific Affairs later reported that

school-based health programs ‘‘constitute a promising avenue for providing health services to adolescents, particularly in medically underserved areas”

and ‘‘such programs hold sufficient promise to

warrant careful evaluation’ (22). Still, the association believes that ideally every child should have a

‘‘medical home” for continuing and comprehensive

health care provided by a private physician, but

recognizes that alternatives need to be explored

when this is not possible.

In a statement similar to those of the American

Academy of Family Physicians and the AMA, the

AAP supported the selective implementation of

SLHCs “in areas where the health care needs of the

school-age population are not being met” (8). Much

as the AMA did, the AAP preferred providing access

to high quality health care services in a ‘‘ ‘medical

home’ where care could be provided in a continuous

and comprehensive fashion’ (8). In this respect, the

AAP noted that there are “limits to the scope of

services provided by [SLHCs] and that ‘‘questions

regarding the efficacy of [SLHCs] remain unresolved” (8).

The AAP also believes SLHC services should be

supervised by a physician, but according to the AAP,

pediatricians are preferred as supervisors of SLHC

services. Interestingly, the AAP endorsed the extension of SLHC services to preadolescent children,

because ‘the roots of adolescent health problems are

found in increasingly younger school-aged children” (8).

The American College of Obstetricians and Gynecologists does not have a policy statement on SLHCs

per se, but, in 1987, it endorsed the development of

“programs, including those located in schools, to

provide reproductive health services in areas where

such services are not available to adolescents and

where they have the support and input of parents and

communities’ (17).

SAM endorses SLHCs as a model of care with the

potential to address the unmet health needs of

adolescents and acknowledges the need for evaluation of the effectiveness of SLHC programs (259).

Evaluations of SLHCs--What is a successful

outcome for a SLHC? Measuring success is not easy

given the wide range of ambitious goals often hoped

for by advocates of SLHCs, which include improving adolescents’ access to a broad range of needed
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . ///-53

health care services; preventing pregnancy and

sexually transmitted diseases among adolescents;

reducing or eliminating substance abuse among

adolescents; and reducing violence, chronic school

absenteeism, academic failure, and school dropout

among adolescents. In general, systematic evidence

of the ability of SLHCs to improve health outcomes

is not available, although this lack of information is

not unique to SLHCS.

69

Only two fairly rigorous evaluations of SLHCs

have been conducted (143,316). The first was

conducted to evaluate the impact on adolescent

pregnancy of an SLHC in Baltimore, Maryland

(316).70 This evaluation, by Zabin et al., demonstrated a 30-percent drop in the pregnancy rate at the

end of 3 years for sexually active adolescent females

in the schools involved in the program; during the

same time period, conceptions among adolescent

females in the comparison schools increased 57

percent. Males and females at the schools that

received classroom-based sex education and that

were linked to the clinic demonstrated significant

gains in sexual and contraceptive knowledge in

comparison with a matched sample of students from

similar urban Baltimore schools. Zabin et al. found

that the SLHC was able to get participation among

the male adolescents in the schools, particularly in

informal group discussions and individual meetings

with social workers who provided information on

and distributed contraceptive devices (315). Another

finding was that students exposed to the SLHC

program increased their use of contraceptives and

were more likely than students in comparison

schools to visit the clinic for contraceptive counseling before initiating intercourse or in the first few

months after initiating sexual activity. These results

were strongest for those students who were exposed

to the program for 2 years or more. The success of

the program in terms of pregnancy prevention was

attributed largely to the program’s intensive focus

on this goal. In addition, even though the SLHC was

not on school grounds, it was nearby, and clinic staff

worked with the schools, providing health education. The fact that the clinic was off-campus, and

thus operated after school hours, was thought by

some to be an advantage.

The second fairly rigorous evaluation of SLHCs

is a CPO evaluation of six on-site SLHCs by Kirby,

Waszak, and Ziegler (143). In comparison to early

evaluations of SLHCs, which focused on the outcomes of delaying sexual activity and pregnancy,

this evaluation compared a range of health outcomes

for students in schools having SLHCs physically

located in the schools with health outcomes for

students in sociodemographically similar comparison schools in the same communities (four schools)

or with baseline data (two schools). It is important to

note that, for the most part, the Kirby et al. study

assessed outcomes for the entire student body in

both SLHC and non-SLHC schools, not just for

clinic users. Although this approach was methodologically necessary in this case,71 and fair in the

sense that SLHCs are intended to affect the health of

the entire student body, it does place a large burden

on the SLHC schools in terms of demonstrating

effectiveness. Other methodological approaches taken

in this study that could have affected the outcome

measures were basing almost all of the health

outcome data on student self-reports, and using

samples that, although quite large, were not sufficiently large to detect small changes or changes in

infrequently occurring outcomes such as pregnancy.

In general, Kirby et al. found, the SLHC schools

varied considerably in the extent to which they had

an impact on sexual activity, contraceptive use, and

the other risk-taking behaviors that were assessed

(school absenteeism, alcohol consumption, and smoking) (143). On the positive side, students in the

SLHC schools were not more likely to report being

sexually active than their peers in the comparison

schools. In two of the SLHC sites, students initiated

sex at older ages (an average of 8 months later) than

students in comparison schools; in the other SLHC

sites, there were no differences between SLHC and

69A long.tem ~v~Mtlon of we Ro&fi Wood Johnson Fo~dation’s School-Based Adolescent Heal& Care Program is cunently underway ad iS

designat to identify the health and health-related outcomes of the SLHCS supported by the foundation (230). In additio% DHHS Centers for Disease

Control (within PHS) is funding an evaluation of the ability of SLHCS to prevent adolescent pregnancy (290a).

ToSee ch. 10, ‘‘~e~cy and Parenting: prevention and SemicW, ‘‘ in Vol. II, for a more complete description of this evaluation.

71comp~som between ~llnlc uSers ad nonusers ~ tcms of cllfic impact have tie disadvantage of possible selection bias due to the different

characteristics and motivations of students who choose to use the clinic and those who do no~ and it was not possible to randomly assign students to

use or not use the SLHC (143). It should also be noted that schools are not randomly chosen to have SLHCS or not. Comparison schools were chosen

on the basis of physical closeness to the SLHC schools and relevant sociodemographic characteristics. Thus, although this evaluation was carefulIy done

in a relative sense, it has some methodological flaws.
III-54 . Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

non-SLHC schools; and in one community, data

were not available to enable a comparison.

Students in two of the SLHC schools—schools in

which the health center staff provided aggressive

outreach for contraceptive education within the

school—had higher rates of contraceptive use than

students in the comparison groups did.72 In three

SLHC sites in which contraceptives were dispensed,

however, students did not report higher rates of

contraceptive use. According to Kirby et al., these

findings suggest that the mere accessibility of

contraception may not be sufficient to increase

adolescents’ contraceptive use. In the three SLHC

schools in which clinic users were compared with

nonusers, however, contraceptive use was higher

among the clinic users, and, overall, from 44 to 90

percent of the pregnancies that occurred were to

students who never had attended the clinic. None of

the SLHC programs reviewed was able to demonstrate a significant impact on self-reported pregnancy rates73 or birth rates74 (143).

Kirby et al. ’s findings with regard to other

risk-taking behaviors similarly varied by school:

●

●

Absenteeism—Relative to absenteeism due to

illness in comparison schools in the same

communities as the SLHC schools or baseline

data, as relevant, there was less absenteeism

due to illness in two SLHC schools, more

absenteeism in one SLHC school, and no

difference in absenteeism in three SLHC

schools. There were no differences in number

of days skipped (nonexcused absences) between any of the SLHC schools and the

comparison schools.

Cigarette Smoking—-Relative to cigarette smoking in comparison schools in the same communities as the SLHC schools or baseline data, as

relevant, there was less frequent smoking at one

SLHC site (where students at the SLHC school

underwent a psychosocial assessment at their

first clinic visit designed to identify students

who engaged in risk-taking behaviors and

might therefore need counseling) and no difference in the frequency of smoking at the three

other SLHC sites where cigarette smoking was

measured as an indicator of effectiveness.

Alcohol Consumption—Relative to alcohol

consumption in comparison schools in the

same communities as the SLHC schools or

baseline data, as relevant, there was significantly lower alcohol consumption at three of

four SLHC sites where alcohol consumption

was measured; differences were primarily in

the “never or rarely consumed” categories.

Illegal Drug Use-Relative to illegal drug use

in comparison schools in the same communities as the SLHC schools or baseline data, as

relevant, there were no differences in illegal

drug use at the two SLHC sites where questions

about illegal drug use were asked.75

Kirby et al. also attempted to measure the impact

of SLHCs on students’ utilization of medical care

(143). Only the SLHC that employed a full-time

physician and arranged for all students to receive an

examination when they first entered the school had

an impact on the likelihood of students’ having seen

a doctor recently: 72 percent of students in the SLHC

school, but only 61 percent of the students in the

comparison school, had seen a doctor within the

previous 12 months. The percentage of students who

had received a physical examination, a blood test,

and a urine test within the last 2 years, or who had

seen a dentist recently, also was higher in the SLHC

school than in the comparison school. According to

Kirby et al., these findings suggest that “clinics that

have a large staff, offer a wide array of services, and

make a concerted effort to bring students into the

clinic would have greater impact on students’ receipt

of health care than clinics that do not meet these

conditions’ (143). There were no differences in any

SLHC schools in students’ receipt of care in

hospitals or emergency facilities,

Many of the adolescents who use SLHC services

are those who have no other source of care, and

adolescents who use the centers typically use them

for typical urgent care for illness and injuries and for

services otherwise unavailable without high levels

of income, generous insurance policies, or breaches

72some of & ~~ge5 ~t~buted t{] one school’s prog~ may ~ve resulted from fie inte~ive education about acquired immunodeficiency syndrome

(AIDS) that was occurring concurrently (143).

TJ~ese ~~ were at the school level, not just for clinic users compared with nonusers.

TAB~ rates were measured in tWO Sik% O~y.

75Kfiby et al. sugge.q that it may not be valid to measure illegal drug use through SeE-repOrts (143).
Chapter 15—Major Issues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . 11/-55

of confidentiality (e.g., mental health counseling,

reproductive health care) (1 17,143,156).

Quality of Care in SLHCs--OTA is not aware

of any study examining the quality of care provided

in SLHC settings. It is not yet known how well

patients are followed or if centers are appropriately

linked to community health care providers (184).

One indication of quality of care is patient

satisfaction (275). Although little is known systematically about students’ satisfaction with SLHCs,

anecdotal evidence suggests that adolescents who

use the services are often very satisfied with them.

In addition, Kirby et al. ’s evaluation of six on-site

SLHCs found that adolescents used and were

satisfied with the services for many of the reasons

such services have been provided on or near school

grounds. Kirby et al. found that the three reasons for

using the SLHC most often cited were: 1) the clinic

was part of the school and users felt they could trust

it, 2) the clinic was easy to get to, and 3) the staff was

caring (143), Students who cited one of these

reasons used the SLHC more frequently and for a

greater variety of services than students who did not

cite these reasons (143). Kirby et al. found that the

longer students had been in a school, the more likely

they were to have used the SLHC (143). Most (43 to

87 percent) of the students who did not use the

SLHC cited lack of need. Some of these students

(8 to 21 percent) said they did not feel comfortable

at the clinic, and others (O to 12 percent) were

concerned about confidentiality. In general, however, little is known about the differences between

adolescents who use SLHCs and those who do not,

and obtaining such information is key to understanding how well SLHCs serve adolescents in need

(184).

Limitations of SLHCs--The SLHC model for

the delivery of care to adolescents has several

important limitations. Some communities are resistant to any model of care that confronts the issue of

adolescent sexuality (154). Despite evidence that

there have been no increases in adolescents’ sexual

activity or pregnancy rates after the opening of an

SLHC, community and parents’ concerns that SLHCs

will encourage adolescents to engage in sexual

activity have been able to halt or delay the introduction and funding of programs on both the local and

Federal level.76 Shortages of adequately trained

providers, especially bilingual/bicultural nurse practitioners and mental health professionals, are also a

significant obstacle to the large-scale implementation of SLHC programs (154).

Even with mandatory school attendance laws,

many U.S. adolescents-especially those at high

risk for bad health outcomes---drop out of school by

the 10th grade (154). Nationwide, 27 percent of

American students drop out of school before high

school graduation; twice as many drop out from

schools located in poor, urban areas.77 Thus, if

SLHC programs were widely implemented but

limited to adolescents attending school, many adolescents would not be reached.

Another limitation of SLHCs is that most SLHCs

operate only during or around school hours, thus

precluding access to care on weekends, holidays,

and summer vacations. Although it could be improved, however, this feature does not make SLHCs

much different from many private, office-based

physicians’ practices.

Finally, it should be noted that not all SLHCs are

able to establish reliable referral ties to community

hospitals and other local health care providers (154).

Following their multiyear, in-depth evaluation of

six SLHCs in cities throughout the Nation, Kirby et

al. identified several specific limitations of SLHCs

and suggested that SLHCs could take a number of

steps to enhance their effectiveness in preventing

pregnancies and reducing students’ risk-taking behavior in other areas (143):78

● Finding that SLHCs ‘‘generally do a good job

of treating and counseling students who seek

their services, but they rarely have aggressive

programs to identify risk-taking teens who are

not motivated to come to the [SLHC], ’ Kirby

et al. suggested that SLHCs identify and target

students engaged in risk-taking behaviors. To

improve the identification and targeting of such

?6~c ~~lte House ~~ ~c~owl~g~ that school cllnics could reduce adolescent pregnancy rates and tie number of single-parent fMI_dleS but WM

reported to have rejcctcd a proposal by an interagency group to fund school clinics because the proposal would be seen as ‘‘promoting promiscuity’

and ‘ ‘may cause political problems among groups that are opposed to birth control’ (214).

‘See ch. 4, ‘ ‘Schools and Discretionary Time, ’ in Vol. II.

78 Kirby et ~~ *,o~cd tit some SLHc~ ~d ~~~dy imp]emen[ed the suggested re~ommenfitio~, mUS, not all deficiencies are ChMaC&mlStiC Of d]

SLHCS.
III-56 . Adolescent Health—Volume III: Crosscutting Issues in the Delivery of Health and Related Services

●

●

●

●

●

students, SLHCs could schedule routine physical examinations for all incoming students,

administer psychosocial assessments, and urge

teachers and other personnel to refer risk-taking

adolescents to them.

Finding that “most students use SLHCs infrequently,” Kirby et al. suggested that SLHCs

conduct more outreach in the schools (e.g., by

participating in a comprehensive sexuality

education program, placing posters about the

center and health-related topics throughout the

school, writing a regular column in the school

newspaper, and making presentations at school

assemblies).

In another recommendation aimed at increasing

students’ access to health services and information, Kirby et al. recommended that SLHCs

offer group sessions facilitated by trained

clinic staff to provide students with more

opportunities to resolve difficult personal dilemmas about sex and other risk-taking behaviors. At the same time, such sessions would

help students become familiar with clinic staff.

Finding that “students were far more likely to

use a [SLHC] for reproductive health care if the

clinic prescribed or dispensed contraceptives as

well as offered counseling about birth control

methods and pregnancy testing, ” Kirby et al.

suggested that SLHCs provide comprehensive

reproductive health services.

Finding that ‘‘teens are impulsive and may not

be willing to wait a week or longer to make

important decisions about sex, ’ Kirby et al.

suggested that appointments for family planning counseling and for birth control should be

offered promptly, ideally on a walk-in basis,

and that clinics fol!ow up family planning

patients more effectively in order to improve

contraceptive continuation rates.

Finding that males have been much less likely

than females to visit a school-based clinic for

contraceptives, but that it is possible to increase

the use of condoms by males, Kirby et al.

suggested that reproductive health programs

should place greater emphasis on male responsibility and attempt to reach males through

●

●

●

●

sports physicals, classroom activities, and the

media.

Finding that many adolescents were not highly

motivated to delay pregnancy, Kirby et al.

suggested that SLHCs initiate measures to

provide greater motivation for delaying pregnancy.

79

Finding that SLHCs “cannot effectively address any difficult social problem in isolation,’

Kirby et al. suggested that SLHCs develop

communitywide programs that involve parents,

youth-serving agencies, religious and other

community leaders, and the media.

Finding that many adolescents are already

sexually active by the time they enter high

school, Kirby et al. suggested that SLHC

services and health education be delivered

earlier (e.g., in middle and junior high

schools).

Finding that some of the cost-saving measures

engaged in by SLHCs lead to heavy staff

turnover, reducing the continuity of the relationships that can be developed between the

clinic and students,80 Kirby et al. suggest that

SLHCs increase permanent staff. In order to

implement the strategies proposed by Kirby et

al., many SLHCs would also need to hire

additional staff.

Adelman and Taylor came to somewhat similar

conclusions about the limitations and unmet opportunities for SLHCs in their review of the provision

of mental health services in SLHCs (5). Adelman

and Taylor are the recipients of a Robert Wood

Johnson Foundation grant to develop, implement,

and evaluate models and networking resources for

the mental health component of SLHCs (5), and they

have developed a guidebook (271), newsletter (e.g.,

272), clearinghouse, and other activities using the

grant.

Adelman and Taylor found that mental health

services, although the most frequently requested

services in many schools and SLHCs, are not

comprehensive and underserve students; existing

programs tend to follow the traditional model of

serving only those who seek care (5). The integration

T~orexmple, Kirby et al. suggmted that pregnancy prevention messages be presented within the context of a life planning cticuhml where students

are encouraged to extend their education and begin a career before beginning a family, and that role models and job opportunities in the community be

provided (143). Pregnancy prevention strategies are discussed more fully inch. 10, “Pregnancy and Parenting: Prevention and Services, ” in Vol. II.

~or example, ‘‘to save money, some clinics use rotating physicians from nearby medical schools, ’ othem ‘pay low wages and lose fidl-tirne staff

once they have gained sufficient experience to command higher salaries elsewhere, ” and others ‘‘reassign more experienced staff to several schools or

community health clinics in order to take wider advantage of their skills” (143).
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-57

of mental health services into the daily life of school

has been difficult, and SLHC mental health staff

have often tended to operate in relative isolation

from other school programs. In Adelman’s and

Taylor’s view, better integration is necessary for the

development of new and potentially more effective

models for mental health intervention, such as group

counseling and other means of early intervention.

Adelman and Taylor see the development and

testing of such models as a research opportunity for

the mental health field.

In conclusion, SLHCs are a relatively new and

potentially promising way of reaching adolescents

in need of health services. There are still ways in

which existing SLHCs can be improved upon;

improvements will continue to require fresh and

creative approaches to the delivery of health care and

the integration of clinical services with health

promotion and education, systematic evaluation of

these approaches, and resources to both implement

and evaluate the SLHC approach.

Other Innovations in the Delivery

of Health Services to Adolescents

Integrated Health Services

The previous discussion focused on various types

of comprehensive health centers for adolescents,

including adolescent health care clinics associated

with hospitals, multiservice centers such as the

Door, and SLHCs located in or near schools.

Although providing comprehensive services to adolescents at a single site (“one-stop shopping”) may

be preferred (34), it is sometimes not feasible. In

such cases, community health delivery programs can

strive to be integrated.

According to an interdisciplinary study group

convened at the 1986 conference on Health Futures

of Adolescents, integrated programs for adolescents

could provide comprehensive services at a single

site and offer extensive community referral, networking, tracking and followup services; conduct

multiproblem needs assessments of adolescents

seeking services as well as for the larger target

population of adolescents; coordinate the services of

interdisciplinary teams of health professionals; ensure unrestricted eligibility for services; have a

single, primary contact person to coordinate services; and rely on a single, unified record for each

adolescent (34).

Numerous administrative, clinical, and programmatic factors interfere with the delivery of integrated

services to adolescents, however (34,182) (see box

15-F). Recommendations to promote and maintain

integrated community health delivery for adolescents have included the following:

●

●

●

●

●

●

●

●

collecting and disseminating of an expanded

information on both National and State levels

regarding demographic and morbidity profiles

of adolescents;

supporting systems designed to promote the

integration of comprehensive interdisciplinary

services for adolescents;

training service providers to facilitate their

assimilation into interdisciplinary health teams;

evaluating the effectiveness of integrated models to promote implementation of optimally

designed systems to meet adolescent health

needs;

widely disseminating evaluation research;

supporting funding philosophies and policies

consistent with the goal of integration of

services;

supporting the development and continuation

of integrated health delivery models that, at a

minimum, include: general medical, family

planning, mental health, and social services;

exploring methods of expanding traditional

health services to include the following (either

directly or through community linkages): legal

assistance, vocational guidance; learning disabilities assessment; nutrition counseling; prenatal care; drug abuse assessment and counseling; recreational opportunities (34,307).

Similar recommendations were recently made by

the Education and Human Services Consortium,

although those recommendations were not limited to

services for adolescents, and they addressed relationships among agencies, as well as relationships

among providers within agencies (182). According

to the consortium, five elements are key to high

quality comprehensive service delivery: 1) the

availability of a wide array of prevention, treatment,

and support services; 2) techniques to ensure that

children and families actually receive the services

they need (e.g., co-location of staff from one

organization to ‘‘branch offices’ located at other

agencies whose clients they share; ‘‘one-stop shopping, ’ and an approach to case management that

makes it a problemsolving partnership among
III-58 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

practitioners and clients); 3) a focus on the whole interventions in terms of outcomes for clients (182).

family; 4) giving children and families a voice in Further, the Consortium suggested that both service

identifying and planing how best to meet their own delivery and systems levels81 

go beyond initial

needs; 5) measurement of the effectiveness of stages of cooperation to true collaboration in order

g~~cord~g t. tie Consofim at tie service delive~ level, interagency initiatives focus on meeting the needs of individual Chil(hn md f~b.

.

At the system level, initiatives are foeused on creating a set of policies and practices that can help to build a communitywide network of comprehensive

semice delivery (182).
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-59

to connect children and families with comprehensive services.82 83

Efforts To Involve Adolescents in Health Services

Planning and Management

A third innovation in the delivery of health

services to adolescents involves encouraging adolescents’ participation in policysetting and service

delivery. This approach has recently been used by

health providers in some mainstream institutions.

Two health maintenance organizations, for example,

are involved in efforts to make their programs more

responsive to adolescents’ needs by routinely seeking the advice and working participation of adolescents (134,159).

As part of this adolescent health assessment, OTA

established a youth advisory panel to provide OTA

staff with an adolescent perspective on the issues in

the report. The youth advisory panel consisted of 21

individuals who ranged in age from 10 to 19. Panel

members represented a range of backgrounds: racial/

ethnic (white, non-Hispanic; Hispanic; Asian; black),

socioeconomic, and experiential (e.g., homeless,

substance use, pregnant, parenting, children of

divorce, children from stepfamilies and extended

families). Although all were from the greater Washington, DC, metropolitan area, they came from

central city, suburban, and rural areas. During its

meetings, the youth advisory panel highlighted

important health issues for adolescents, developed a

list of desirable features of health services and made

recommendations to the project staff on ways to

improve adolescent health. Representatives of the

youth advisory panel also attended various workshops and meetings held by OTA. In one of the

panels’ meetings, members were asked to “role

play’ groups of service providers, program adminisPhoto credit: Kaiser Teen and Young adult Health Center,

Granada Hills, CA

Adolescent partiapation can take the form of special

adolescent advisory panels of adolescent representatives

on general advisory boards. The Kaiser Permanence HMO

in Granada Hills, California, asks adolescents to provide

advice on a regular basis.

trators, and health planners. Box 15-G summarizes

each group’s recommendations regarding key components of health care services for adolescents.

Conclusions and Policy Implications

Conclusions

Adolescents’ Need for Health Services

This Report makes it clear that adolescents do

have need for health services. The health-related

conditions of adolescents that cry out for prevention

and treatment intervention include, but are not

limited to:84

● fatal injuries, from accidents,85 suicide, % and

homicide87

;

82According to the consortium, “In a cooperative arrangement at the service delivery leve~ partners help each other meet their respective

organiza tiollal goals. . without making any substantial changes in the basic services they provide or in the rules and regulations that govern their

agencies. ” At the systcm level, ‘‘cooperative inifi”afi”ves assess the need for more comprehensive services and rccommcnd strategies to coordinate

existing services. ” At the service delivery level, “collaborative parznersh”ps establish common goals. . . . W to pool resources, jointly pl~

implement, and evaluate new services and proccdurcs, and delegate individual responsibility for the outcomes of their joint efforts.” ColZaborafi”ve

ventures at the system level arc cmpowercd. . .to negotiate, as well as to advocate for, programs and policies leading to more comprehensive service

deLivcry” (182).

ss~e consofi~’s nqMrt provides examples of human services agencies that have been succcmfid in structuring partnerships.

84Adolewent h~~ ~obl~ me flso di~uss~ in dew in Vol. H: BaCkgrOu~u~ the Efl&tiveneSS of selt?ct~pn?wnfim and Treatment Sem”ces,

and mrnmr&d in app. B to this volume, “Burden of Health Problems Among U.S. Adolescents.”

SSSW ch. 5, “Acciden~ Injurics: Prevention and Services, ” in VO1. H.

~See ch. 11, “Mental Health Problems: Prevention and Services, ” in Vol. II.

67s& ch. 13, ‘‘De@uency: Prevention and Services, ” in VO1. ~.
111-60. Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Box 15-G--Summary of Recommendations by the Youth Advisory Panel for

OTA’s Adolescent Health Project

An unusual feature of OTA’s adolescent health assessment was that it included a youth advisory panel to

provide 0TA staff with an adolescent perspective on issues in the report. At one of the group’s meetings, youth

advisory panel members were asked to “role play” groups of service providers, program administrators, and

health phanners. The recommendations of each group with respect to key components of health care services for

adolescents are presented below.

Recommendations of 66 Service Providers"

1,

2.

3.

4.

5.

6.

7.

8.

9.

10.

Clinics should be free.

Adolescents need many services, including dental care, dermatology, counseling, and gynecology

services. Health care providers should not assume that all adolescents seeking services are pregnant.

Services should not be different by racial/ethnic group. However, services must be sensitive to

geographic and cultural needs.

Services should remain open during evening hours for emergencies and on weekends.

Services should be centrally located and offered under one roof (comprehensive services), and the

number of sites should be determined by population size.

Shuttle bus service should be provided.

There should be separate clinics for adolescents. Adolescents should be able to bring their own children

to the clinic, but their parents should not be able to attend the clinic unless the adolescent asks-=

to come.

Services should be provided at school in school-based clinics or near the school.

Sex education in the schools should be made mandatory.

Hot line charges should not appear on phone bills (e.g., hot line calls should be 1-800 numbers).

Recommendations of "Program Administrators” .

1.

2.

3.

4.

5.

6.

7.

8.

9.

Money to run the services should come from the Federal Government and should be specific to

adolescents.

Funds from services that are already targeting adolescents should be pooled into one adolescent fund.

The Federal Government must develop a payment/insurance plan for services where adolescents can pay

a particular amount to receive ail services (almost like a health maintenance organization). This system

must be voluntary.

Eligibility for services should be based on some socioeconomicCriteria.

Special attention should be paid to low-income adolescents and those not in school.

Adolescents should be informed about available services through word of mouth, television, radio,

recreation centers, posters, and flyers in the mail.

Services should be based on developmental needs and not necessarily on age (e.g., not all lo-year-old

adolescents need the same services).

Adolescents under age 21 should be able to receive services but should not be automatically cut off at

that age.

The system should be flexible.

Recommendations of “Health Planners)’

1. Adolescents should be included as full voting members on adolescent youth service agency boards.

2. There should continue to be a youth advisory group advising Congress on adolescent issues.

3. Youth awareness about particular health problems should be increased.

4. Adolescents should be involved in outreach activities (e.g., counseling adolescents who have been raped

or have thought about suicide).

5. Youth should be encouraged to volunteer. Although adolescents do not necessarily have to be paid for

their work they need to know why they are doing what they are doing.

SOURCE: Cmcc of ‘RdulOlogy Asscssmcu t 1991.
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . ///-61

●

●

●

●

●

●

●

●

●

family problems, such as maltreatment, which

is higher among adolescents than among younger

children88;

school problems, such as the potential for

dropping Out89

;

appropriate use of discretionary (nonschool)

time 90

;

physical problems, such as acute respiratory

illnesses, which are the leading cause of school10SS days91; serious chronic physical illness and

disability, experienced by perhaps 5 percent of

adolescents (see ch. 692); or sports injuries,

which account for at least 1.04 million emergency room visits in a year (1988 data)93);

new problems experienced on reaching puberty, such as dysmenorrhea and acne94

;

nutritional concerns, such as overweight or

obesity95

;

dental problems, such as dental malocclusion,

experienced by perhaps 13 to 16 percent of

12- to 17-year-olds (1970 data)96

;

problems associated with involvement in

unprotected sexual activity, such as sexually

transmitted diseases; including HIV infection,

which is as high as 3.7 percent among homeless

and runaway adolescents at a shelter in New

York97; and pregnancy, experienced by 1 million female adolescents a year98);

mental health and behavioral problems,

such as subjective distress, experienced by

perhaps 25 to 40 percent of adolescents;

diagnosable mental disorders, experienced by

18 to 22 percent of adolescents; suicide attempts, made by 15 percent of 10th graders99

;

heavy drinking,l00 reported by 11.1 percent of

●

●

The

high school seniors; daily cigarette smoking,

reported by 7.7 percent of high school seniors;

daily marijuana use, reported by 2.9 percent of

high school seniors

101 ;commission of an illegal (delinquent) offense, reported by the majority of adolescents (1976 data)’ 02

;

hopelessness and associated health problems,

estimated to be experienced by 1 million

adolescents; and1

°

3

further, some adolescent behavioral problems are interrelated (8l,209a), itself suggesting the need for an integrative approach to

service delivery.

Adequacy of the Mainstream Health Care

System for Adolescents

It is not clear that American adolescents’ needs for

health services are, or can be, met entirely by the

traditional U.S. mode of health service delivery—

i.e., care provided on a routine or as-needed basis by

private office-based physicians. Some of the health

problems experienced by adolescents are conditions

experienced by individuals of other ages (e.g.,

respiratory disease, chronic disabilities), and one

might expect that adolescents with these conditions

would seek care from physicians in the mainstream

health services system. Other problems, though not

unique to adolescents, may be new for them (e.g.,

gynecological and skin problems). For some problems, adolescents may not seek care from the

mainstream health services system. Some issues

may be considered ‘ ‘normal’ for adolescents (e.g.,

acne, dysmenorrhea, subjective distress, delinquent

behavior), and adolescents may not be advised that

the problems are amenable to health services inter88 See ch. 3, ‘ ‘Parents’ and Families’ Influence on Adolescent Health,” in Vol. Il.

SgSee ~h 4, 4‘S~hoo]s and Discretionary Time, ’ ~ VOI. ~.

~See Ch. 4, ‘‘SChOO]S and Discretionary Time, ” ~ VO1. ~.

glsee ch, 6, ‘ ‘Chronic Physical Illnesses: Prevention and Services, ” b VO1. H.

w.’ CWnlc physical Il~esses: Prevention and Services, ’ in VO1. ~.

g~see ch. S, ‘‘Accidentd Injuries: Prevention ad Services, ” in VO1. Il.

%$see Ch, 6, ~ ‘C~onic fiysi~ ~~esses: prevention ad services, h VO1. ~.

9 5 see Ch, 7, 1‘Nurntion ad Fitness problems: prevention and Services, ’ h VO1. ~.

%.CJee Ch. 8, $ ‘Den~ ad ~~ Heal~ problems: prevention and Services, ” in VO1. ~.

WSee ch. 9, ‘‘AIDS and Other Sexually Transmitted Diseases: Prevention and Services, ” in Vol. II.

98see Ch 10, $ ‘~epcy ad pmenting: prevention and Services, ’ in VO1. H.

mSee ch. 11, ‘‘Mental Health Problems: Prevention and Services, ’ in Vol. II.

l~eavy ~~ng is def~ed as having had five or more drinks ‘‘in a row’ in the 2-week period prior to the survey.

10 I see Ch. 12, 6 ‘Alcohol, Tobacco, ~d D~g Abuse: prevention and Services. ’

Iozsee ch, 13, “Delinquency: Prevention and Services, ’ in VO1. ~.

103see Ch. 14, ~

< Hopelessness: prevention ~d Services, ’ ‘ in Vol. H.
III-62 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

vention. Finally, some problems may not be amenable to resolution through the health care system, but

may require other types of human services (e.g.,

legal assistance, job training, tutoring, recreational

opportunities).

This chapter has addressed selected major issues

in the role of the mainstream primary health care

system in meeting the health care needs of U.S.

adolescents.l04 Historically, the provision of health

care has been viewed primarily as the province of

physicians (80,1 19). Thus, care provided by private

office-based physicians has been the focus of much

of the research on health care providers’ ability to

meet the health care needs of adolescents (e.g.,

286,287). primary care has not been defined to

everyone’s satisfaction, but some definitions suggest that the primary care physician should be able

to provide the ‘‘medical home" for continuing and

comprehensive health care that adolescents, and

individuals in all age groups, need (21,263). OTA

found that U.S. adolescents are relatively unlikely to

use the services of private office-based primary care

physicians, having the lowest rate of use of any age

group. Although 73 percent of U.S. adolescents

reportedly had one or more physician contacts in

1988, adolescents had the lowest rate of visits per

person per year (1.6 visits per person per year to

private office-based physicians on average; lower

for nonwhite adolescents). Adolescents are also

among the least likely to be hospitalized.

Among the possible reasons why adolescents with

health concerns may not seek the services of

physicians for health care is that, with the exception

of specialists in adolescent medicine—who are few

in number-there is no group of physicians who are

clearly defined as appropriate to provide care to

adolescents. The American Academy of Pediatrics

has suggested that pediatricians be the primary

health care providers for individuals up to age 21. A

1980-81 survey of pediatricians found, however,

that only 40 percent of pediatricians continued

adolescent care to the age of 18, and 42 percent

refused to accept a new patient who had reached the

age of 16 (226).105 Thus, it is not surprising that only

about one-quarter (23 percent) of adolescents’ visits

to private office-based physicians in 1985 were to

pediatricians, and two-fifths were to general and

family practice physicians (35 percent) or internists

(5 percent).106 However, other physicians are also

unlikely to report much interest in providing health

care to adolescents.

Despite the fact that only about one-quarter of

adolescents’ visits to office-based physicians are to

pediatricians, much of the research on aspects of

physician behavior with adolescent patients has

been conducted with respect to pediatricians. Research suggests that pediatricians spend an average

of approximately 1 minute more with adolescents

than they do with other noninfant patients, for an

average of 11 minutes per visit.l07 The duration of

visit is potentially important because it is believed

that many adolescent health problems may be

preventable if adolescents are provided with ‘‘anticipatory guidance’ from health care providers. As

can be inferred from the listing of problems above,

adolescents are at high risk of mortality and morbidity caused by social, and perhaps preventable,

factors. However, the only study that assessed the

amount of time spent by physicians (pediatricians)

providing anticipatory guidance found that officebased general pediatricians spent an average of

7 seconds per visit on anticipatory guidance for

adolescent patients ages 13 to 18 (223). This study

and others have varied in their findings concerning

what physicians discuss with their adolescent patients, with a more rigorous (e.g., direct observational) study and surveys of adolescents themselves

finding that little time is spent discussing the “new

morbidities” issues or the health concerns of importance to adolescents themselves.

Another important area of physician behavior that

may affect adolescents’ seeking of health care from

private physicians is patient confidentiality. Again,

findings reported in the present chapter, limited

though they are, are variable, with 75 percent of

members of The Society for Adolescent Medicine

l~~e c~pters that discussed the prevalence and incidence of problems among adolescents also dkuSsed the capability Of problem-spx~lc ~th

and related care systems to meet the needs of adolescents who do experience these problems (e.g., STD diagnosis and treatment clinics, the mental health

systeu the substance abuse treatment syst~ the juvenile justice system), and found thah atthough information about utilization and access is scarce

and Mlcult to come by, gaps appear to exist in almost all services.

lo51t my ~ fipo~t to note tit rhis s~ey WaS published in 1983, and that more recent information on pediatricians’ practices is not available.

106& dis~ssed in ch. 6, ‘Chronic Physical Illnesses: l%wention and SerViCeS, ‘‘in Vol. II, leading reasons for visits to private ol%ce-based physicians

were for respiratory system diseases (1’7 percent), injuries (16 percent), and skin conditions (10 percent).

107~e avemge Visit tie a~ss ~1 physici~s WaS Ixxween () Wd 10 minutes (S* figure 15-3).
Chapter 15—Major Issues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents ● III-63

and a random sample of pediatricians expressing

support for confidentiality for adolescent patients,

but a survey using a specific example (a pregnant

15-year-old’s desire that her mother not be told of

the pregnancy) finding that the majority of physicians would not abide by the patient’s request for

confidentiality. 108 Some adolescents with ready

access to a private physician expressed their unwillingness to seek a private physician’s care for

concerns about certain issues (sexuality, substance

abuse, emotional upset) or to seek care for those

problems with their parents’ knowledge (175).

A third important issue in health care providers’

behavior examined by OTA is competence in

diagnosing and treating adolescents’ specific problems. Research on this issue, too, is limited. Among

other concerns (e.g., lack of methodological rigor),

a very small body of empirical work has explored

this issue, most studies in this area have focused on

the identification of mental health and substance

abuse problems, and most of the work has involved

the practices of pediatricians. The evidence that is

available, however, suggests the following:

Primary care physicians appear to have difficulty in identifying children who have behavioral and emotional problems.

Physicians as a group are currently not able to

identify substance abuse problems very effectively.

Primary care physicians appear able to identify

acne in adolescent patients, but their ability to

treat acne has not been tested.

Hospital services do not appear to adequately

document health problems in adolescent patients.

● Physicians, nurses, social workers, psychologists, and nutritionists all consider themselves

relatively untrained in important areas of adolescent health (e.g., sexuality, handicaps, endocrine problems, contraception, psychosocial

concerns). l09

The important issue of health care providers’

ability to interact with adolescents-regardless of

the specific problem that an adolescent may have--

has received very little investigation.110 111

Perhaps more disturbing than findings that many

health care providers are apparently not able to treat

adolescents, several studies have found that health

care providers have expressed relatively little interest in additional training. Although there are no

systematic national counts of the number of U.S.

health care providers who have been specially

trained to deal specifically with adolescents, approximately 1,400 nonpsychiatrist physicians (most of

whom are pediatricians) identify themselves as

adolescent medicine specialists, 1,400 psychologists

express a special interest in adolescents, and there

are 1,500 members of the American Society for

Adolescent Psychiatry. There are no counts of other

health care providers specializing in the treatment of

adolescents. A structured experience in adolescent

health became a required aspect of training for future

pediatricians in January 1990, although no patient

age range nor duration of trainin g was Specified.

Neither family practice nor internal medicine include specific curricula regarding adolescents. Thus,

those adolescents who seek health care are likely to

see providers who have not been specially trained to

work with them.

los~e bWS, etic~ statements of health care provider organiza tions, and consequences of not respecting confidentiality, are discussed more fully in

ch. 17, ‘‘Consent and Confidentiality in Adolescent Health Care Decisio nmaking,” in this volume.

l~ssues related to tie role of emergency persomel who come in contact with adolescents (e.g., those who have been in accidents, been ~=ulted, or

attempted suicide) are discussed in ch. 5, “Accidental Injuries: Prevention and Services,” in Vol. II.

] Iqt is ~potit t. note tit even~e limited ~omt of rese~h on tie afii~des and be~viorof h~~c~e providers suggests tit there is considerable

variability among providers. With respect to some aspects of health care provider behavior and perceived competence+-the provision of anticipatory

guidance, maintaining contldentiality-yotmger physicians, and physicians who have more adolescent clients, have been found to be more likely to

behave in ways that are compatible with adolescents’ stated needs for health care delivery. In the case of the 15-year*ld who wished to keep her

pregnancy from her mother, the majority of obstetrician-gynecologists were likely to maintain cotildentiality. With respect to the self-perceived

competence of health care providers, there are substantial differences by physician specialty and profession. Physicians specializing in adolescent

medicinefew as they are-are more likely to support confidentiality of care for adolescent.., and have been found to evoke more satisfaction from

adolescent clients. In the one study that involved nonphysician health care providers, nurses, social workers, and psychologists expressed more interest

in additioml training than did physicians.

11 IF~cl~ issues may & a quite impo~t f~tor in tie abfli~ of my pficul~ adolmcent to gfi acce,$s to health care services. bck Of COv~ge

may affect physicians’ willingness to see adolescents, and the willingness of health care and other orga.nizations to implement new services (see below).

Both the problem of having no health insurance-which affects one out of seven adolescents-and the problem of having inadequate benefits for semices

or settings of importance to adolescents-which affects many of the other six out of seven adolescents-are discussed in ch. 16, “Financial Access to

Health Semices, ‘‘ in this volume.
III-64 . Adolescent Health-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Federal support for interdisciplinary training in

adolescent health care is lower than it was in fiscal

year 1981. In fiscal year 1990, the Federal Government was supporting only six such programs, at an

average level of $300,000 annually (212). The small

number of such programs, the limited funding for

them, and program goals emphasizing research and

leadership development over actual health service

delivery have meant that few frontline health care

providers have received interdisciplinary training in

adolescent health care. Except for this interdisciplinary training program, Federal support for training

specifically in adolescent health care for providers—

across all disciplines-who are likely to care for

adolescents and for those health care professionals

who currently provide health and related services to

adolescents is nonexistent.

Innovations in the Delivery of Health

and Related Services to Adolescents

Given the apparent failure of both the primary

health care system and the specialty health care

systems to meet the health care needs of all U.S.

adolescents, several innovations in health care

delivery have been attempted. These include the

provision of comprehensive health services at a

single site (e.g., hospital-based adolescent health

care clinics, community-based adolescent health

care clinics, a teen center at an HMO, ‘free clinics,’

multiservice centers, and, most extensively, SLHCs),

attempts to integrate services, and efforts to involve

adolescents in health services planning and management.

Attempts to provide a range of health and related

services to adolescents in a single setting using

providers from multiple disciplines-so-called comprehensive services-have generally been well received by parents and adolescents. To one degree or

another, centers that provide comprehensive services for adolescents also make a special attempt to be

responsive to common themes of adolescent health

care, such as enhancing access through free care or

use of sliding-fee scales, evening and weekend hours

of operation, and guaranteed confidentiality of

services. In addition, staff members who work in

comprehensive health programs for adolescents

choose to work there because they are committed to

and enjoy helping adolescents. They often perceive

themselves as advocates for adolescents, and work

with adolescents to coordinate programs of care

(230a,292). In school settings, coordination with

school staff, and consequent attempts to influence

school environments are important aspects of special adolescent health care centers (230a).

Systematic evidence of the effectiveness of comprehensive programs in terms of improving health

outcomes is scarce, however. The only study to date

that compared special hospital-based adolescent

health clinics to hospital-based clinics without a

special adolescent focus found no outcome differences after a year (84). However, the specially

funded clinics were more successful in getting

adolescents to disclose behavioral and lifestyle

problems to their clinical providers, and consequently to obtain care for such problems (84).

Reductions in school absenteeism, alcohol consumption, smoking, sexual activity, and pregnancy

have been found in some schools with SLHCs,

though not consistently.

What has frequently been found is that many of

the adolescents who use the services of SLHCs are

adolescents who have no other source of health

care,

112 and that adolescents use SLHCs for typical

urgent care for illness and injuries and for services

otherwise unavailable without high levels of income, generous insurance policies, or breaches of

confidentiality (e.g., mental health counseling, reproductive health care). Further, one of the few

systematic studies of SLHCs suggests that efforts to

meet the more intangible needs of adolescents have

been successful: the primary reasons cited by

students for using the SLHC in their school were that

users felt they could trust it because it was part of the

school; the SLHC was easy to get to; and the staff

was caring (143). The number of repeat visits to

some SLHCs is also cited as suggestive that SLHCs

are responsive to the needs of adolescents as they

perceive them (230a).

When it comes to adolescents, then, SLHCs and

some community- and health-care-organizationbased adolescent health care centers appear to

respond to many of the shortcomings of the traditional health care system: They attempt to address

the range of problems that many adolescents face

(e.g., by providing care for acute physical illnesses;

1 IZI’& fi~g ~ confoud~ Somewkt by the fact that most SLHCS bave been purposefully situated in communities deemed to b mdically

undeserved.
Chapter 15—Major lssues Pertaining to the Delivery of Primary & Comprehensive Health Services to Adolescents . III-65

general medical examinations in preparation for

involvement in athletics; mental health counseling;

laboratory tests; reproductive health care; family

counseling; prescriptions; educational services; vocational training; legal assistance; recreational opportunities; advocacy; coordination of care (e.g.,

with school personnel); advocacy 113). Services are

free or low-cost. Services are confidential. Staff are

knowledgeable about adolescents. Staff are committed to helping adolescents in a way that is meaningful to the adolescents themselves. Settings are

designed with adolescents in mind, to the extent

possible. Adolescents are often involved in the

design and management of the programs. In the case

of SLHCs, the services are physically accessible,

because they are located in or near where adolescents spend much of their waking day.

For a variety of reasons, however, a reorganization of adolescent health services to meet desirable

criteria for adolescent health services has not been

realized. The obstacles to reorganization are both

formidable and interrelated. They include community resistance to the provision of contraceptive

services and abortion counseling to adolescents;

resistance of organized medicine; resistance by

schools to adding yet another responsibility to the

educational infrastructure; lack of a core of adequately trained professionals to staff comprehensive

programs; State Medicaid administrative barriers;

lack of conclusive and convincing data on the

effectiveness of such programs in reducing a number

of highly socially visible adolescent health problems, and, finally, lack of financing.

Policy Implications

A number of possibilities for Federal action to

improve the delivery of health services to adolescents suggest themselves.

One clear need is for increased Federal attention

to training of health care professionals in the area of

adolescent health.

Several levels of trainin g are important: for

students at an early stage in their careers, for

graduate and postgraduate students, and for professionals who are already in practice. Similarly, a

range of health care professionals should be included

in any increase in Federal attention to training issues

at all levels of experience: nurses, psychologists,

social workers, health educators, youth services

workers, primary care physicians (pediatricians,

internists, family physicians), and specialist physicians (e.g., obstetricians, gynecologists, dermatologists). Training should emphasize the interdisciplinary nature of work in adolescent health services.

Finally, any innovations in training (or, failing

innovations, current training experiences) should be

subject to rigorous evaluation from a variety of

perspectives, including health outcomes and patient

satisfaction. Evaluations should consider not only

the clinical ability of providers to identify and

manage specific problems, but their adolescentspecific interpersonal skills.

Improvements in the skills of health care providers would be of benefit whether or not any other

changes in the health care delivery system for

adolescents were made. To improve adolescents’

access to appropriate health and related services,

Federal support for the reorganization of the delivery

of health services to adolescents may be necessary.

Increasingly, States and private foundations have

seen the value in making comprehensive, integrated,

approachable services immediately accessible to

adolescents. However, States are increasingly

strapped for money to dedicate to health and other

human services (270a). Foundation funding is typically time-limited. The Federal Government could

provide seed money to States, communities, health

care organizations, or schools that wish to implement either school-linked or community-based centers that offer comprehensive adolescent health care.

For those comprehensive adolescent health centers

that exist but are in danger of losing their funding,

the Federal Government could create a mechanism

to help provide continuation funding, perhaps

through a matching grant program.

In addition, or alternatively, either Congress or

the U.S. executive branch could address, through

legislation or regulation, existing barriers to the

delivery of comprehensive services in adolescent

health centers. These barriers include, but may not

be limited to, State Medicaid administrative barriers

limiting or prohibiting reimbursement for services

delivered in SLHCs; and State and Medicaid restrictions on reimbursement of nonphysician providers.

A study (e.g., by the U.S. General Accounting

I I sNot all s~i~s me available at all centers. Referral and integration of services is an extremely important aspect Of providing appropriate c= for

adolescents (34).
III-66 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Office) specifying such limitations might be useful

before Congress took action.

Federal support for evaluation research on a range

of comprehensive adolescent health care centers

would also be useful. As described in this chapter,

although there is a considerable body of very

valuable anecdotal and clinical knowledge that can

be used to guide improvements in health care

delivery for adolescents, the systematic knowledge

base concerning the most effective ways to structure

and deliver health services to adolescents is extremely limited. Collection, dissemination, and utilization of specific additional information can only

help to improve the health care system, not only for

adolescents, but for other Americans as well.

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Chapter 16

FINANCIAL ACCESS TO

HEALTH SERVICES

Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Adolescents Without Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

How Many Adolescents Lack Health Insurance and Who Are They? . . . . . . . . . . . . . . . . . . . . . . 77

Sociodemographic Characteristics of Uninsured Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Adolescents With Private Health Insurance or Medicaid: What Coverage Provides . . . . . . . . . . . . 81

Private Health Insurance Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Trends in Private Health Insurance Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Limitations of Data on Private Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

What Private Health Insurance Coverage Provides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Medicaid Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Who Pays for Medicaid? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Medicaid Expenditures on Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Which Adolescents Are Eligible for Medicaid? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

What Medicaid Coverage Provides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

Physician Reimbursement and Participation Under Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Estimated Effects of Employer Mandates and Medicaid Expansions on the Number of

Adolescents Without Health Insurance . . . . . . . . . . . . . . . .....*.* . . . . . . . . . . . . . . . . . . . . . . . . 110

Estimated Effects of Employer Mandates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Estimated Effects of Medicaid Expansions . . . . . . . . .,.,.,*,* ● ,*...... ● . . . . . . . . . . . . . . . . . . 112

Combined Approach: Employer Mandate With a Medicaid Expansion . . . . . . . . . . . . . . . . . . . . . 113

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

Adolescents Without Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

Adolescents With Private Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Adolescents in the Medicaid Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Conflict Between Confidentiality and Insurance Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Summary of Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Chapter 16 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Boxes

Box Page

16-A. Analysis of Trends in Adolescents' Health Insurance Status, 1979-86 . . . . . . . . . . . . . . . . . . 79

16-B. Provisions of the Omnibus Reconciliation Acts of 1989 and 1990 That Affect Medicaid

Coverage of Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Figures

Figure Page

16-1. Trends in the Percentage of U.S. Adolescents Ages 10 to 18 Without Health Insurance,

1979-86 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

16-2. Percentages of U.S. Adolescents Who Live With Insured Parents, Uninsured Parents,

or No Parents, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

16-3. Distribution of Uninsured Adolescents, by Parent’s Health Insurance Status, 1988 . . . . . . . 78

16-4. Percentage of the Nonelderly Population Without Health Insurance, by State, 1987-88 . . . 81

Tables

Table Page

16-1. Health Insurance Status of U.S. Adolescents Ages 10 to 18, by Family Income, 1988 . . . 80

16-2. Health Insurance Status of the Nonelderly Population, by State, 1987-88 . . . . . . . . . . . . . . 82

16-3. Two Surveys’ Estimates of the Percentage of Participants in Employment-Based Group

Health Insurance With Some Coverage for Selected Benefits, 1988 . . . . . . . . . . . . . . . . . . . 85

16-4. Coverage of Mental Health Care: Percent of Full-Time Participants in Plans With

Coverage by Extent of Benefits, Medium and Large Firms, 1988 . . . . . . . . . . . . . . . . . . . . . 86

16-5. Coverage of Alcohol Abuse Treatment: Percent of Full-Time Participants in Plans With

Coverage by Extent of Benefits, Medium and Large Firms, 1988 . . . . . . . . . . . . . . . . . . . . . 89

16-6 Coverage of Drug Abuse Treatment: Percent of Full-Time Participants in Plans With

Coverage by Extent of Benefits, Medium and Large Firms, 1988 . . . . . . . . . . . . . . . . . . . . . 90

16-7. Estimated Medicaid Enrollment and Expenditures, by Age Group, Fiscal Year 1988 . . . . 95

16-8. Estimated Medicaid Expenditures on Adolescents Ages 10 to 14 and 15 to 18,

by Type of Service, Fiscal Year 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

16-9. Annualized Income Thresholds for Medicaid Eligibility, by State, January 1990 . . . . . . . . 97

16-10. Mandatory and Optional Services Covered Under Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . 101

16-11. EPSDT Screening Costs, by Age Group, Fiscal Year 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

16-12. EPSDT Periodicity Schedules in State Medicaid programs . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

16-13. Coverage of and Restrictions on Physicians’ and Physician-Supervised Services in

State Medicaid Programs, 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

16-14. Coverage of and Restrictions on Hospital Outpatient Services in State Medicaid

programs, 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

16-15. Factors Cited by Pediatricians as “Very Important” to Decision To Participate in

Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

16-16. Comparison of Medicaid and Medicare Reimbursement Rates for a Brief Followup Visit

to a Physician Specialist, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

16-17. Extending Health Insurance to Uninsured Adolescents: Potential Effect of Three

Employer Mandates on Uninsured Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

16-18. Extending Health Insurance to Uninsured Adolescents: Potential Effect of Medicaid

Expansions on Uninsured Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

16-19. Extending Health Insurance to Uninsured Adolescents: Potential Effects of Various

Combinations of Employer Mandates and Expansions in Medicaid on

Uninsured Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Chapter 16

FINANCIAL ACCESS TO HEALTH SERVICES

Introduction

Financial issues are of paramount importance in

any discussion of U.S. adolescents’ access to health

services. It is well established that health insurance

coverage and ability to pay may determine when—

or even whether-a person in this country seeks

medical services (47,60,65). It has also been shown

that while individuals in households with incomes

below the poverty level have significantly fewer

physician contacts than others in the same state of

health, Medicaid coverage can help mitigate the

effects of poverty on access to care (55).

This chapter explores the health insurance status

of U.S. adolescents and addresses the following

questions:

●

●

●

●

●

How many adolescents are without health

coverage and why are some adolescents insured

and others not?

Has the number of uninsured adolescents

changed over time? If so, why has this change

occurred?

What are the benefits of private health insurance particularly for adolescent health needs?

Who is eligible for Medicaid and what coverage does Medicaid provide?

How many adolescents would be affected by

three potential approaches to reducing the

number of uninsured: a mandate that employers

provide health insurance to their workers (and

their dependents), an expansion of the Medicaid program, or a combination of the two?

Adolescents Without Health lnsurancel

How Many Adolescents Lack Health Insurance

and Who Are They?

In 1988, about 4.6 million U.S. adolescents ages

10 through 18— 15 percent overall-had no public

or private health coverage. 2 The percentage of

uninsured U.S. adolescents rose nearly 5 percent

from the previous year, paralleling an overall

increase in the Nation’s nonelderly population

without health insurance. The decline in coverage

among adolescents and nonelderly adults in 1988

primarily results from a drop in the percentage of the

population with private health insurance, particularly among those with coverage provided by small

businesses employing fewer than 100 employees.

U.S. adolescents who have health insurance are

more than twice as likely as 25- to 54-year-olds to be

covered by Medicaid.3

According to data from the Current Population

Survey, there was a 25-percent increase in the

percentage of adolescents without health insurance

between 1979 and 1986 (see figure 16-1). Trends in

adolescents’ health insurance status from 1979

through 1986 are briefly discussed in box 16-A. (In

1988, the health insurance section of the Current

Population Survey questionnaire was modified substantially; therefore survey data from 1979 through

1986 cannot be compared with more recent statistics.)

Sociodemographic Characteristics of

Uninsured Adolescents

Ninety-four percent of U.S. adolescents ages 10 to

18 live with their parents. 4 Eleven percent of U.S.

adolescents live with parents who do not have health

insurance (see figure 16-2), and 63 percent of

IData for ~~ -ly~i~ come from ~ent Popu]atlon Smeys fie]ded ~ 1980 to ]989 by the U.S. BUrGNJ of the Census (77). Ikh Marc~ a

supplement to the survey asks a variety of questions about work history and income during the previous year, and includes a set of health insurance

questions. Responses to these questions are the basis for the analyses presented in this section. For a more in-depth analysis of these issues, see the July

1989 OTA background paper prepared by R. Kronick, Adolescent Health Insurance Status: Analyses of Trends in Coverage and Preliminary Estimates

of the Effects of an Employer Man&te and Medicaid Expansion (44).

%stimates on the number of adolescents without health insurance were developed by R. Kronick for OTA and are based on U.S. Census Bureau’s

Current Population Sumey data (44,45).

JThe individ~s at greatest risk for being uninsured are 19- to 24year-olds (~).

4Th1s fiWe ~c]udes ado]esmnts fiv~g ~~ two Pments (70 percent), adolescen~ livfig witi their mother only (2 1 pereent), ad adolescents living

with their father only (3 percent) (44). Adolescents living with two parents do not necessarily live with their biological parents.

-111-77-
III-78 . Adolescent Health-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Figure 16-1—Trends in the Percentage of U.S.

Adolescents Ages 10 to 18 Without Health Insurance,

1979-86a

Percent uninsured

25 ~- 1

I

25% increase from 1979-1986 I

)

I I

1979 - 1981 1982 1983 1984 1985 1986

Year

aln Ig6g the Current Population Study questionnaire WSS modified

substantially; therefore, survey data from 1979 through 1986 cannot be

compared with more current data.

SOURCE: R. Kronick, Ado/eecent I+edtfr /nsurance Status: Ana/yses of

Tren& in Coverage and Preliminary Estimates of the Effects of

an Employer Mandate and Medicaid Expanslo~ground

Paper (Background Paper for OTA’s Project on Adolescent

Health), prepared under contract to the Carnegie Counal on

Adolescent Development and Carnegie Council of New York, for

the Office of Technology Assessment, U.S. Congress, OTA-BPH-56 (Washington, DC: U.S. Government Printing Office, July

1969).

uninsured adolescents live with parents who are also

uninsured (see figure 16-3). To a large extent, then,

the problem of uninsured adolescents is related to

the problem of uninsured parents.

Family income is the most important determinant

of health insurance status for all age groups. Those

who are poor, regardless of other factors, are the

most likely to be uninsured. Adolescents in poor or

near-poor families5 are much more likely to lack

health insurance than others; one-third of them are

without any coverage whatsoever (see table 16-1). In

contrast, only 14 percent of adolescents in families

with income at between 150 and 299 percent of the

Federal poverty level and 4 percent of adolescents in

families at 300 percent of poverty or above are

uninsured.

Despite the strong relationship between poverty

and the likelihood of being uninsured, it is by no

means true that all the uninsured adolescents are

poor. About two-thirds of uninsured adolescents live

in families with incomes above the Federal poverty

Figure 16-2—Percentages of U.S. Adolescents Who

Live With Insured Parents,a Uninsured Parents,

or No Parents,b 1988

Adolescents

with insured

83%

who

pare

Adolescents who

w

live with

uninsured parents

11%

Adolescents not

~ living with parentsb

6%

~his figure refers to the health insurance status of household head unless

only the spouse had employment-based health coverage.

%his category includes adolescents not living with their parents and

married adolescents living with their parents.

SOURCE: R. Kronick, Adjunct Professor, University of California, San

Diego, CA, calculations based on U.S. Department of Commerce, Bureau of the Census, March 1989 Current Population

Survey public use files, 1990.

Figure 16-3--Distribution of Uninsured Adolescents,

by Parent’s Health Insurance Status, 1988a

Uninsured adolescents living

with uninsured

63%

GliiJ 7

Uninsured

7 adolescents living

with insured parents’

19%

Uninsured adolescents

not living with parentsb

18%

aRefers t. the health i~urance status of household head unle~ onlY the

spouse had employment-based health coverage.

%his category includes adolescents not living with their parents and

married adolescents living with their parents.

SOURCE: R. Kronlck, Adjunct Professor, University of California, San

Diego, CA, calculations based on U.S. Department of Commerce, Bureau of the Census, March 1989 Current Population

Survey public use files, 1990.

level: 33 percent of uninsured adolescents live in

families with incomes between 100 and 199 percent

of the Federal poverty level, and 29 percent live in

families with incomes at 200 percent of poverty or

above. 6 7

Several demographic characteristics have fairly

strong relationships with health insurance status

Spoor f~le~ ~ ~se ~~ ~omes ~IOw 10(J p~cent Of tie F~er~ pove~ level, md near-poor families are those with incomes between 100

and 149 percent of the Federal poverty level.

bper~n~~ do not total 100 percent owing to rouding.

T~e F~er~ poverty level for a family of_ WSS $10,56O in J~~ 1990.
Chapter 16--Financial Access to Health Services . III-79

Box 16-A—Analysis of Trends in Adolescent Health Insurance Status, 1979-86

From 1979 through 1986, the percentage of American adolescents without any health insurance increased by

25 percent. In the early 1980s, the rise in the percentage of uninsured adolescents was strongly associated with

increased poverty and a decline in Medicaid coverage of the poor and near-poor. Later, in the mid-1980s, as the

country recovered from recession, these trends improved slightly; however, the percentage of the adolescent

population at each income level with private insurance declined substantially. For a combination of reasons

(including a decline in the absolute number of 10- to 18-year-olds from 1979 to 1986), there was no change in the

aggregate number of uninsured adolescents.

The decline in Medicaid coverage of adolescents from 1979 to 1986 was greatest among adolescents living

in or near poverty. This decline was due in part to Federal regulations, issued under the 1981 Omnibus Budget

Reconciliation Act of 1981 (Public Law 97-35), that limited the working poor’s eligibility for Aid to Families With

Dependent Children (AFDC) and Medicaid benefits. Also, because many States did not adjust the income eligibility

standards for inflation, the income threshold as a percentage of the Federal poverty level deteriorated substantially.

In 1979,48 percent of adolescents living in families with incomes between 50 to 99 percent of the poverty level

had Medicaid coverage.1 By 1983, this figure had dropped to 38 percent, but it rebounded slightly to 42 percent in

1984 and 1986. Meanwhile, almost half of the adolescents in families with incomes from 100 to 149 percent of

poverty who were in the Medicaid program in 1979 had lost coverage by 1982.

The decline in private health insurance coverage of adolescents from 1979 to 1986 was also most significant

among the poor. In 1979, 17 percent of adolescents in families with incomes below 50 percent of the poverty level

were covered by some form of private insurance; by 1986$ only 11 percent were enrolled in a private health plan.

Adolescents in families with incomes between 50 to 99 percent of poverty experienced a similar trend; the

proportion with private health coverage dropped from 27 to 22 percent during the same time period.

Eighteen percent of the overall rise in the percentage of U.S. adolescents without health coverage from 1979

through 1986 was due to a fall in the coverage rate among adolescents not living with any parent. In 1979,61 percent

of these adolescents were uninsured by 1986, the figure had increased to 74 percent.

A principal reason why more U.S. adolescents were uninsured in 1986 than in 1979 is simply that more

adolescents lived with uninsured parents in 1986 than in 1979. During the period 1979-86, the percentage of

adolescents who lived with uninsured parents increased from 8.8 to 10.5 percent, accounting for 37 percent of the

overall 1979-86 increase in the percentage of uninsured adolescents. At the same time, the percentage of uninsured

adolescents who lived with uninsured parents also rose, increasing from 92 to 96 percent (contributing an additional

10 percent to the overall climb in the uninsured). The percentage of adolescents who obtained health insurance from

their own jobs declined precipitously.

ITJw method used km? to deterllline my income aQd poverty status differs slightly fkom the cakuMms used by the U.S. Bureau of

the Census aud affects those adokacents who live in a “suMunily,” for example, an unmarried Ill-year-old female and her cidid who radde

with the 18-year-old’sparem~ -US method for de@mining family income would considertbis family unit as a4-pc#onfamily and count

t.tw I&year-old’s income as weii as kpartmts’ in cd-totai fhdy irEOHke -Povu’ty Status. The resuks rqmrted here tmatcd the

M-year-eldas asepratefamilyunit tmddid xx)tcount berparents’ imornerndetc?mbing total franilyincomc. Consequently, the above estimates

of the percentage of adokscents living in poverty are slightly II@CZ than _Burcauqor&. However, the @ercnces are minor and do MN

affect any Substautke conclusions. Note that the Census methodology is used for an Ot.lm poverty d family income aniuwes premlt m W

chapter.

SOURCB: R. Kronkk Adolescent Health Znsurance Status: Analyses qf Trends in Coverage and Preliminmy Estimates of the E#ects of an

Employer A4m&te and Me&aid Eapansion4ackgmund Paper @ackground Rtper for OTA’s Project on Adokacent Heakb),

PW4 under contract to the Carnegie Council on MokscumDevebpmcat and Carnegie Corporation of New Yorlq for the Office

of TMmology AMeSmng Us. Cor)gress, OTA-BP-H-56 (washin@% DC: Us. (30Vmlmm _m, J~Y 1989)s

independent of family income. These include His- in poverty are more likely than others to include both

panic ethnicity, parent’s education, parental self- husband ‘and wife, they will be less likely to be

employment, and region. Hispanic adolescents are eligible for Medicaid. In addition, Hispanic adolesmuch more likely than others to be uninsured, cents who are undocumented immigrants are not

regardless of family income. This may be because eligible for Medicaid.

Hispanics are more likely than others to work in

agriculture and domestic service, where coverage . Although black adolescents are much more

rates are historically low. If Hispanic families living likely than whites to live in or near poverty and
///-80 . Adolescent Health-Volume III: Crosscutting Issues in the Delivery of Health and Related Services

●

●

●

●

Table 16-1—Health Insurance Status of U.S. Adolescents Ages 10 to 18,

by Family Income, 1988

Health insurance status

Family income Proportion of

as a percent all adolescents Lack health Have health insurance:

of the-Federal at the specified insurance Private Medicaid

poverty levele poverty Ievelbcoverage only only Otherc Total

Less than 50 percent . . . . . 7.8% 29.8°/od

1 3.7% 51 .I% 5.3% 100.00/0

50 to 99 percent . . . . . . . . . 9.1 35.8d

21.4 36.4 6.5 100.0

100 to 149 percent . . . . . . . 9.8 30.9 47.9 13.3 7.9 100.0

150 to 199 percent . . . . . . . 9.7 19.8 68.6 5.0 6.6 100.0

200 to 299 percent . . . . . . . 20.1 11.9 79.4 1.2 7.4 100.0

300 percent and above . . . 43.4 4.6 0.6 0.6 5.4 100.0

100.0%

aln 1988, the F~eral poverty level was $9,431 fOr a family of three.

here were 30.8 million adolescents, ages 10 to 18, in 1988.

Wther includesi he Civilian Health and Medical Program of the United States, Medieare, oraeombination of public and

private coverage.

d~erall, one-thi~ of adolescents living in poverty had no health insurance.

SOURCE: R. Kroniek, Adjunct Professor, University of California, San Diego, CA, calculations baaed on U.S.

Department of Commeree, Bureau of the Census, March 1989 Current Population Survey public use filee,

1990.

to be uninsured, the correlation between race

and lack of health insurance coverage almost

disappears when family income is taken into

account.

At each income level, adolescents whose parents have little formal education are much more

likely to be uninsured than adolescents whose

parents have had more education.

Among adolescents in middle- and upperincome families, those whose parents are selfemployed are much more likely than others to

be uninsured.

Adolescent children of parents who work for

small firms (under 25 employees) are more

likely to be uninsured than dependents of other

working parents.

More than 1 of 5 Southern and Western

adolescents are uninsured, while less than 1 of

10 Northeastern and Midwestern adolescents

are without coverage.

Reliable data on adolescents’ health insurance

status by State are not available, but estimates of the

overall nonelderly uninsured population in each

State are good indicators of the percentage of

adolescents without coverage (see figure 16-4; table

16-2). The percentage of nonelderly people who lack

health insurance among the States ranges from about

8 percent in Rhode Island to more than 26 percent in

New Mexico.8

Further analysis shows that regional variations in

health insurance coverage among adolescents are

due primarily to differences in income-specific rates

of Medicaid and private health coverage.9 In the

South, it appears that more stringent Medicaid

income eligibility requirements are key to the

greater percentage of uninsured adolescents. If

income limits for Medicaid eligibility were as high

in the South as in the North, the percentage of

Southern adolescents without health coverage would

drop by approximately 25 percent.10 In the West,

lower rates of private coverage appear to be the most

critical factor, although lower Medicaid coverage

rates are important as well. If income-specific rates

of private insurance coverage were as high in the

West as in the North, the percentage of uninsured

Western adolescents would be reduced by about 19

8~ew ~St&tes were ~wfTom comb~ed March 1988 and March 1989 Current Population SUIVeYS ~d were ~c~ated @ ~c~d fio~ck for

O’IA. Current Population Surveys’ wunpling precludes developing reliable estimate-s for the adolescent population alone,

me U.S. census regions are def~ as follows: North includes ComecticuL Maine, Massachusetts, New Hampshire, New Jersey, New York

Pennsylvar@ Rhode Island, and Vcamont; Midwest includes Illinois, Indi% Iowa, Kansas, Michigu hfi.nneso~ Misso@ Nebraa~ North Dako@

Ohio, South Dako@ and Wisconsti South includes Ala-Arkansas, Delaware, Flori@ Georghu Kentucky, huis~ Maryland, Mississippi, North

Caroh OklahonuL South Carolina. ‘llmnessee, lkxas, Virgin@ and West Virgi@ and West includes Alaska, Arizona, California, Colorado, Haw@

Idaho, MonU Nevada, New Mexico, Oregou Utah, Washington, and Wyoming (76).

Iqt is important to note that this adysis e xarnined the effects of applying Medicaid income standards used in Northern States to Southern States but

did not consider how the cost of living differs between the two regions. Obviously, an income of $1,500 in Mississippi for example, would not have

the same value in New York.
Chapter 16--Financial Access to Health Services . III-81

Figure 16-4-Percentage of the Nonelderly Population Without Health Insurance, by State, 1987-88e

r- — - - — T J

J

.— ——

L.–- _- ! Below 10% ‘~i From 15 to 19% _ From 25 to 29%

r–n From 10 to 14 - From 20 to 24%

aRat= are rounded to the nearest whole number. See table 16-2 for actual data, standard errors, and confidence internals.

SOURCE: R. Kronick, Adjunct Professor, University of California, San Diego, CA, calculations based on U.S. Department of Commerce, Bureau of the Census,

March 1988 and March 1989 Current Population Survey public use files, 1990.

percent. These results make clear that public policies

designed to expand health insurance coverage--e.g.,

mandating employers to provide coverage or expanding Medicaid-would have markedly different

regional effects. The effects in Western and Southern States would be quite different from the effects

in the North.

Adolescents With Private Health

Insurance or Medicaid: What

Coverage Provides

Adolescents with health insurance coverage, whether

private or public, do not always have benefits for

some of the health services they need. This section

describes the benefits of both private health insurance and Medicaid. The emphasis is on those

services most likely to be used or needed by

adolescents, such as mental health care, substance

abuse treatment, maternity care and related services,

preventive services, services provided by nonphysician providers, dental care, and others.11

An important caveat to this review relates to the

question of confidentiality in adolescent health care.

Even if appropriate benefits are available, adolescents who are concerned about confidentiality may

be reluctant to seek care from providers if their

private health plan requires parents to submit a claim

for reimbursement (as most do). An adolescent with

Medicaid coverage who must present a parent’s

Medicaid card to gain access to care faces the same

dilemma. 121 3

1 l~s section sho~d not b taken as an endorsement of specific services. Much of the remainder of OTA’s adolescent health Report is devoted to

analyzing the effectiveness of various services. See especially Vol. II of this Report.

I% five States (i.e., Californi% Kansa.s, Mmyland, New Hampshire, and New York), adolescents who are dependents living in families that receive

Medicaid are given theti own Medicaid card.

ljFor ~er dis~sion of cordldentirdity issues in adolescent health care, S= ch. 17, “Consent and Confidentiality in Adolescent Health Care

Decisionmakm‘ g,” in this volume.
111-82. Adolescent Health-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Table 16-2--Health Insurance Status of the Nonelderly Population, by State, 1987-88a

Health insurance status

Lack health

insurance 95 percent Have health insurance

coverage Confidence Private Medicaid

(in rank order) intervals only only Otherc

Rhode Island , . . . . . . . . . . . . . .

Massachusetts . . . . . . . . . . . . . .

Wisconsin . . . . . . . . . . . . . . . . . . .

Minnesota . . . . . . . . . . . . . . . . . .

Iowa . . . . . . . . . . . . . . . . . . . . . . . .

Michigan . . . . . . . . . . . . . . . . . . . .

Pennsylvania . . . . . . . . . . . . . . . .

Connecticut . . . . . . . . . . . . . . . . .

North Dakota . . . . . . . . . . . . . . .

New Jersey . . . . . . . . . . . . . . . . .

Ohio . . . . . . . . . . . . . . . . . . . . . . . .

Hawaii . . . . . . . . . . . . . . . . . . . . . .

Maryland.. . . . . . . . . . . . . . . . . . .

Maine . . . . . . . . . . . . . . . . . . . . . .

Delaware . . . . . . . . . . . . . . . . . . .

Kansas . . . . . . . . . . . . . . . . . . . . .

Illinois . . . . . . . . . . . . . . . . . . . . . .

Vermont . . . . . . . . . . . . . . . . . . . .

Nebraska . . . . . . . . . . . . . . . . . . .

New Hampshire . . . . . . . . . . . . .

Virginia . . . . . . . . . . . . . . . . . . . . .

Missouri . . . . . . . . . . . . . . . . . . . .

New York . . . . . . . . . . . . . . . . . . .

Utah . . . . . . . . . . . . . . . . . . . . . . . .

Washington . . . . . . . . . . . . . . . ,.

South Carolina . . . . . . . . . . . . . .

Indiana . . . . . . . . . . . . . . . . . . . . .

Wyoming . . . . . . . . . . . . . . . . . . .

North Carolina. . . . . . . . . . . . . .

South Dakota . . . . . . . . . . . . . . .

Colorado . . . . . . . . . . . . . . . . . . . .

West Virginia . . . . . . . . . . . . . . . .

Tennessee . . . . . . . . . . . . . . . . . .

Georgia . . . . . . . . . . . . . . . . . . . . .

Oregon . . . . . . . . . . . . . . . . . . . . .

Montana . . . . . . . . . . . . . . . . . . . .

Idaho . . . . . . . . . . . . . . . . . . . . . . .

Kentucky . . . . . . . . . . . . . . . . . . .

District of Columbia . . . . . . . . . .

Alaska . . . . . . . . . . . . . . . . . . . . . .

Alabama . . . . . . . . . . . . . . . . . . . .

California . . . . . . . . . . . . . . . . . . .

Nevada . . . . . . . . . . . . . . . . . . . . .

Mississippi . . . . . . . . . . . . . . . . . .

Arizona . . . . . . . . . . . . . . . . . . . . .

Florida . . . . . . . . . . . . . . . . . . . . . .

Oklahoma . . . . . . . . . . . . . . . . . . .

Louisiana . . . . . . . . . . . . . . . . . . .

Arkansas . . . . . . . . . . . . . . . . . . .

Texas . . . . . . . . . . . . . . . . . . . . . .

New Mexico . . . . . . . . . . . . . . . . .

8.1%(0.010)

8.4 (0.005)

8.7 (0.009)

8.8 (0.009)

8.8 (0.009)

8.8 (0.005)

8.9 (0.005)

9.0 (0.010)

9.7 (0,009)

9.8 (0.005)

10.1 (0,005)

10.3 (0.010)

10.6 (0.010)

10.6 (0.010)

11.1 (0.011)

11.1 (0.010)

11.3 (0.006)

11.5 (0.011)

11.6 (0.010)

12.1 (0.012)

12.4 (0.010)

12.6 (0.011)

12.8 (0,005)

13.3 (0.011)

13,3 (0.011)

13.9 (0.011)

13.9 (0.011)

14.1 (0.013)

14.9 (0.006)

15.4 (0.010)

15.5 (0.013)

15.9 (0.013)

16.0 (0.012)

16.5 (0.011)

17.1 (0.014)

17.2 (0.012)

17.3 (0.012)

17.5 (0.013)

18,4 (0.014)

18.5 (0.012)

18.8 (0.014)

19.4 (0.006)

20.3 (0.014)

20.7 (0.013)

20.9 (0.014)

21.2 (0.007)

21.9 (0.013)

22.3 (0.014)

22.6 (0.014)

24.8 (0,007)

26.3 (0.014)

6.1-10.O%

7.4-9.3

6.9-10.4

6.9-10.6

7.0-10.6

7.9-9.8

8.0-9.9

7.0-11.0

8.0-11.5

8.8-10.8

9.1-11.1

8.3-12.3

8.7-12.5

8.6-12.7

9.0-13.2

9.2-13.1

10.2-12.4

9.3-13.8

9.7-13.6

9.8-14.3

10.5-14.3

10.5-14.7

11.8-13.8

11.2-15.3

11.1-15.5

18.8-15.9

11.8-16.0

11.6-16.7

13.7-16.1

13.4-17.4

13.0-17.9

13.4-18.4

13.6-18.3

14.3-18.8

14.4-19,8

14.8-19.7

14.9-19.6

15.0-20.0

15.7-21.1

16.1-20.9

16.2-21.5

18.3-20,6

17.5-23.1

18.2-23.3

18.3-23.6

19.9-22.5

19.3-24.5

19.6-25.0

20.0-25.3

23.4-26.0

23.6-28.9

79.3%(0.015)

79.7 (0.007)

82.4 (0.012)

79.9 (0.013)

82.3 (0.012)

75.9 (0.007)

80.4 (0.007)

84.2 (0.013)

79.1 (0.012)

82.1 (0.007)

76.9 (0.007)

70.0 (0.015)

74.7 (0.014)

73.2 (0.015)

76.3 (0.015)

80.3 (0.013)

75.1 (0.008)

78.1 (0.015)

75.6 (0.013)

81.6 (0.014)

70.9 (0.013)

76.0 (0,014)

71.3 (0.007)

78.8 (0.013)

72.9 (0.015)

71.0 (0.014)

77.2 (0.013)

75.1 (0.016)

73.3 (0.008)

73.3 (0.013)

70.9 (0.016)

65.9 (0.016)

69.3 (0.015)

68.5 (0.014)

72.1 (0.016)

67.5 (0.015)

72.9 (0.014)

67.9 (0.016)

66.3 (0.017)

56.6 (0.016)

66.6 (0.016)

64.2 (0.007)

68.4 (0.016)

59.2 (0.016)

67.8 (0.016)

65.1 (0.008)

63.0 (0.016)

59.5 (0.016)

61.2 (0.016)

62.6 (0.008)

55.8 (0.015)

5.8% (0.008)

6.8 (0.004)

5.4 (0.007-)

7.6 (0.009)

5.7 (0.007)

8.8 (0.005)

61 (0.004)

3.0 (0.006)

2.5 (0.005)

4.9 (0.004)

8.0 (0.005)

3.4 (0.006)

6.5 (0.008)

8.6 (0.009)

5.6 (0.008)

2.6 (0.005)

9.1 (0.005)

4.7 (0.008)

4.9 (0.007)

1.0 (0.004)

5.2 (0.006)

6.8 (0.008)

11.0 (0.005)

3.6 (0.006)

6.1 (0.008)

6.6 (0.008)

3.6 (0.006)

3.8 (0.007)

4,2 (0.003)

4.4 (0.006)

5.2 (0.008)

11.4 (0.011)

8.3 (0.009)

6.9 (0.008)

5.9 (0.009)

7.6 (0.009)

3.7 (0.006)

7.9 (0.009)

10.4 (0.011)

8.3 (0.009)

8.5 (0.010)

9.2 (0.004)

2.9 (0.006)

11.4 (0.010)

3.1 (0006)

5.1 (0.004)

6.0 (0.008)

12.6 (0.011)

9.6 (0.010)

5.4 (0.004)

7.0 (0.008)

6.8%

5.1

3.6

3.7

3.2

6.5

4.6

3.7

8.7

3.2

5.0

16.3

8.2

7.6

7.0

6.0

4.6

5.7

7.9

5.4

11.6

4.5

5.0

4.3

7.7

8.6

5.2

6.9

7.7

6.9

8.5

6.8

6.5

8.1

4.9

7.7

6.1

6.7

4.9

16.6

6.1

7.1

8.4

8.7

8.2

8.6

9.1

5.6

6.6

7.2

11.0

(0.009)

(0,004)

(0.006)

(0.006)

(0006)

(0.004)

(0.004)

(0007)

(0.009)

(0.003)

(0.004)

(0.012)

(0.009)

(0009)

(0.009)

(0.008)

(0004)

(0.008)

(0.008)

(0.008)

(0.009)

(0,007)

(0003)

(0.006)

(0.009)

(0.009)

(0.007)

(0.010)

(0005)

(0.007)

(0.010)

(0.009)

(0.008)

(0.008)

(0.008)

(0.009)

(0.008)

(0.009)

(0,008)

(0.012)

(0.008)

(0.004)

(0.010)

(0.009)

(0009)

(0.005)

(0009)

(0.008)

(0.008)

(0004)

(0010)

aResults inparenthe5es are standard errors.

bconfi~na intervalsforestimates of the proportion of the State population without health insuranc=

@therincludesthe Civilian Health and Medical Program ofthe United States, Medicare, or any combination ofpublicand privatecoverage.

SOURCE: R.Kronick,Adjunct Professor UniversityofCalifornia, San Diego, CA,calculationsbasedon U.S. DepartmentofCommerce, BureauoftheCensus,

March 1988and1989Current Population Survey publicusefiles, 1990.
Chapter 16--Financial Access to Health Services ● III-83

Private Health Insurance Coverage14

About 21.7 million U.S. adolescents ages 10

through 18 (70 percent) are covered by private health

insurance (44). What follows is a review of recent

trends in private health insurance coverage, the

limitations of existing data sources on current health

benefits, the general nature of health insurance

coverage, and an analysis of benefits provided by

private health plans.

Trends in Private Health Insurance Coverage

The nature of private health insurance coverage

changed dramatically in the 1980s, and the 1990s

promise more change. Taking note of some of these

trends is important because they have a direct effect

on what private health benefits provide. One striking

development has been the growth of self-insurance

among the Nation’s employers, largely due to the

passage of the Employee Retirement and Income

Security Act (ERISA) (Public Law 92-104) in

1974.15 ERISA freed self-insured plans from State

health insurance regulations including State premium taxes and State mandates to insurers to

provide minimum coverage for specific services,

categories of providers, diseases, or individuals who

might have difficulty in obtaining coverage ( 13,27).16

There is some evidence that many employers have

chosen to self-insure to escape the costs and

administrative burden of conforming with State

mandates (28). It is not clear whether mandates are

the principal cause of the shift to self-insurance, but

it is certain that the potential pool of health plans that

might be affected by mandates has greatly diminished. From the time of ERISA’s enactment in 1974

to 1987, the percentage of employees covered by a

self-insured employer-sponsored conventional

health plan rose from about 5 percent to nearly 60

percent (26).

Since the 1970s, many States have enacted

mandates expanding the health insurance benefits

provided by traditional commercial health insurers

and Blue Cross and Blue Shield plans .17 Between

1978 and 1988, the number of State-mandated

benefits grew from 343 to 732 (28). There is now

growing concern that the onus of providing ever

more comprehensive coverage has contributed to

growth in the population of the uninsured, particularly among workers (and their dependents) in small

businesses (42). This concern is reflected in the

growing number of States that have passed laws

requiring evaluation of the social and financial

impact of mandated health insurance benefits (39).

The way dependents are covered by employmentbased health plans is changing, and there is reason to

be concerned that increasingly higher premium costs

for family coverage combined with greater costsharing for dependent coverage may lead to more

uninsured adolescents and other family dependents.

About 47 cents of every dollar of health care expense

incurred by privately insured employees is reported

to be for the treatment of dependents (57). The

average monthly cost of family health coverage

exceeded $260 in 1989 (parents paid an average

share of $55 to $81 per month for the entire family

depending on the type of plan) and was approximately 18 percent higher than the previous year (36).

The ever-increasing cost of health benefits, in

general, and dependent care, in particular, has

recently moved employers to require parents to pay

a larger portion of their health insurance premiums

and to share more of the costs for their dependents

(9,15,67). From 1980 to 1988, the percentage of

participants, in medium and large private group

health plans, required to contribute for family

coverage increased from 46 to 63 percent (15). The

U.S. General Accounting Office, in a 1988 investigation of the effects of cost increases on health

coverage, found that some firms provide little or no

contribution to dependent coverage’ and ‘‘for

lower-income families, the high cost of family

coverage can lead to decisions to forgo dependent

coverage’ ‘(66). Meanwhile, some employers are

planning to restrict or exclude dependent coverage,

especially for mental health or substance abuse,

14~ this discussion, the terms private health insurance, private health plans, and group health plans are often used interchangeably to refer to

employment-based group plans regardless of sponsorship or fwcing arrangement (i.e., conventional plans, self-insured plans, health maintenance

orga.niza tions, etc).

ISA ~elf-in~ured ~l~n is a he~~ benefit p~ ~ w~ch tie fiici~ fisk for provided medi~ semices is usurned by the emplOyer Or SpOnSOr.

16A ~onventioml hea/th plan is a ~ltio~ ind~ty or fe~for-semice he~~ pl~ tittypic~ly reimb~es the hdth provider on a ‘‘reasonable

and customary’ basis or as bilk%.

ITIt is fiwfimt to be awwe thathealthcoverage provided by self-insured employers, Wth rnaintenanceorganizations (HMOs), and individual family

plans are usually not affected by State mandates. HMOS are often regulated independently from indemnity carriers and, as noted, self-insured plans are

exempt from State insurance regulations. HMOS may be subject to their own mandated benefit rules.
///-84 . Adolescent Health-Volume III: Crosscutting Issues in the Delivery of Health and Related Services

while retainin g the benefits for their own employees

(9,57).

Equally important has been the rapid growth in

managed health care. In 1987, more than 60 percent

of Americans with group health insurance coverage

were enrolled in a health maintenance organization

(HMO), preferred provider organization (PPO), or a

managed fee-for-service health care plan (27).18

Patients in managed health care plans do not have

open access to physicians or hospitals and usually

must obtain prior approval before admission to a

hospital. HMOs and PPOs may also require that the

health provider’s treatment plan be reviewed to

ensure that the hospital care is necessary. Patients

who do not follow the HMO or PPO guidelines may

face larger out-of-pocket costs or be denied payment

altogether (13). On the other hand, case management

may allow for more flexibility in the care of

high-cost illnesses. Some managed health care plans

contain ‘‘individual benefits management’ programs that allow for payment of otherwise uncovered benefits, such as home- and community-based

services, in order to avoid more costly covered

services (24).

Limitations of Data on Private Health Insurance

Comprehensive national data on benefit coverage

are fairly limited. Survey data are the principal

source of information on benefit coverage and have

several key limitations.19 Surveys of benefits are

often confined to health plans provided by medium

and large private employers and thus do not reflect

coverage offered by small employers and nongroup

family plans that are almost always less comprehensive and generous than others (41 ).20 To date there

have been no surveys of private health benefits that

have focused on adolescent needs in particular.

Because available surveys examine benefits in

general and do not report whether equivalent dependent coverage is available, this review must

assume that survey findings apply to both the

subscriber and his or her dependents. A notable

exception, however, is maternity care, which often is

provided only to the policyholder and spouse.21

What Private Health Insurance Coverage Provides

Group health plans have traditionally served as

protection against the major costs of hospital and

physician-provided services for the care of acute

illness. Most Americans who participate in an

employment-based group health plan have benefits

for a wide range of hospital and medical services

particularly if the subscriber works for a medium or

large employer. Health benefits surveys by the

Bureau of Labor Statistics and the Health Insurance

Association of America show that 90 percent or

more of employees with employer-based group

health coverage have health benefits for hospital

room and board, surgical services, physician visits

(i.e., for the diagnosis, evaluation, and treatment of

an illness or injury), diagnostic X-ray and laboratory

procedures, outpatient prescription drugs, mental

health, and substance abuse (see table 16-3). Other

medical care services, such as routine physical

exams, preventive diagnostic procedures (e.g., pap

smears), vision, hearing, dental, home health, and

extended care are less likely to be covered (see table

16-3) (31,32,84).

Most conventional private health plans require

annual deductibles and coinsurance payments before

IBHea/th ~intenanceorganizatlon~ (HMOS) are entities that act as both insurer and provider of comprehensive but specifledmedical SeWiCeS iU rehLM

for prospective, periodic per capita payments. Pr#erred provider plans (PPOS) are groups of health providers that contract with employers, insurers,

third-party administrators, or other sponsoring groups to provide services on a discounted fee-for-service basis; health plan participants who use these

providers pay lower deductible and coinsurance payments. A munaged feefor-service heaith care plan is a conventional health plan which requires

patients to obtain prior approval before admission to a hospital and prospective utilization review.

IYIWO Smeys SeNe as tie pficip~ rIata sources for this discussion. The most representative of employment-based group coverage is the Hdt.h

Insurance Association of America’s 1988 survey of 1,665 randomly seleeted employers who offer health insurance to thek employees (32). This sample

represents an estimated 84 percent of those who receive employment-based health insurance from small, medim and large fiis in the private and public

sectors. Interviews were conducted by telephone. Federat employees and individuals who obtain their own insurance were not included (32). Another

sumey, although not representative of small fins, is the U.S. Department of Labor annual sumey of employee benefits in medium and large firms that

is conducted by the Bureau of Labor Statistics (84,85). In 1988, the Bureau of Labor Statistics survey included a stratiled sample of 1,922 private,

nonfarm establishments employing at least 100 employees (84). Data for the sumey were drawn from health plan documents colkcted by Bureau field

representatives and analyzed by Bureau staff in Washington (84).

mM~i~ ~d ~ge f~s me generally those with at least 100 or 250 employees, depending upon the industry, and represent approxtitely 49 PXent

of the Nation’s work force (8). Non(group fam”/y plans refer to health insurance plans that are purchased on an individual basis and are not obtained

through an employment or other membership group contract. Approximately 10 to 12 percent of individuals covered by private health insurance are in

a nongroup individual or family plan.

‘21M~y privately inswed adolescents are not eligible for coverage, in part because of a ‘‘loophole” in the Pregnancy Discrimination kt of 19’78

(Public Law 95-555). See “Maternity Care and Related Services,” below.
Chapter 16-Financial Access to Health Services . III-85

Table 16-3-Two Surveys’ Estimates of the Percentage of Participants in Employment-Based Group

Health Insurance With Some Coverage for Selected Benefits, 1988a

Estimate of Estimate of

percentage percentage

Category of medical care Survey b with coverage Category of medical care Survey b with coverage

Diagnostic X-ray and laboratory . . . . .

Hospital room and board . . . . . . . . . . .

Surgical services

Inpatient . . . . . . . . . . . . . . . . . . . . . . . .

Outpatient. . . . . . . . . . . . . . . . . . . . . .

Physician visits

In hospital . . . . . . . . . . . . . . . . . . . . . . .

In office . . . . . . . . . . . . . . . . . . . . . . . . .

Mental healthd

Outpatient care . . . . . . . . . . . . . . . . . .

Hospital care . . . . . . . . . . . . . . . . . . .

BLS

BLS

BLS

BLS

BLS

BLS

HIAA

HIAA

980/0

98

98

98

98

98

95

98

Prescription drugs? . . . . . . . . . . . . . . . .

Treatment for substance abusef . . . .

Home health careg

. . . . . . . . . . . . . . . . .

Extended care facilityg

... . . . . . . . . . . .

Preventive diagnostic procedures . . .

General dental caree. . . . . . . . . . . . . . .

Visione . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Immunization and inoculation . . . . . . .

Routine physical exams . . . . . . . . . . . .

Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . .

Orthodontia e 

. . . . . . . . . . . . . . . . . . . . . .

HIAA

HIAA

HIAA

HIAA

HIAA

HIAA

BLS

BLS

BLS

HIAA

HIAA

9 3 %

90

86

79

69

37

35

29

28

27

27

%lote that employment-based group health coverage is the most comprehensive form of health insurance. Details on the scope of coverage offered by

nongroup family plans is very Iim ited, although typically such plans are known to be less generous.

bEstimate~ are drawn from lg88 surveys ~ond~t~ by either the Health Insurancg Assodation of Amefica (HIM) or the Bureau of Labor Statistics (BLS).

Data from the HIAA survey are provided when available as they are more representative of employment-based group coverage; the H IAAsample indudes

1,665 randomly selected employers and reflects an estimated 84percent of those who receive employment-based health insurance from small, medium, and

large firms in the private and public sectors (30). The BLS survey includes a stratified sample of 1,922 private, nonfarm establishments employing at least

100 employees (77).

%harges incurred in the outpatient department of a hospital and outside of the hospital.

dBenefits for mental health problems, iwluding diagno~ble mental disorders, almost a~ays are more limit~ than for “physical” health problems. Benefits

are often subject to one or more of the following restrictions that are separate from other medical coverage: a limited allowance of hospital days (e.g., 30 per

lifetime) and/or number of outpatient visits, a maximum ceiling on total dollars reimbursed, a higher coinsurance rate (e.g., 50 percent), no ceiling on

out-of-pocket expenses, and a separate copayment or deductible.

e~nefi~ are ty~lly subj~t t. limitations s~h as sch~ul~ dollar allowa~ ad ded~ti~es, mpay~nts, and coinsurance requirements that are separate

from other covered benefits.

fsub~tana abuse beneflfs are almost a~ays more Iim it~ than for “physical” health problems. ~verage is usual~ subject to S(ipa@f3 lkTIitatiOnS including

a limited allowance of hospital days for detoxification or rehabilitation, a restricted number of outpatient visits, a maximum ceiling on total dollars reimbursed,

a higher coinsurance rate, no ceiling on out-of-pocket expenses, a separate copayment or deductible, and a separate lifetime maximum.

9.Some plans provide this care only to a patient who was previously hospitalized and is recovering without need of the extensive care provided by a general

hospital. D& not include hosp~e care.

SOURCE: Office of Technology Assessment, 1991.

any benefits are paid; although total out-of-pocket

expenses are often capped at a maximum less than

$2,000 per year (32).22 Once the insured’s covered

expenses exceed that amount, the health plan pays

for the full cost of any subsequent covered expenses.

HMO coverage is prepaid and members do not pay

deductibles or coinsurance although minimal outpatient visit copayments may be required.

Preventive Services--A number of preventive

services are typically recommended for adolescents:

routine physical examinations, immunizations, and

certain diagnostic tests (e.g,, hematocrit, urinalysis)

and preventive procedures including pap smears and

screening for sexually transmitted diseases for the

sexually active (62). The likelihood that an adolescent has preventive benefits depends largely on

whether he or she is enrolled in a conventional health

plan or HMO. Whether in an HMO or not, if routine

physical exams are a covered benefit, coverage may

be limited to a periodicity schedule such as that

recommended by the American Academy of Pediatrics.23 The 1988 Bureau of Labor Statistics survey

found that only 28 percent of all participants in

employer-sponsored group health plans were covered for routine physical exams, as compared with

99 percent of HMO members (84). Coverage rates

for immunizations and inoculations also varied by

the type of health plan: 29 percent for all participants

in group health plans and 99 percent for HMO

members (84).

Benefits for preventive diagnostic tests and procedures (e.g., pap smears, mammograms) are also

related to the type of health plan and, in conventional

health plans, may be linked to whether the insurer

2A deductible is a ~Wc~lc do~m ~oun~ us~y abut $4.00 Wr family, tit must& p~d ~fore a health plan begins paying benefits. COl?lSUranCe

payments are a spedled percentage, commonly 20 Percenc that the insured must pay for each covered medical service up to an annual limit (e.g., $ 1,500),

after which the health plan pays 100 percent of covered benefits (36,70).

~For a discussion of periodicity scheduIes for routine health assessments, see ch. 15, “Major Issues Pertaining to the Delivay of Primary and

Comprehensive Health Services to Adolescents, ” in this volume.
III-86 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

views the procedure as diagnostic. Coverage may

depend upon whether the physician “justifies” the

procedure with a specific suspected diagnosis.

Benefits for diagnostic laboratory tests are virtually

universal among medium and large employers (83).

In contrast, the Health Insurance Association of

America survey of employer-sponsored group

health insurance found more limited coverage of

preventive diagnostic procedures; coverage was

available in 61, 72, and 98 percent of conventional,

PPO, and HMO plans respectively (32).

Mental Health Care—Although coverage of

mental health services is often provided by employersponsored group health plans, the benefits for mental

health problems, including diagnosable mental disorders, are almost always more limited than for the

benefits of “physical” health problems (see table

16-4). While 98 percent of employees in group

health plans provided by medium and large employers have some inpatient and outpatient mental health

coverage, only 27 percent are covered for inpatient

mental health as for other illnesses and only 3

percent have equivalent mental and physical health

outpatient coverage (84). Mental health benefits are

often subject to one or more of the following

restrictions that are separate from other medical

coverage: a limited allowance of hospital days (e.g.,

30 per lifetime); a limited number of outpatient

visits; a maximum ceiling on total dollars reimbursed; a lower coinsurance rate (e.g., 50 percent);

no ceiling on out-of-pocket expenses; and a separate

copayment or deductible.

These benefit restrictions clearly have a major

impact on the use and overall cost of mental health

services (25). In fact, the amount of mental health

services and the settings in which they are provided

is often determined largely by the extent of reimbursable services (38). More details on benefit

limitations are described below.

Inpatient Care for Mental Health—Many mental

health professionals report that inpatient mental

health benefits significantly influence both hospital

admissions and length of stay (49). Mental health

inpatient stays are commonly limited to 30 or 60

days per year, compared with 120 or 365 days for

other hospital stays (84). Among participants in

employer-sponsored health plans with mental health

coverage, 45 percent had separate limitations on the

duration of a hospital stay for mental illness in 1988

(84).

Table 16-4-Coverage of Mental Health Care:

Percent of Full-Time Participants in Plans With

Coverage by Extent of Benefits, Medium and

Large Firms, 1988

Inpatient Outpatient

mental mental

Coverage limitation health care health care

With coverage . . . . . . . . . . . . . . . . . . . . . . . . 98%

Covered the same as other

illnesses . . . . . . . . . . . . . . . . . . . . . . . . . 27

Subject to separate Iimitationsa. . . . 

. 

. 71

Limit on days or visits . . . . . . . . . . . . 45

Per year . . . . . . . . . . . . . . . . . . . . . . 36

Per lifetime . . . . . . . . . . . . . . . . . . . . 2

Coinsurance limit . . . . . . . . . . . . . . . . . 8

50 percent . . . . . . . . . . . . . . . . . . . . . 4

Other b . . . . . . . . . . . . . . . . . . . . . . . . . 4

Ceiling on out-of-pocket expenses

does not apply . . . . . . . . . . . . . . . . . . . 13

Separate copayment or deductible . . . 1

Not covered . . . . . . . . . . . . . . . . . . . . . . . . . . 2

980/o

3

95

36

35—

62

49

14

43

14

2

Whe total is less than the sum of the individual items because many plans

had more than one type of limitation on mental health coverage.

b[nd~es pla~ with reduced cohsurance other than 50 percent and pkW3

where the rate of reimbursement varied during the treatment period,

SOURCE: U.S. Department of Labor, Bureau of Labor Statistics, Employee

Benet7Cs in kfeofwn and Large Fhns, Bulletin 2338 (Washington, DC: U.S. Government Printing Office, 1989).

There is some evidence that limiting the number

of allowable mental health days may affect adolescents and adults differently. One study of the

psychiatric claims of eight companies covered by

the same insurance carrier found that, given any use

of mental health services, children and adolescents

were much more likely than adults to be inpatient

users (38). They also had significantly longer

average lengths of stay, were more likely to have

very long lengths of stays, and had a greater chance

of incurring a catastrophically expensive psychiatric

claim (38). Whether existing mental health and

substance abuse benefits, which were designed

principally for adults, are appropriate for adolescents is not clear. In 1986, the Oregon Health

Planning and Development Agency was required by

statute to evaluate the effects of a 1983 State

mandate to provide insurance coverage of mental

health and chemical dependency treatment. The

planning agency concluded that the minimum benefit levels established for adults were ‘ ‘ wholly

inadequate for children and adolescents” (59). The

following year the Oregon legislature enacted a bill

requiring separate, higher benefit levels for children

and adolescents age 17 and younger (58).

Many observers are also concerned that mental

health benefits in private health plans that favor

inpatient over outpatient or community-based care
Chapter 16---Financial Access to Health Services ● III-87

have led to inappropriate hospitalizations and overutilization of inpatient services by some adolescents

(29).24 One particularly in-depth look at this issue

led the researcher to conclude in referring to

State-mandated mental health benefits that “the

policies of jurisdictions that seek to discourage

insurance-carrier discrimination against persons suffering from mental health problems may, in fact, be

perpetuating a pattern of financial incentives that is

detrimental to the well-being of the population they

seek to serve’ (86).

Partial Hospitalization—Partial hospitalization,

also known as day treatment, is an alternative to

traditional inpatient and outpatient care that provides adolescents an alternative to hospitalization

and a transitional level of mental health services

after discharge from an inpatient psychiatric unit or

residential treatment facility. It can be used for

adolescents who no longer need 24-hour care but are

not yet ready to reenter school (7). When partial

hospitalization is available, it can help avoid institutional placement. In 1986, less than 11 percent of

participants in employment-based health plans were

covered for partial hospitalization (4).25

Outpatient Care for Mental Health--Coverage

for outpatient mental health care may be limited in

a variety of ways. For more than 60 percent of

participants in health plans surveyed by the Bureau

of Labor Statistics in 1988, reimbursement for

outpatient mental health services may not exceed an

annual dollar maximum (e.g., $750 to $1,000) and a

coinsurance rate of 50 percent rather than the usual

20 percent per visit may be required. (The average

charge for a visit to a psychiatrist was $80 in 1986

(4).) Thirty-six percent of participants in employersponsored health plans surveyed by the Bureau of

Labor Statistics have an annual visit limit (84); more

than 84 percent with visit limits are allowed more

than 30 visits each year (4). An annual 50-visit

maximum is most common (70). Some plans also

limit visit fees (4,70). Combinations of any of these

restrictions are common. The most common effect of

such constraints is to cap total mental health

outpatient coverage at about $2,000 a year (70).

Eligible Mental Health Providers—Many health

plans may not cover mental health services that are

provided by nonphysicians. One employer survey

found that in 1987 only 15 percent of employers

provided plans that covered the services of psychologists and psychiatric social workers in addition to

psychiatrists (23).26 However, most plans accept

claims filed by a psychiatrist for services provided

by another mental health professional under his or

her supervision (23).

Annual and Lifetime Maximums-Annual and

lifetime ceilings on payment for mental health

services are a common feature of many health plans.

One survey found that, among employers who

limited payment for outpatient care, the average

reported lifetime outpatient payment maximum was

$20,000 (19). The Bureau of Labor Statistics survey

found that in 1988 health plans sometimes imposed

a lifetime maximum (e.g., $50,000) on all mental

health benefits (84).27 Lifetime limits on care for

other types of illness are not only more rare but also

significantly higher (e.g., $1 million maximum

reimbursement for all covered expenses) (32).

HMOs’ Mental Health Coverage—It is not known

how many adolescents belong to an HMO, but it is

likely that many young people rely on HMOs for

their mental health as well other health care needs.

In 1989, there were 491 HMOs with a total

enrollment of 34.7 million (30). Almost one out of

five people who are covered by a group health plan

belongs to an HMO (34). A 1985 HMO survey by

Interstudy found that almost all HMOs (99 percent)

provide some level of mental health coverage and

about one-quarter offer additional coverage at extra

cost (37).28 As they are in most conventional health

plans, mental health services in HMOs are strictly

controlled. The most common annual benefit limits

are 30 inpatient days and 20 outpatient visits (30) but

some have 30 inpatient days per lifetime. HMO

copayments, however, are much less burdensome

than those required by conventional health plans.

Out-of-pocket payments for inpatient care are rarely

required and outpatient copayments average only

$15 per visit (after five free visits) (46).

~For a discussion of inpatient mental health utilization by adolescents, SW Ch. 11, “Mentat Health problems: Prevention and Services, ” in Vol. II.

~This figure is based on American Psychiatric Association tabulations of the 1986 Bureau of Labor Statistics employee benefits survey.

26~~ he~& ~nefi~ ~umey ~a~ ~ond~~ted ~ 1987 by Fox H~~ po]icy consul~~ and ticluded 150 SIIMI1, medium and brge employers (23).

zT~s could easily be spent on 1 year of inpatient ~atment.

2$~e rnters~dy HMO sumey in~]~d~ 247 pl~ tit w~e opratio~ for more mI ya at tie end of 19:5 (40).
III-88 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Yet these relatively low fees may be countered by

other access controls. HMOs typically require a

primary care physician to approve of specialty

services, and more than three-quarters of the HMOs

surveyed by Interstudy require members to receive

primary care physician approval in order to gain

access to mental health services (40). Twenty-one

percent of the surveyed plans indicated taking a

careful screening approach to “limit entrance into

the HMO’s mental health system.” Nonetheless,

53 percent reported that they may permit selfreferral. When access is controlled by a prior

approval requirement, it is often limited to mental

health problems that the HMO provider considers

responsive to treatment within the benefit’s time

constraints. More than half of the surveyed Interstudy plans reported that they specifically exclude

treatment of chronic mental illness, long-term psychotherapy, and psychosexual disorders from basic

coverage. Another 17 percent also exclude eating

disorders (40).

Current Changes in Mental Health and Substance

Abuse Coverage Policy--It is important to recognize that employer and insurer attitudes toward

coverage of mental health and substance abuse

treatment (see below) are in flux, especially with

respect to adolescents. In the last decade, utilization

of benefits for mental health and substance abuse

care grew dramatically, particularly among adolescents (12).29 As benefits rapidly became widespreadcoverage for treatment of alcoholism almost doubled

from 36.2 percent of participants in employmentbased health plans in 1981 to 70 percent in 1986-

expenditures soared. Employers spent $207 per

employee for mental health benefits in 1988 (14).

One Blue Cross and Blue Shield plan, Independence

Blue Cross of Philadelphia, experienced a 57-

percent increase in admission rates for substance

abuse treatment in 2 years, while its expenditures for

inpatient substance abuse treatment increased more

than four times, from $4 million to $18.5 million (5).

Claims for mental health and substance abuse

treatment services can now make up as much as 15

to 20 percent of an employer’s health care dollarsmost of it for adolescents (6). One study of the health

insurance claims of a large corporation found that

60 percent of mental health expenditures were for

nonspouse dependents30 (64). A study examining

the experience of more than 200,000 employees

covered by Metropolitan Life Insurance found the

average expense per inpatient mental health admission for nonspouse dependents was $18,036 in 1988,

almost twice the cost for employees and their

spouses (12).31 Inpatient treatment costs for substance abuse were also substantially higher for

nonspouse dependents than for adults. As a result,

many employers and health insurers are reconsidering how and whether to cover mental health and

substance abuse treatment for dependents. A recent

survey of corporate benefits decisionmakers found

that more than half predicted restricting or excluding

coverage for dependent mental health or chemical

dependency illnesses (57).32

Substance Abuse Treatment 33—Although

health coverage for the treatment of alcoholism and

drug abuse has traditionally trailed behind coverage

for other illnesses, it has become much more widely

available in recent years. It wasn’t until the mid1960s that limited coverage for alcoholism treatment was offered by a few commercial health

insurers (50). Now the majority of participants in

group health plans have some level of substance

abuse benefits whether covered by a conventional

plan (87 percent), an HMO (98 percent), or a PPO

plan (93 percent) (32).

Coverage for both alcohol and drug abuse treatment, like that for mental health problems, is usually

subject to special limitations. Employer-sponsored

health plans most often cover short-term inpatient

detoxification and frequently cover inpatient rehabilitation and outpatient treatment as well, though

~or further discussion of adolescent mental health utilizatiorL see ch. 11, “Mental Health Problems: Prevention and Services, ” in Vol. IL

WNonspouse dependents were primarily children under 19 years who have never married but also included full-time college students age 19 to 24

and my unmarried dependents who were physically handicapped or mentally retarded.

slNonspou~ de~dents were found to be principally adolescents ages 11 to 19.

SZTMS Smey WaS conducted by the group insurance division of Northwestern National Life Insurance Co. and included 400 companies representing

3.9 million workers (57).

3qAdditio~ info~tion on substance abuse treatment is presented in ch. 12, “Alcohol, Tobacco, and Drug Abuse: Prevention and Services, ’ in Vol.

Il.
Chapter 16--Financial Access to Health Services . III-89

Table 16-5-Coverage of Alcohol Abuse Treatment: Percent of Full-Time Participants

in Plans With Coverage by Extent of Benefits, Medium and Large Firms, 1988

Inpatient Inpatient outpatient

Coverage limitation detoxification b rehabilitation a c carea d

With coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Covered the same as other illnesses. . . . . . . . . . . . . . . .

Covered the same as mental illness . . . . . . . . . . . . . . . .

Subject to separate Iimitationse . . . . . . . . . . . . . . . . . . . . .

Limit on days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Per year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Per confinement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Per lifetime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Limit on dollars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Per day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Per year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Per lifetime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Coinsurance Iimitf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ceiling on out-of-pocket expenses does not apply . . . .

Separate copayment or deductible . . . . . . . . . . . . . . . . . .

Other Iimitations

g 

...............................,..

Without coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

95%

29

7

59

46

26

18

15

21

1

9

16

6

4

1

1

78%

15

6

57

46

27

16

17

19

1

8

15

5

5

1

1

22

84%

17

18

49

24

24—

7

28

6

19

10

13

10

6

1

16

NOTE: Because of rounding, sums of individual items may not equal totals.

~erall, the Bureau of Labor Statist.ks estimates that 80 percent of full-time participants in health plans provided by

medium and large firms have alcohol abuse treatment benefits. The percents shown in this table apply to those

participants who have benefits. So, for example, 95 percent of the 80 percent of those participants who have alcohol

abuse benefits are covered for inpatient detoxification.

bDetoxif”~tion is the systemat.~ use of medication and other methods under medical Wptision to n3dUC0 or eliminate

the effects of substance abuse.

cRehabilitation is designed to alter abusive behavior in patients once they are fr~ of acute physical and mental

comdications.

%his’category includes treatment in one or more of the following: outpatient department of a hospital, residential

treatment center, organized outpatient clinic, day-night treatment center, or doctor’s office. If benefits differed by

location of treatment, doctor’s office care was tabulated.

ene total is [~sthan the sum of the individual items because some plans contained more than One type of Iim itation.

f~insuranm rate is lower than that applying to other medical Servi-s.

9This category includes plans where coverage was subject to overall deductibles or maximum dollar amounts that

differed from those for other medical services.

SOURCE: U.S. Department of bbor, Bureau of Labor Statistics, Emp/oyee Benefits in Mec#um and Large Firms,

Bulletin 2336 (Washington, DC: U.S, Government Printing Office, 1989).

not to the extent of other illnesses and almost always

with limitations (see tables 16-5 and 16-6).34 In

1988, among full-time participants in health plans

with drug or alcohol abuse coverage, approximately

95 percent had inpatient detoxification benefits,

about 78 percent had inpatient rehabilitation benefits, and 81 to 84 percent were covered for outpatient

care (84).

Although benefits for substance abuse treatment

may be subject to the same restrictions as mental

health care, they are most often provided under their

own separate limitations including a limited allowance of hospital days for detoxification or rehabilitation, a restricted number of outpatient visits, a

maximum ceiling on total dollars reimbursed, a

lower coinsurance rate, no ceiling on out-of-pocket

expenses, a separate copayment or deductible, and a

separate lifetime maximum. It appears that benefits

for alcohol and drug abuse treatment are very

similar; little difference in the scope of coverage for

the two can be found in the results of the Bureau of

Labor Statistics survey.

HMO benefits for alcohol and drug abuse treatment are as strictly controlled as they are for mental

health. Almost one-third of HMOs provide benefits

only for the strict purposes of detoxification and

emergency drug abuse care (46). Interstudy’s 1985

survey indicates that hospitalization, when provided

at all, is most commonly limited to 34 days for

alcohol and 36 days for drug abuse treatment (per

benefit period) (37). Most plans allow 28 outpatient

visits for alcohol abuse treatment while few report

specific limits on ambulatory drug-related care (40).

~Detomfication is tie ~steWtic U of m~ication and o~erme~@ under medical supervision to reduce or eliminate he effects of suM@ce abuse.

Rehubilifation is designed to alter abusive behavior in patients once they are free of acute physical and mental complications (84).

292-872 0 - 91 - 4 QL 3
III-90 . Adolescent Health--Volume III: Crosscutting issues in the Delivery of Health and Related Services

Table 16-6-Coverage of Drug Abuse Treatment: Percent of Full-Time Participants in

Plans With Coverage by Extent of Benefits, Medium and Large Firms, 1988

Inpatient Inpatient outpatient

Coverage limitation detoxification b rehabilitation c

carea d

With coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Covered the same as other illnesses . . . . . . . . . . . . . . . .

Covered the same as mental illness . . . . . . . . . . . . . . . .

Subject to separate limitations . . . . . . . . . . . . . . . . . . . . .

Limit on days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Per year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Per confinement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Per lifetime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Limit on dollars. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

per day . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .

Per year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Per lifetime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Coinsurance limitg

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ceiling on out-of-pocket expenses does not apply . . . .

Separate copayment or deductible . . . . . . . . . . . . . . . . . .

Other Iimitationsh

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Without coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

96%

28

7

61

47

26

18

15

21

—f

9

16

7

5

1

1

4

77%

13

6

58

46

27

17

16

19

7

16

6

5

1

1

23

81 %

17

18

46

21

20—

6

27

6

19

11

13

10

6

2

19

NOTE: Because of rounding, sums of individual items may not equal totais.

~erall, the Bureau of Labor Statistics estimates that 74 percent of full-time participants in health plans provided by

medium and large firms have drug abuse treatment benefits. The percents shown in this table apply to those

partiapants wtro have benefits. So, for example, 96 percent of the 74 percent of those participants who have drug

abuse benefits are cxwered for inpatient detoxification.

bDetoxif~tion is the :;ystematb use of medication and other methods under medical supervision to redUCS or eliminate

the effects of substamee abuse.

cRehabilitation is d~>igned to alter absive behavior in patients once they are frSe of acde physical and mental

complications.

%is category indudes treatment in one or more of the foilowing: outpatient department of a hospital, residential

treatment center, or~anizect outpatient clinic, day-night treatment center, or doctor’s office. If benefits differed by

location of treatment, doctor’s off ioe care was tabulated.

ene total is IeSS tharl the sum of the individual items because many plans had more than one type of limitation.

f~~ than 0.5 f39rC9nt.

9Coinsurance rate is lower than that applying to other medical services.

h~is ~tegoy iw[u~s plans where coverage was subject to overall deductibles or maximum doliar amounts that

differed from those for other meckal serv’kes.

SOURCE: U.S. Department of Labor, Bureau of Labor Statistics, Employee Benefits in Md”um and Large Firms,

Bulletin 2X36 (Washington, DC: U.S. Government Printing Office, 1989).

Maternity Care and Related Services35—Although private health insurance coverage of prenatal

and maternity care is generally comprehensive,

many privately insured adolescents are not eligible

for coverage, in part because of a ‘‘loophole’ in the

Pregnancy Discrimination Act of 1978 (Public Law

95-555).

Pregnancy and Childbirth--Since the enactment

of the Pregnancy Discrimination Act of 1978 (Public

Law 95-555), almost all employment-based health

plans provide maternity care benefits (35).36 The

Pregnancy Discrumination Act, which amends the

Civil Rights Act of 1964 (Public Law 88-352),

requires that employment-based health plans cover

pregnancy, childbirth, or related medical conditions

as they cover other medical care. Nevertheless,

approximately one-third of privately insured adolescents are not covered for maternity-related services

by their parents’ employment-based health plan

(1).

37 38

This situation is in part duetoa‘‘loophole’ in the

Pregnancy Discrimination Act that affects adolescent daughters of privately insured parents more

ssMaternjV care is used here to refer to prenatal, delivery, and postp- We.

36H~th ~vemge provid~ by small employers is ~exceptio~ appm ximately 11 percent of employee groups under 25 do not provide maternity care

benefits. The Pregnancy Discrimir@on Act does not extend to nongroup policies or employees of fm with 15 or fewer employees where maternity

coverage is often limited or not available at all (l).

37This es~te is wed on tie ~an Guttrnach@ Institute’s calculations of data ffom the 1984 Bureau of Labor Statistics survey of employee b3nefitS

in medium and large fins.

sg~ck of ~te~ty coverage ap~ars to be a critical issue for a si~lcant proportion of tie uninsured. One study found that 40 percent of hospital

patients who are self-paying or not billed for care are recipients of maternity care; how many are adolescents is not clear (61).
Chapter 16--Financial Access to Health Services . III-91

Photo reedit: March of Dimes Birth Defects Foundation

Approximately one-third of privately insured adolescents are not covered for maternity-related services by their

parents’ employment-based health plan.

than any other group.

39 The Pregnancy Discrimination Act’s regulations, in referring to dependents

other than spouses, state that employer-provided

health “insurance does not have to cover the

pregnancy-related conditions of other dependents”

(29 CFR 1985 ed. 1604, App.).

In many States, the loophole can be overridden in

cases of pregnancy complications. Twenty-six

States mandate that regardless of whether an individual has coverage for normal pregnancy, insurers

must cover pregnancy complications in the same

manner as any other illness (1).40 Thus, for an

ectopic pregnancy, for example, adolescent mothers

who are otherwise not eligible for maternity benefits

but are privately insured through a parent’s policy

can get coverage for necessary care. The States

typically provide some guidance to health plans as

39Note hat 10 s~t= ~~ol~, me, Mql~d, ~~chu~tts, Meso@ New Jmsey, New York OMO, Vi@r@ and Wisconsin) have !IMIl&td

tit the requirements of the Pregnancy Discrimination Act also extend to nonspouse dependents (e.g., adolescent mothers). (Virginia’ sma.ndate is limited

to children who have been raped or females under 13 years who have been victims of rape or incest.)

~ote that two States limit this requirement to group policies and two others limit it to nongroup policies (l).
III-92 . Adolescent Health-” Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

to what constitutes a complication of pregnancy but

case-by-case decisions are usually made by the

insurance carrier (l).

When a pregnant adolescent dependent has private health coverage for maternity care, she is not

treated differently from any other pregnant health

plan beneficiary. Maternity benefits are rarely subject to special limitations, but standard coinsurance

and deductibles are required. In some plans, the

number of postpartum hospital days may be restricted (l). In addition, some important tests and

procedures (e.g., Rho-gam,4] inpatient well-baby

care) may be excluded from coverage (l).

Waiting periods and preexisting condition exclusions may be required in some health plans and are

especially significant in maternity care given the

critical importance of early prenatal medical attention. Forty-five percent of employees of medium and

large firms are not eligible for health benefits until

after completing some period of service, usually 3

months or less (84). Consequently, adolescents who

become pregnant, before or shortly after a parent’s

job change, may not be covered for prenatal care, at

least during the first trimester of pregnancy.

Waiting periods for preexisting conditions can

also limit or even eliminate maternity coverage if

conception occurred previous to the effective date of

the health policy. The 1984 Bureau of Labor

Statistics survey found that almost 60 percent of

health plan participants were not covered for preexisting conditions for 10 or more months after health

coverage starts (l). It is not clear how many

adolescent mothers lose access to maternity coverage as a result.

It is important to note that the newborn infants of

privately insured adolescent mothers are especially

at risk for being uninsured. In 1987, the Alan

Guttmacher Institute surveyed Blue Cross and Blue

Shield plans and leading commercial insurers regarding maternity and newborn health coverage

(1)42 The survey’s results indicated that almost 70

percent of the health plans did not cover newborns

of nonspouse dependents (e.g., adolescent daughters). Thirty percent of the plans covered neither the

adolescent mother for her maternity-related care nor

her newborn.

Abortion Services--Although there are no data

describing private health coverage of abortion, it

appears that some health plans may exclude it. At

least eight States (i.e., Idaho, Kentucky, Minnesota,

Missouri, Nebraska, North Dakota, Pennsylvania,

and Rhode Island) have mandated some restriction

of private health insurance benefits for abortions

(33). Four States (i.e., Idaho, Kentucky, Missouri,

and North Dakota) require that coverage be provided

only on an optional basis and at extra cost.43

Nebraska, Pennsylvania, and Rhode Island prohibit

abortion coverage in health plans provided to public

employees; however, they allow exceptions when

the mother’s life is threatened.44 Pennsylvania and

Rhode Island also allow coverage for public employees in cases of rape or incest.45 Minnesota prohibits

a State mandate for HMO abortion coverage unless

the mother’s life is threatened (33).

The Pregnancy Discrimination Act does not

preclude coverage, but it specifically relieves employers of any obligation to provide abortion benefits “except where the life of the mother would be

endangered if the fetus were carried to term, or

except where medical complications have arisen

from an abortion” (Public Law 95-555). If abortion

coverage is provided, however, ‘‘the employer must

do so in the same manner and to the same degree as

it covers other medical conditions” (29 CFR 1985

ed. 1604, App.).

Each year since 1982, the Federal Government

has prohibited funding for abortion in the Federal

Employee Health Benefits Program except when the

life of the mother would be endangered if the fetus

41A ~ho.ga~ @o ~~e globufin imm~~tion) is fidi~t~ for M negative pre~t women to p~vent the fo~tion Of antibodies agtit the

fetus that can cause a miscarriage or stillbirth (l).

42~e Am Gumcher ~ti~te sWTey Wm conduct~ ~ e~ly 1987 ~d includd 100 lading commercial group health insurers ~d d] the Nation’s

Blue Cross and Blue Shield plans; the response rate was 73 percent (l).

ds~e pemylv~a re~ation rq~g ~ ~ditio~ pre~w for abofion covmage W~ feud to ~ unconstitutional h FMI~id COWI [American

College of Obstetricians v. Thornberg 737 F2d 283,303 [3rd Cir.1984]]. The State continues, however, to prohibit abortion as a “basic” benefit and

requires that coverage for induced abortions be offered only on an optional basis.

44A 1984 Feder~ co~ decision ~]ed tit mode Iskmd could not dir~t municip~itim from withholding funds for abortion coverage but the Stilte

may (and does) prohibit abortion coverage for State employees.

ds~ode Isl~d’s reW1ation m~bting that coverage be offered only as an optional benefit and at extra cost was struck down w mm~titutiontd by

a Federal court decisiow National Education Association of Rhode Island et al. v. J. Joseph Garrahy et a!. in 1984 (598 F. Supp.1374, 1984).
were carried to term (Public Law 100-202, Title V,

Sec. 517, 1987).

Contraception—Although health benefit survey

data do not provide specific details on family

planning coverage, some inferences can be drawn

from available information on preventive services

and prescription drugs. The typical adolescent family planning visit consists of several components,

including a pelvic examin ation, pap smear, sexually

transmitted disease screening, counseling, and possibly a prescription for a birth control drug or device.

Since private health plan benefits for routine physical exams and related tests are often not covered,

except in an HMO setting, it is less likely that such

a visit would be reimbursable unless the claim was

associated with a diagnosis (e.g., nonmenstrual

bleeding). The laboratory tests would always be

covered if they were interpreted by the insurer as

“diagnostic’ rather than preventive. Prescription

drug benefits are available to 93 percent of participants in employee-based health plans, Thus, most

privately insured adolescents probably have coverage for birth control pills. Whether birth control

devices (e.g., diaphragms) are covered by most

health plans is not known.

Dental Care-In 1988, 37 percent of participants

in employer-sponsored group health plans had

general dental care coverage and 27 percent were

covered for orthodontic expenses (32). Most of these

plans include benefits for preventive care, such as

routine examinations and X-rays, and restorative

procedures (e.g., fillings, periodontal care).

Dental benefits are typically provided with separate annual dollar maximums, deductibles, and

coinsurance requirements. In 1988, the most common annual maximum benefit was $1,000. Coinsurance requirements often depend on the type of

procedure. The less costly procedures (e.g., examinations, X-rays) are usually covered at a higher rate,

typically ranging from 80 to 100 percent of the

‘‘usual, customary, and reasonable’ charge (84).

Expensive procedures, including orthodontia, are

commonly limited to a 50-percent maximum. Payment for orthodontia is also frequently restricted to

a lifetime maximurn of no more than $1,000 per

child dependent (84).

Chapter 16--Financial Access to Health Services . III-93

Long-Term Care for the Chronically Ill or

Disabled—In 1987, a survey focusing on private

health insurance coverage of chronically ill children

younger than 18 years old was conducted for the first

time (24).46 The findings are summarized below.

Ancillary Services, Equipment, and Supplies—

The researchers concluded that the basic therapeutic

needs of chronically ill children are not always met

by employment-based health plans (24). Physical

therapy, speech therapy, and occupational therapy

were covered by 89 percent, 77 percent, and 57

percent, respectively, of the surveyed health plans.

In some benefit plans, these therapies were only

available for short-term rehabilitation purposes.

However, many ancillary medical services, such as

diagnostic X-ray and laboratory services, medical

supplies and medical equipment, and outpatient

prescription drugs were covered by more than 90

percent of the surveyed health plans. Benefits for

nutritionists’ services were rarely available and

coverage was restricted to physician prescriptions

for purposes other than weight loss or control.

Long-Term Care—Traditional benefits for longterm care, such as institutional care, visiting nurse,

and home health aide services are usually rather

limited if available at all (24). Most of the health

plans surveyed restrict the number of in-home nurse

and home health aide services; only one-third

provided for a limited stay in a skilled nursing home

facility. Yet health insurance coverage of high-cost

illnesses and conditions that require long-term

attention is evolving. Many insurers and employers

have introduced more comprehensive coverage that

includes skilled nursing, home health aides, physical

therapy, respiratory therapy, and benefits for medical social work, in order to contain the more

expensive costs of institutionalization. Sixty-nine

percent of the surveyed health plans took this

approach, although the number of covered visits for

most of the plans was limited to 90 visits per year.

Home care benefits are often provided as a substitute

for hospitalization and are usually not reimbursable

unless they help reduce or avoid a stay in a more

costly institution. Sometimes home care benefits are

provided only in order to cut short an ongoing

hospital stay.

~’IMS Sumey hcluded 150 employms including 50 small (O to 100 employees), 46 medium (101 to 500 employees), ~d 54 lmge (mom @500

employees) firms chosen at random from the Dun and Bradstmet U.S. Business Directory and the Business Insurance Direcfmy (24).
III-94 . Adolescent Health-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Some health plans reflect a new flexibility in the

coverage of costly chronic conditions and now

include provisions for ‘‘inclividual benefits management” (24). These new health plan provisions allow

for payment of otherwise uncovered home- and

community-based services as long as the total cost

of providing care is less than the cost of more

expensive covered services. Half of the surveyed

health plans either had such a program or allowed it

on a case-by-case basis when requested by a

physician or family member even if the provided

services were not explicitly covered.

Nonphysician Providers and Alternative Settings--Private health insurance coverage is principally oriented towards payment for physicians and

physician-supervised or physician-ordered services.

Data describing coverage of nonphysician providers

is sketchy at best. How nurse practitioners, psychologists, clinical social workers, drug addiction counselors, and other nonphysician health care providers

are paid for their services can be key to developing

additional low-cost community adolescent health

resources. While many States allow these providers

an expanded scope of practice, they may face

obstacles in getting direct reimbursement for their

services whether they practice in a traditional health

care setting or elsewhere. Although many States

mandate private health insurance coverage of some

nonphysician providers, especially psychologists,

social workers, nurse practitioners, and clinical

nurse midwives, it is not clear how many health

insurance plans allow for direct payment for their

services since a substantial percentage of employmentbased health coverage is free from State insurance

regulation (see earlier discussion of the Employee

Retirement and Income Security Act).

Medicaid Coverage 47 48 49

An estimated 4.58 million U.S. adolescents ages

10 through 18 had Medicaid coverage at some point

in time during fiscal year 1988.50 Although nearly all

adolescents with Medicaid coverage live in families

with incomes below the Federal poverty level, poor

adolescents are still more likely to be uninsured than

others. In fact, in calendar year 1988, one out of three

poor adolescents, more than 1.7 million overall, had

neither Medicaid nor private health insurance coverage. An additional 932,000 adolescents whose

families lived just above the poverty level (i.e., from

100 to 149 percent of the Federal poverty level) were

also without coverage.51

Instead of being regarded as a single program, the

Medicaid program may be more aptly described as

a confederation of 50 State programs, Although

Federal guidelines determine broad eligibility and

coverage criteria, each State designs and manages its

own Medicaid program. Consequently, eligibility

requirements, services offered, utilization limits,

and provider payment policies vary widely among

the States. How well Medicaid covers poor adolescents depends to a large extent on these Statespecific features and, thus, they are the focus of this

review. The State-specific information reported

here, unless noted otherwise, is based on a 1989

survey of State Medicaid benefits and eligibility

policies, conducted by Fox Health Policy Consultants and McManus Health Policy, Inc. (48).52

d7For ~ mom in.dep~ diwwslon mld review of tie ~mplex regulations governing Medicaid eligibility ~d coverage, see tie Medicaid Source Book:

Background Data and Analysis (69).

4SEveV Sttie but fizom p~cipates ~ tie Medic~d pro~~q ~ZOM provides f~e~ly tided mtical assistance through a demonstration

program that has received waivers of certain Medicaid requirements. The Arizom Medicaid program is not included in this review.

d~e Dis~ct of Columbia is included in my data 5 ummarizing State Medicaid programs.

%s estimate was developed for OTA by the Office of the Actuary, Health Care Financing Administration (HCFA), U.S. Depatrnent of Health and

Human Sewices, and includes all individuals ever-enrolled in fiscal year 1988. HCFA estimates that children in the AFDC program are enrolled for an

average of 9 months during a ftscal year (see app. C in this volume for details on HCFA’S method of estimation). In contrast, data from the March 1989

Current Population Survey, a household-based survey of noninstitutionalized persons, found that 2.% million adolescents had Medicaid coverage only

in calendar year 1988. An additional 23 to 25 percent had both Medicaid and private coverage in 1988 according to the Curnmt Population Survey.

51~5 nu~r is wed on e5~~e; ffom tie U.S. census BW~U’S hh1 $)89 @rrent Population Survey developed by Rickd IQonick for OTA

(45).

52~5 Me&~d -ey Wm ~pprt~ by a ~mt (# MCH-0635Q from the Bwtiu of Maternal md Child Health and Resources Developmen~ ~d

the Bureau of Health Care Delivery and Assistance, Health Resources and Services Adrninistratiow Public Health Service, U.S. Department of Health

and Human Semices. The survey was conducted by telephone in the spring of 1989 and focused on selected mandatory and optional Medicaid services

critical to adolescents. An attempt was made to interview each State’s director of Medicaid coverage policy. If that person was unavailable, a deputy

or other responsible individual was contacted. Draft summary tables of the survey findings were returned to the State Medicaid director for their review

and comment.
Chapter 16--Financial Access to Health Services . /11-95

Table 16-7—Estimated Medicaid Enrollment and Expenditures, by Age Group,

Fiscal Year 1988

Estimated

number of Average Estimated Percent

enrollees cost per expenditures

Age group

of total

(in millions) enrollee b

(in millions) program costsc

0-5d . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.048 $ 669 $4,046 8.40/’

6-14 . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.417 445 2,411 5.0

10-18 . . . . . . . . . . . . . . . . . . . . . . . . . . 4.583 725 3,322 6.9

15-20 . . . . . . . . . . . . . . . . . . . . . . . . . . 2,737 1,109 3,035 6.3

21-24 . . . . . . . . . . . . . . . . . . . . . . . . . . 6.642 1,939 12,879 26.6

45-64 . . . . . . . . . . . . . . . . . . . . . . . . . . 2.079 3,627 7,541 15.6

65 and over . . . . . . . . . . . . . . . . . . . . 3.779 4,899 18,513 38.2

All ages . . . . . . . . . . . . . . . . . . . . 26.702 $1,814 $48,425 100,070

aNumbers ofindividualsever enrolled in fisealyear 1988.

bCWts per enrollee were ~~ulated based on the number of individuals ever enrolled in Medieaid in fiscal year 1988.

cpercentages may not total 100 due to rounding.

din ~me sates, expenditures for newborn infants maybe assigned to the mother.

SOURCE: Off iee of Technology Assessment, 1991, based on unpublished HCFA-2082 data on Medieaid enrollment

and expenditures in fiscal year 1988 from the Off iee of the Actuary, Health Care Financing Administration,

U.S. Department of Health and Human serviees, Baltimore, MD, June 1990.

Throughout this review, it is critical that the

reader keep in mind that what is described are State

policies, not actual availability of services. It is well

established that despite the features of Medicaid that

have enabled some poor children and adolescents to

gain access to health care, this access is often

constrained by both Federal and State Medicaid

policies and requirements.

Who Pays for Medicaid?

Medicaid is a joint Federal-State entitlement

program and its costs are shared by Federal and State

governments. The Federal share in each State’s

Medicaid program ranges from 50 to 80 percent and

in fiscal year 1990 total expenditures were projected

to total approximately $70.5 billion (71). Federal

funds account for 56.9 percent of total Medicaid

program expenditures, an estimated $40.2 billion in

fiscal year 1990 (71).

Medicaid Expenditures on Adolescents53

Actual data on Medicaid expenditures for adolescents are not available. Using vendor payment data

from a sample of 35 States, however, the Health Care

Financing Administration (HCFA) has estimated

that fiscal year 1988 national Medicaid expenditures

for adolescents ages 10 to 18 totaled approximately

$3.322 billion; about 44 percent of this was spent on

10- to 14-year-olds and 56 percent on 15- to

18-year-olds (81). Overall, adolescents ages 10 to 18

made up 17.1 percent of Medicaid enrollment and

6.9 percent of overall Medicaid expenditures in

fiscal year 1988 (see table 16-7).

Table 16-8 shows the allocation of fiscal year

1988 Medicaid expenditures by type of service.

Hospital inpatient, physician services, and intermediate care facilities for the mentally retarded (ICF/

MR) accounted for more than half of all Medicaid

expenses incurred for adolescents. Although the

distribution of costs for younger adolescents (10- to

14-year-olds) v. older adolescents (15- to 18-yearolds) was similar, per enrollee expenditures were

almost three-quarters higher for older adolescents

than for the younger group, Per enrollee costs for

family planning, hospital inpatient, ICF/MR, home

health care, inpatient mental health, and physician

services were substantially higher for 15- to 18-yearolds than for younger adolescents.

Which Adolescents Are Eligible for Medicaid?

One reason that so many poor adolescents are not

covered by Medicaid is that eligibility has generally

been linked to participation in the AFDC cash

welfare program (69). AFDC eligibility hinges not

53~eSe ~StfiateS ~me developd by me OffICe of the Actq, Heal~ Ctie Fi~C~g ~fis~atlon (HCFA), us. Dep~ent of Health ~d Hum~

Services and were based on fiscat year 1988 HCFA-2082 (vendor payment) data for Alabama, Alaska, Arkansas, Colorado, District of Columbia, Floric@

Georgia, Idaho, Illinois, Iowa, Kansas, Imuisian~ Maine, Maryland, Massachusetts, Mississippi, Montana, Maine, Nevada, Ncw Jersey, New Mexico,

New York North Carolina, North Dakota, Ohio, Oklahom% Orego~ Rhode Island, South Carolina, South Dakot~ Tennessee, Texas, Ut@ Virgini~

and West Virginia (81 ). Enrollee data include all institutionalized and noninstitutionalized individuals ever enrolled in Medicaid during fiscal year 1988.

For further details regarding HCFA’S method of estimating Medicaid enrollees and expenditures, see app. C in this volume.
111-96. Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Table 16-8-Estimated Medicaid Expenditures on Adolescents Ages 10 to 14 and 15 to 18, by Type of Service,

Fiscal Year 1988

Estimated expenditures Estimated costs

(in millions) Percentage of total costsa

per enrolleeb

Type of service 10-14 15-18 10-18 10-14 15-18 10-18 10-14 15-18

Hospital (general)c . . . . . . . . . . . . . . . . . . . . . . . . . . $ 421 $ 667 $1,088 28.70/. 36.0% 32.8% $159 $346

Hospital (mental health) . . . . . . . . . . . . . . . . . . . . . 155 193 348 10.6 10.4 10.5 58 100

Intermediate care facility for the mentally

retarded (lCF/MR) . . . . . . . . . . . . . . . . . . . . . . . . . 145 252 397 9.9 13.6 12.0 55 131

Intermediate care facility/other . . . . . . . . . . . . . . . 7 4 11 0.5 0.2 0.3 3 2

Skilled nursing facility . . . . . . . . . . . . . . . . . . . . . . . . 29 30 59 2.0 1.6 1.8 11 15

Physician services . . . . . . . . . . . . . . . . . . . . . . . . . . 172 210 382 11.7 11.3 11.5 65 109

Dental services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 55 128 5.0 3.0 3.9 28 28

Other practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 19 44 1.7 1.0 1.3 10 10

Hospital outpatient. . . . . . . . . . . . . . . . . . . . . . . . . . 154 153 307 10.5 8.3 9.2 58 79

Clinic services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 53 116 4.3 2.9 3.5 24 28

Home health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 20 37 1.2 1.1 1.1 6 11

Family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 13 16 0.2 0.7 0.5 1 7

Lab/radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 36 64 1.9 1.9 1.9 11 18

Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 66 142 5.2 3.6 4.3 29 34

EPSDT d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 5 15 0.7 0.3 0.5 4 3

Rural health clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 2 —e —e —e 1 1

Other care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 6.1 4.1

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,468 $1,854 $3,322 100.0% 100.0% 100.0% $552 $963

apermntag~ may not total 100 because of rounding.

%sts per enrollee were esleulated using the followhg estimates of individuals ever enrolled in fiscal year 1988: 2.657 million lo-to 14-yeardds and 1.926

million 15- to 18-year-oids.

~his includes mental health stays in psychiatric units of general, acute care hospitals if the unit is not administratively separate for billing purposes.

dEady ad pefiod~ %eening, Diagnosis, and Treatment program benefit sCf*ning costs OnlY.

eL~s than 0.5 percent.

SOURCE: Office of Technolgy Assessment, 1991, based on estimates from unpublished HCFA-2082 data on Medicaid enrollment and expenditures in fiscal

year 1988from theoffiee of the Actuary, Health Care Financing Administration, U.S. Department of Health and Human !%rviees, Baltimore, MD,

June 1990.

only on whether family income and resources fall

within the State’s AFDC limits but also, with few

exceptions, on whether the family has a so-called

‘‘deprivation factor’ (i.e., at least one parentis dead,

disabled, continually absent from the home, or, as of

October 1990, in two-parent families whose principal breadwinner is unemployed).54

States have the option, under Federal law, to offer

Medicaid to “medically needy” children and adolescents when their family income and resources lie

above the AFDC need standards if they meet

AFDC’s categorical requirements (e.g., an absent

parent or disability). Thirty-seven States currently

operate medically needy programs (53). Each State

has the right to set its own medically needy

eligibility standards, provided they do not exceed

133.33 percent of the maximum AFDC assistance

thresholds for similarly sized families (see table

16-9). Through a spend-down provision, individuals

with incomes above the medically needy standard

also may become eligible if their medical expenses

are high enough to reduce their countable income

below the medically needy maximum. Those who

enter the program by ‘‘spending down” typically

have erratic access to Medicaid and may only be

eligible for a single accounting period (e.g., 6

months). If a State has a medically needy program,

it must provide participants all mandatory Medicaid

benefits and may elect to offer the same optional

benefits package available to the categorically needy

in the State.55 Most of the 37 States with medically

fi~e Ftily SUPPOII kt of 1988 @bLic IAW 100-485) requires Uuic starting (kt. 1, 1990, all States provide AFDC and Medicaid coverage to

families whose principal wage-earner is unemployed if they meet AFDC income and resource requirements. Coverage is limited, however, to 6 months

out of any 12-month period.

55’ ‘Categorically needy’ refers to those who are Medicaid-eligible by belonging to certain categories of poor people, such as those who am a member

of a family with dependent children where one parent is absentj incapacitated, or (in some States) unemployed.
Chapter 16--Financial Access to Health Services . III-97

Table 16-9-Annualized Income Thresholds for Medicaid Eligibility,a by State, January 1990

AFDC threshold for Percent of poverty level Medically needy threshold Percent of poverty level

States a family of 3 ($10,580’) for a family of 3C

($10,580b)

Alabama . . . . . . . . . . . . . . . . . . . . $ 1,416 13.4% NA NA

Alaska . . . . . . . . . . . . . . . . . . . . . . 10,152 76.9 NA NA

Arizona . . . . . . . . . . . . . . . . . . . . . 3,516 33.3 NA

Arkansas . . . . . . . . . . . . . . . . . . . 2,448 23.2 $ 3,300 31.370

California . . . . . . . . . . . . . . . . . . . 8,328 78.9 11,208 106.1

Colorado . . . . . . . . . . . . . . . . . . . . 5,052 47.8 NA NA

Connecticut . . . . . . . . . . . . . . . . . 6,660 63.1 8,856 83.9

Delaware . . . . . . . . . . . . . . . . . . . 3,996 37.8 NA NA

District of Columbia . . . . . . . . . . . 4,908 46.5 6,540 61.9

Florida . . . . . . . . . . . . . . . . . . . . . . 3,528 33.4 4,800 45.5

Georgia . . . . . . . . . . . . . . . . . . . . . 4,968 47.0 4,404 41.7

Hawaii . . . . . . . . . . . . . . . . . . . . . . 7,224 59.5 7,224 59.5

Idaho . . . . . . . . . . . . . . . . . . . . . . . 3,780 35.8 NA NA

Illinois . . . . . . . . . . . . . . . . . . . . . . 4,404 41.7 5,904 55.9

Indiana . . . . . . . . . . . . . . . . . . . . . 3,456 32.7 NA NA

lowa . . . . . . . . . . . . . . . . . . . . . . . 4,920 46.6 6,600 62.5

Kansas . . . . . . . . . . . . . . . . . . . . . 4,596 43.5 5,580 52.8

Kentucky . . . . . . . . . . . . . . . . . . . 6,312 59.8 3,696 35.0

Louisiana . . . . . . . . . . . . . . . . . . . 2,280 21.6 3,096 29.3

Maine . . . . . . . . . . . . . . . . . . . . . . 7,824 74.1 7,296 69,1

Maryland . . . . . . . . . . . . . . . . . . . . 4,752 45.0 5,508 52.2

Massachusetts . . . . . . . . . . . . . . 6,468 61.3 9,300 88.1

Michigan . . . . . . . . . . . . . . . . . . . . 6,900 65.3 6,660 83.1

Minnesota . . . . . . . . . . . . . . . . . . 6,384 60.5 8,508 80.6

Mississippi . . . . . . . . . . . . . . . . . . 4,416 41.8 NA NA

Missouri . . . . . . . . . . . . . . . . . . . . 3,468 32.8 NA NA

Montana . . . . . . . . . . . . . . . . . . . . 4,308 40.8 4,920 46.6

Nebraska . . . . . . . . . . . . . . . . . . . 4,368 41.4 5,904 55.9

Nevada . . . . . . . . . . . . . . . . . . . . . 3,960 37.5 NA NA

New Hampshire . . . . . . . . . . . . . . 7,116 67.4 6,072 57.5

New Jersey . . . . . . . . . . . . . . . . . . 5,088 48.2 6,792 64.3

New Mexico . . . . . . . . . . . . . . . . . 3,168 30.0 NA NA

New York . . . . . . . . . . . . . . . . . . . 7,476 70.8 8,508 80.6

North Carolina . . . . . . . . . . . . . . . 3,324 31.5 4,404 41.7

North Dakota. . . . . . . . . . . . . . . . 4,632 43.9 5,220 49.4

Ohio . . . . . . . . . . . . . . . . . . . . . . . 3,852 36.5 NA NA

Oklahoma . . . . . . . . . . . . . . . . . . . 5,652 53.5 5,196 49.2

Oregon . . . . . . . . . . . . . . . . . . . . . 5,184 49.1 6,900 65.3

Pennsylvania . . . . . . . . . . . . . . . . 5,052 47.8 5,604 53.1

Rhode Island . . . . . . . . . . . . . . . . 6,516 61.7 8,700 82.4

South Carolina. . . . . . . . . . . . . . . 5,028 47.6 3,300 31.3

South Dakota . . . . . . . . . . . . . . . . 4,524 42.8 NA NA

Tennessee . . . . . . . . . . . . . . . . . . 4,644 44.0 3,000 28.4

Texas . . . . . . . . . . . . . . . . . . . . . . 2,208 20.9 3,204 30.3

Utah . . . . . . . . . . . . . . . . . . . . . . . 6,192 58.6 6,192 58.6

Vermont . . . . . . . . . . . . . . . . . . . . 7,944 75.2 10,596 100.3

Virginia.. . . . . . . . . . . . . . . . . . . . 3,492 33.1 4,296 40.7

Washington . . . . . . . . . . . . . . . . . 6,012 56.9 7,188 68.1

West Virginia . . . . . . . . . . . . . . . . 2,988 28.3 3,480 33.0

Wisconsin . . . . . . . . . . . . . . . . . . . 6,204 58.8 8,268 78.3

Wyoming . . . . . . . . . . . . . . . . . . . . 4,320 40.9 NA

Average State . . . . . . . . . . . . . $5,008 46.9% $ 6,114 57.7%

NA-notapplicable; the State does notcover themadicalty needy under its Medicaid program.

~heterm ’’threshold” refers tothat income Iimitthattruly drives program eligibility. inmost States, this is the payment standard. lnColorado, Georgia,

Kentucky, Maine,Michigan, Mississipp~ Oklahoma,South Carolina, Tennessee, andUtah, thethreshold istheState’sneed standard. Please note,inthese

IOStates,thethresholdthatappears on thetableisnotwhatthe State paystoAFDCrcdpients.These States’ paymentstandardsare actually significantly

Iowerthan the eligibility threshold.

%heFederaIpovertyievelforafamily ofthree is$10,580inallStatesbutAlaska and Hawaiiwherethelevelsarehighe~ Alaskafamilyofthree-$13,200;

Hawaii family ofthree=$12,150.

~he’’medicallyneedy’’arenotcovered inAlabama,Alaska,Arizona,Colorado, Delaware, ldaho, lndiana, Mississipp~ Missouri, Nevada,New Mexico,Ohio,

South Dakota, and Wyoming.

SOURCE: National Governors’ Association, ’’MCH Update-State Coverage of Pregnant Women and Children:’ Washington, DC,January 1990.
III-98 . Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

needy programs provide participants the full range

of Medicaid benefits offered in their State (80).56

Eligibility for Medicaid among poor adolescents

varies a great deal among the States because income

and resource standards for the AFDC and medically

needy programs are determined by the individual

States. In many States, the standards underlying

eligibility are quite stringent. In the South, as noted

earlier in the discussion on uninsured adolescents, it

appears that more stringent income eligibility requirements are key to that region’s greater proportion of uninsured adolescents.57

As of January 1990, very few State AFDC and

medically needy income standards approached Federal poverty levels and many fell short of 50 percent

of the Federal poverty guideline of $10,560 for a

family of three (see table 16-9).58 Annual AFDC

Medicaid eligibility thresholds for a family of three

range from a low of $1,416 in Alabama to a high of

$8,328 in California (53).59 In many cases, the States

have failed to adjust the AFDC income standards for

inflation and, consequently, the income threshold as

a percentage of poverty has been eroded substantially, from an average of 71 percent in 1975 to 47

percent in January 1990 (51). Whether all States

would be able to bear the burden of improving

eligibility requirements, without further Federal

assistance, is unclear.

The Medicaid link with AFDC participation is the

Primary, but not the only, way to establish Medicaid

eligibility. Under Federal law, in addition to providing mandatory Medicaid coverage of AFDC recipients, States may also choose to cover children who

meet the AFDC program’s income and resource

requirements but are without a “deprivation factor”—

e.g., adolescents who live in a financially needy

two-parent family.60 Thirty-four States have implemented this option.61 62 The Family Support Act of

1988 (Public Law 100-485) requires that, starting

October 1, 1990, all States must provide AFDC

coverage to families whose principal wage earner is

unemployed if they meet the income and resource

requirements of AFDC eligibility.

Congress has acted in recent years to sever the

eligibility link between Medicaid and AFDC for

pregnant women and young children. But with the

exception of some pregnant adolescents, today’s

generation of poor adolescents have not benefited

from these reforms. The most recent Medicaid

eligibility reform occurred in the Omnibus Budget

Reconciliation Act of 1990 (OBRA-90) (Public Law

101-508) and required States to provide Medicaid

coverage to all children ages 6 to 19, born after

September 30, 1983, with family incomes up to 100

percent of the Federal poverty level. In the previous

year, the Omnibus Budget Reconciliation Act of

1989 (OBRA-89) (Public Law 101-239) required

that as of April 1, 1990, States provide Medicaid

benefits to all pregnant women and children up to

age 6 with family incomes up to 133 percent of the

Federal poverty level. (See box 16-B for a summary

of OBRA-89 and OBRA-90’s Medicaid provisions

affecting adolescents.) Earlier legislation gave

States the option to extend Medicaid eligibility up to

185 percent of poverty for pregnant women, and 15

States have done this;63 and another 4 States have

fi~en~.~o Sh(es prOVi& tie full range: CaMo@ Comedicut, District of Columbi& GeorgiA Hawtdi, Illinois, KMNM, Kentucky, W,

Maryland, Massachusetts, Michigan, Minneso@ Montana, Nebraska, New Hampshire, New York North Carom North Dakota, lkxas, Vermont, and

West Virginia (80),

ST~e U.S. BU.WN of tie Census; defines Southern States as Alab~ Arkansas, Delaware, Florida, Georgi% Kentucky, huisti,-~d,

Mississippi, North Carol@ Oklahoma, South Carob lkmessee, T&as, Virginia, and West Virginia (77).

sg~ order t. ~ e~gible for AFDC paymen~ and automatically eligible for Medicaid, a family must pass two iIICOXIK tCNS: a gTOSS inCOme test ~d

a‘ ‘countable’ income test. Gross monthly income cannot exceed 185 percent of the State’s need standard. Countable income must be less than the State’s

need standard allowing for child care costs up to $160 per child and a standard allowance of $75 per month. AFDC recipients are allowed an additional

“income disregard” as an incentive to return to or enter the workforce (69).

5~e eli@bi~~ ~mhold ~ -a is eva ~@er (i.e., $10,152), but MS is not Cornpuable (0 the thresholds in the contiguous 48 States. The Federal

Government has established separate poverty levels for both Alaska and Hawaii because of their unique economic conditions.

~~ten refe~ed to ~ “Wbicoff cw~n” after former Senator Ribicoff, the sponSor Of 1e@Slation rill?hOril@ COverage fOr MS grOup.

bl~e 3.4 s~tm me Nmti, klUWISaS, morr@ Connecticu~ District of Columbi4 FIori@ Georg@ Hawaii, Illinois, Iowa, -as, KmtuckY,

Maine, Maryland, Massachusetts, Michig@ Minna o@ Mississippi, Missouri, Nebras@ New Jersey, New York+ North Caroliruu North Dakom Ohio,

Oklahoma, Pennsylvania, South CaroliruL lknnessee, ‘Ikxas, Utah, Vermon4 Virginia, and Wisconsin.

62S~tes my choo~ t. extend categroric~y needy cove~e (0 o~ergroups of ~-rela(~persons; for greater detail see tie~edicaid~ourceBook:

Background Data and Analysis (69). ‘

63~e 15 Smte5 me ~o~ Colmaticut, fiwfii, Iowa,u,al~d, ~~chuset~, hlichig~ Minnesota, Mississippi, New York Rhode

Island, South Carolina, Vermon4 and Washington.
Chapter 16--Financial Access to Health Services . III-99

Box 16-B—Provisions of the Omnibus Budget Reconciliation Acts of 1989 and 1990 That Affect

Medicaid Coverage of Adolescent

Me&aid Eligibility

. States must extend Medicaid eligibility to all pregnant women and children and to children up to age 6 with

family incomes up to 133 percent of the Federal poverty level (i.e., the poverty level is $10,560 for a family

of three). (OBRA-89)

● States must extend Medicaid eligibility to all children ages 6 to 19, who were born after September 30, 1983,

and whose family incomes are up to 100 percent of the Federal poverty level.2 (OBRA-90)

Medicaid Coverage

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) (OBRA-89)

● Any State Medicaid coverage limitations on diagnosis or treatment are eliminated for health conditions

identified during the course of an EPSDT screen as long as the services are within the limits of Federal

Medicaid guidelines and are deemed medically necessary.

● States are required to provide periodic screens at intervals which meet reasonable standards of medical and

dental practice as determined by the State after consultation with recognized medical and dental

organizations. Unscheduled screenings must be permitted if medically necessary.

. Screening services must include health education and anticipatory guidance.

● Vision, hearing, and dental services must be provided, each according to its own periodicity schedule that

meets reasonable practice standards.

Pediatric and Family Nurse Practitioners (OBRA-89)

. State Medicaid programs must cover certified pediatric and family nurse practitioners to the extent that they

are legally authorized by State law to provide services, even if they are not practicing under the supervision

of, or associated with, a physician or other provider.3

Physician Payment (OBRA-89)

● States must submit annual plans specifying Medicaid payment rates for obstetrical and pediatric services for

the Secretary’s review, and in 1992 average Medicaid payments for specific obstetric and pediatric

procedures must be reported

● The Physician payment Review Commission must examine the adequacy of physician payment, physician

participation, and access to care by Medicaid beneficiaries and report to Congress by July 1,1991.

Medicaid and Private Insurance (OBRA-89)

● Requires States to pay group health insurance premiums with Medicaid funds, if cost effective, for

individuals or families with one Medicaid eligible member (whose incomes are below the Federal poverty

level) if they are eligible for such insurance coverage.4

Other Provisions

● States must cover the ambulatory services of community health centers, migrant health centers, and health

care for the homeless programs receiving funds under sections 329,330, or 340 of the Public Health Service

Act, and must reimburse these services at 100 percent of reasonable cost. Health center services must include

physician services, physician assistant and nurse practitioner services (to the extent allowed by State law),

clinical psychologist services, and clinical social worker services. (OBRA-89)

● The Secretary is directed to Conduct demonstration projects in several States to assess ways of extending

Medicaid coverage, or alternative coverage, to pregnant women and children up to age 20 who are otherwise

ineligible for Medicaid and whose family incomes are below 185 percent of poverty. Alternative coverage

may include, but is not limited to, such options as enrollment under employer plans, the State’s plan for its

own employees, a State uninsured plan, or an HMO. (OBRA-89)

1~ ~mvisiom of ~o~~ Budg~ R~~~tion ~t of 1989 ~b~c ~W 101-239) mm Mtik.dd eligibility or Wbecame effective Apr. 1, 1990, unless noted otherwise.

2~~ ~VMon of & ~~Badget R@o@~fjo~ ~t of 1990 @b~c ~W lol-5~) becomes effective Ju]y 1, 1991, ~d W] &

phased in over 10 years.

-s provision became efkcdve July 1,1990,

4’Ihis provision became effective Jan. 1, 1991. Continued on next page
111-100 . Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Box 16-B—Provisions of the Omnibus Budget Reconciliation Acts of 1989 and 1990 That Affect

Medicaid Coverage of Adolescents-Continued

. The Secretary is directed to conduct up to four demonstration projects to test innovative methods of

providing health insurance to medically uninsurable children underage 19. (OBRA-89)

. The Secretary is directed to conduct 3-year demonstration projects in three four States to provide Medicaid

to families with incomes below 150 percent of poverty who are currently ineligible for Medicaid

(OBRA-90). Each project must begin no later than July 1,1991.

SOURCE: 1989 provisions: Commerce Clearinghouse, Inc., “omnibus Budget Reconciliation Act of 1989, Explanation of the Conference

CommiWX ~ecting Medicare Medicaid Program” Medicare and A4edicaid Guide, vol. 3 (Chicago, IL: Dec. 1S, 1989); 1990

provisions: U.S. Congress, House of Representatives, “Omr.ubu “ s Budget Reconciliation Act of 1990, Confercnec Report 101-964”

(Washington, DC: U.S. Government Printing Off@ 1990).

raised the income eligibility limit to 150 percent of

Poverty64 (53).

Federal law also dictates that children and adolescents under age 21 are eligible for Medicaid if they

are in foster care under Title IV-E of the Social

Security Act. In addition, every State but New

Hampshire has extended Medicaid coverage to blind

or disabled children and adolescents receiving cash

assistance from the Supplemental Security Income

(SSI) program. States have the option of Limiting

coverage of SSI recipients by requiring them to meet

more restrictive eligibility standards although 42

States cover all disabled adolescents who receive

Federal SSI cash assistance (21).

Although adolescents principally gain access to

Medicaid through their parents, some, especially

poor pregnant or parenting adolescent females, may

establish eligibility on their own. Total numbers are

not available; however, among adolescents ages 10

to 18 who received AFDC benefits in fiscal year

1987, approximately 5 percent participated in AFDC

(and presumably Medicaid as well) as an “adult” or

head of household (78). Overall, more than 110,000

female adolescents and almost 11,000 males were

‘‘adult’ AFDC recipients that year.

What Medicaid Coverage Provides

As noted earlier, each State defines not only the

eligible Medicaid populatiom it serves but also its

own Medicaid benefit package (within broad Federal guidelines). All States are required to offer a

core group of services, referred to as ‘‘mandatory, ’

including but not limited to inpatient and outpatient

hospital services, laboratory and radiology services,

physician services, clinical nurse midwife services, 65 certified pediatric and family nurse practitioner services, family planning services and supplies, 66 and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services for children

and adolescents under age 21 (see table 16-10).

In addition, Federal law permits State Medicaid

programs, at their discretion, to provide a range of

‘‘optional’ services to the categorically needy,

including clinic services, dental services, physical

therapy, occupational therapy, speech pathology and

audiology, rehabilitative services, case management, inpatient psychiatric services for persons

under age 21, other licensed practitioner services

(such as psychologists), and prescription drugs (see

table 16-10),

Although a Medicaid card appears to entitle a

poor adolescent to a rather expansive package of

health benefits, States can and do establish strict

limits on the frequency and number of covered

services regardless of whether they are mandatory or

optional benefits. In addition, States may impose

utilization control measures to ensure that services

are medically necessary. Under Medicaid, ‘‘a serv-

~~e fo~ States are Florida, Kansas, North CaroLiM, and West Virginia.

s5~&toV nmse midwife semic(:s are w~tever services the nurse midwife is authorized to practice under State law or reWla60n.

66 Mandator/ family Plarming services and supplies include services and supplies for women of childbearing age, including sexually active minors

who desire such services and supplies. Abortions are excluded f~om family pl arming services, and Federal Medicaid matching payments for abortions

have been limited, by language in the IJ.S. Department of Health and Human Services’ appropriations bills, to cases where the life of the mother is in

danger (69).
Chapter 16-Financial Access to Health Services ● III-101

Table 16-10-Mandatory and Optional Services

Covered Under Medicaid

Mandatory services

Inpatient hospital services

Outpatient hospital services

Physician services

Early and Periodic Screening, Diagnosis, and Treatment

services for children under age 21

Family planning services and supplies

Laboratory and X-ray procedures

Skilled nursing facility and home health care services for adults

(i.e., 21 years and older)

Rural health clinic services

Services of certified nurse-midwives, pediatric and family nurse

practitioners

Community health centers, migrant health centers, and health

care for the homeless program~receiving funds under sections

329, 330, or 340 of the Public Health Service Act

Optional services

●

●

●

●

●

●

●

●

●

●

●

●

*

—

Case management

Additional home health services

Dental services

Services of other licensed practitioners, including psychologists, chiropractors, optometrists, and podiatrists

Clinic services

Other diagnostic, screening, preventive, and rehabilitative

services

Prescription drugs

Intermediate care facility services, including intermediate care

facility services for the mentally retarded

Eyeglasses, prosthetic devices, dentures, and orthopedic

shoes

Home and skilled nursing facility care for children

Private duty nursing

Inpatient psychiatric care for children under age 21

Physical, occupational, and speech, hearing, and language

disorder therapies

Other medical or remedial care recognized under State law,

including personal care in the home, transportation, and

emergency services, skilled nursing facility for children under

age 21, Christian Science nurses and sanitariums, hospice

care services, respiratory care service

aTothe extent they are authorized to practica under State law or regulation.

SOURCE: U.S. Department of Health and Human Serviees, Health Care

Financing Administration, Division of Intergovernmental Affairs,

Med”ca\d Serwkes State by State, HCFA Pub No. 02155-90

(Washington, DC: U.S. Govermnent Printing Office, October

19S9).

ice is medically necessary if it is reasonably

calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that

endanger life, cause suffering or pain, result in

illness or infirmity, threaten to cause or aggravate a

handicap, or cause physical deformity or malfunction, and if there is no other equally effective

(although more conservative or less costly) course of

treatment available or suitable for the recipient

requesting the service” (10).

State Medicaid benefits of particular relevance to

adolescents—including the EPSDT benefit, physician services, nurse practitioner services, hospital

outpatient services, school-based clinics, mental

health care services, and substance abuse treatment—

are reviewed below.

The Early and Periodic Screening, Diagnosis,

and Treatment (EPSDT) Benefit-As part of

OBRA-89 (Public Law 101-239), Congress significantly expanded adolescents’ and other children’s

access to Medicaid-covered services by reforming

the EPSDT program.67

States are mandated by the Federal law to

periodically screen

68 Medicaid-eligible adolescents

for any illnesses, abnormalities, or treatable conditions and refer them for definitive treatment. Screens

must contain certain key components, including the

following:

●

●

●

*

●

comprehensive health and developmental history (including assessment of both physical and

mental health development),

comprehensive unclothed physical exam,

appropriate immunizations according to age

and health history,

laboratory tests, and

health education (including anticipatory guidance) (42 CFR 441.56(a)).

Vision, hearing, and dental services must be provided as well, each according to its own periodicity

schedule that meets reasonable practice standards.

The EPSDT benefit is, in effect, the Nation’s

largest preventive health program for children and

adolescents (68). The OBRA-89 amendments dramatically broadened Medicaid coverage of children

and adolescents by essentially eliminating any State

Medicaid limitations on diagnosis or treatment for

any health condition identified during the course of

an EPSDT screen as long as the services are within

the limits of Federal Medicaid guidelines and are

deemed medically necessary. Services provided

under EPSDT must be sufficient in amount, duration, or scope to reasonably achieve their purpose;

however, States are permitted to set “appropriate”

limits on EPSDT services based on medical necessity (79). The act further aims to improve access to

bTThe EPSDT ~endmen~ became effective Apr. 1, 1990.

@see det~ls on the periodicity schedule bdow.
III-102 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Table 16-11—EPSDT Screening Costs, by Age Group, Fiscal Year 1988

Estimated number Estimated total

of enrollees Average screening expenditures

Age group (in millions) cost per enrollee (in millions)

0-5 . . . . . . . . . . . . . . . . . . . 6.048 $15 $90.7 (72.00/o)

6-14 . . . . . . . . . . . . . . . . . . 5.417 5 27.1 (21.5%)

10-14 . . . . . . . . . . . . . . . . . 2.657 4 10.6 (8.4%)

15-18 . . . . . . . . . . . . . . . . . 1.926 3 5.8 (4.60A)

15-20 . . . . . . . . . . . . . . . . . 2.737 3 8.2 (6.5%)

Overall

(20 and under) . . . . . . . 14.202 $9 $126.0 (100%)

SOURCE: Office clf Technology Assessment, 1991, based on estimates from unpublished HCFA-2082 data on

Medicaid enrollment and expenditures in fiscal year 1988 from the Office of the Actuary, Health Care

Financing Administration, U.S. Department of Health and Human SeMces, Baltimore, MD, June 1990.

EPSDT by expanding the pool of eligible EPSDT

providers and permitting more frequent screenings.

Here is an example of the potential of EPSDT to

go beyond the limitations of a State’s Medicaid

program:

A 14-year-old boy receives an EPSDT health

screen and evidence of cocaine use is detected. After

intense questioning, the boy admits to regular use of

cocaine and his parents agree to have him enter a

drug detoxification and counseling program. Under

the State plan, the only drug treatment Medicaid will

reimburse is heroin detoxification, Medicaid now

would be obligated to reimburse for the boy’s

detoxification and counseling program to the extent

it is medically necessary since the need for the

treatment was discovered during the EPSDT screen

(20).

Clearly, the potential for providing comprehensive health services using EPSDT will not be fully

realized, however, if adolescent Medicaid recipients

do not get screened. Although the EPSDT program

has been shown to improve children’s health and

reduce health care costs, however, use of EPSDT

services by children of all ages is extremely low,

especially in rural areas (82), Average program

expenditures were only $9 per Medicaid enrollee up

to age 20, in fiscal year 1988, and were directed

largely towards younger children. HCFA estimates

that while, in fiscal year 1988, average per enrollee

expenditures for EPSDT screening were $15 per

child under age 5, they were only $4 for adolescents

ages 10 to 14 and $3 for adolescents ages 15 to 18

(see table 16-11). If all eligible children were

screened by the EPSDT program, the costs would be

higher. overall, approximately 72 percent of HCFA

expenditures for EPSDT screening have been for

O-to 5-year-olds. In addition, although EPSDT was

intended to encompass mental as well as physical

assessment, it has tended to be more concerned with

the identification and treatment of physical problems (19).

The broad sweep of the OBRA-89 reforms led one

policy analyst to conclude that ‘‘the potential of this

legislation both to improve the health status of poor

adolescents and to stretch the limits of State

Medicaid programs is great” (54). However, the

statute comes ‘‘at a time when the Federal Government is requiring States to shoulder more and more

of the burden of health care financing” (54). There

is reason to be concerned about the States’ capacities

to assume these new responsibilities. Medicaid

programs now consume an average 14 percent of

States’ budgets, up from 9 percent in 1980 (43).

EPSDT Screening Schedules-OBRA-89 codifies the periodic nature of EPSDT services and

requires that screens be provided at intervals which

meet reasonable standards of medical and dental

practice as determined by the State after consultation

with recognized medical and dental organizations

(79). It also requires that any medically necessary

interperiodic screening service be covered. But little

is known about what health screening periodicity is

most appropriate and effective for poor adolescents,

especially those at high risk for the common

morbidities of adolescence.

The American Academy of Pediatrics recommends that, from ages 10 to 18, adolescents should

be screened five times (2). The U.S. Preventive

Services Task Force concluded that, from the ages of

7 to 18, except for routine pap smears for sexually

active girls from ages 13 to 18, and a tetanusdiphtheria booster between 14 and 16 years, the

scheduling of additional visits and the frequency of

individual preventive services should be left to
Chapter 16--Financial Access to Health Services . ///-103

Table 16-12—EPSDT Periodicity Schedules in State Medicaid Programs

Number of EPSDT scheduled

State screenings for ages 10 to 21

Number of EPSDT scheduled

State screenings for ages 10 to 21

States that offer fewer than five

scheduled EPSDT screens:

Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . .

Arkansas . . . . . . . . . . . . . . . . . . . . . . . . .

California. . . . . . . . . . . . . . . . . . . . . ., , .

Colorado . . . . . . . . . . . . . . . . . . . . . . . . .

Connecticut . . . . . . . . . . . . . . . . . . . . . . .

District of Columbia . . . . . . . . . . . . . . . . .

Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . . .

lowa . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kansas . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kentucky . . . . . . . . . . . . . . . . . . . . . . . . .

Louisiana . . . . . . . . . . . . . . . . . . . . . . . . .

Mississippi . . . . . . . . . . . . . . . . . . . . . . .

Missouri . . . . . . . . . . . . . . . . . . . . . . . . . .

Montana . . . . . . . . . . . . . . . . . . . . . . . . . .

Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . .

New Hampshire . . . . . . . . . . . . . . . . . . .

New Jersey . . . . . . . . . . . . . . . . . . . . . . .

New Mexico . . . . . . . . . . . . . . . . . . . . . . .

North Carolina . . . . . . . . . . . . . . . . . . . .

Oklahoma . . . . . . . . . . . . . . . . . . . . . . . . .

South Carolina. . . . . . . . . . . . . . . . . . . . .

South Dakota . . . . . . . . . . . . . . . . . . . . . .

Tennessee . . . . . . . . . . . . . . . . . . . . . . . .

Texas . . . . . . . . . . . . . . . . . . . . . . . . . . .

Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Virginia . . . . . . . . . . . . . . . . . . . . . . . . . .

Wyoming . . . . . . . . . . . . . . . . . . . . . . . . .

4

3

3

4

4

3

1

3

4

4

4

3

4

3

3

3

3

3

4

2

3

3

3

2

3

3

3

States that offer five or more

scheduled EPSDT screens:

Alabama . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Delaware ....., . . . . . . . . . . . . . . . . . . . 6

Florida . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Hawaii . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Illinois . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Indiana . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Maine . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Maryland . . . . . . . . . . . . . . . . . . . . . . . . . 11

Massachusetts . . . . . . . . . . . . . . . . . . . . 6

Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Nebraska . . . . . . . . . . . . . . . . . . . . . . . . 5

New York . . . . . . . . . . . . . . . . . . . . . . . . . 6

North Dakota . . . . . . . . . . . . . . . . . . . . . 11

Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Oregon . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Pennsylvania . . . . . . . . . . . . . . . . . . . . . . 6

Rhode Island . . . . . . . . . . . . . . . . . . . . . 6

Vermont . . . . . . . . . . . . . . . . . . . . . . . . . 6

Washington . . . . . . . . . . . . . . . . . . . . . . . 10

West Virginia . . . . . . . . . . . . . . . . . . . . . . 7

Wisconsin..... . . . . . . . . . . . . . . . . . . . . 6

States that schedule as many EPSDT screens

as medically necessary:

Minnesota . . . . . . . . . . . . . . . . . . . . . . . . NA

NA.notappliible.

SOURCE: P.McManus, H.Fox,P.Newatiwk,etal,un~bhshd&tafromal989suweyofSateMdtitipr~rms,sup~fldbyagrant(#MCH463~)

fromthe Bureauof Maternal and Child Health and Resources Developmen~ and the Bureau ofHealth Care Delivery and Assistance, Health

Resources and Services Administration, Public Health Service, U.S. Department ofHealthand Human Services, Rockville, MD,1989.

clinical discretion because of lack of data and

differing patient risk profiles (85).69

In 1989, State EPSDT periodicity schedules

varied widely. Twenty-two States covered five or

more EPSDT visits for adolescents and young adults

ages 10 to 21 (see table 16-12). Maryland, North

Dakota, Ohio, and Washington State covered annual

EPSDT visits compared with only minimal allowances for one or two preventive visits from ages 10

to 21 in Idaho, 0klahoma, Texas, and Wyoming.

Minnesota covers as many EPSDT visits “as

medically necessary.”

Partial EPSDT Screening---OBRA-89 also clarifies that Statesman not restrict ’’partial screeners.”

This means that the use of all types of providers is

now encouraged and those who are qualified to

furnish only one EPSDT service cannot be prevented

from participating in the program (79). In the past,

many States accepted only those providers able to

perform “complete” EPSDT screens. Here is an

illustration of how this provision might make

EPSDT screening services more available to adolescents:

A teenage girl visits a Planned Parenthood clinic

for information on birth control methods. She has no

regular primary care physician. Although the clinic

does not provide vision or hearing services, it has

been certified as an EPSDT screening provider for

the purposes of furnishing the comprehensive health

and developmental screening component. As a

result, the girl is able to obtain a partial EPSDT

screening service at the same time she receives

family planning services (20).

It is important to note that because of the recent

expansion in the EPSDT program, State Medicaid

@Issues regarding the cost-effectivenessof particular periodicityschedules for younger children were addressed indepthin a 1988 OTAstudy, Heahhy

Children: lnvesrirrg in the Fufure (73).
III-104 . Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

program limits on the physician and other services

described below only apply to conditions that are

not discovered by EPSDT screening services.

Physician Services-Although all State Medicaid programs are required by Federal law to cover

physician services, many States restrict visits to

physicians. States may place limits on settings

where Medicaid recipients’ care can be provided, on

the number of visits, and the types of physician

services to be covered. Table 16-13 displays each

State Medicaid program’s coverage of and restrictions on physician services.70 In 1989, nine States

imposed some ceiling on the annual number of office

visits to physicians, ranging from 12 to 24 visits per

year. Six States did not permit more than one or two

physician visits per day; two others set monthly visit

limits. Five States require prior authorization for

additional physician care after a specified number of

visits.

Services of Nurse Practitioners and Other

Nonphysician Providers--Whether a State Medicaid program covers nonphysician providers can be

key to the development of community resources for

adolescent health care. Many school-linked and

community-based health centers are staffed principally by nurse practitioners and other nonphysician

providers.71 Under OBRA-89, starting July 1, 1990,

State Medicaid programs must cover certified pediatric and family nurse practitioners to the extent that

they are legally authorized by State law to provide

services, even if they are not practicing under the

supervision of, or associated with, a physician or

other provider. Thirty-one States currently recognize nurse practitioners in statute or regulation and

grant them an expanded scope of practice beyond

that of registered nurses (20), but nurse practitioners’ legal scope of practice, and the extent of

physician supervision they must receive, vary from

State to State. Since HCFA regulations are not yet

available and only seven States (Florida, Idaho,

Kansas, Montana, New Hampshire, Nevada, and

Washington) covered nurse practitioners previous to

OBRA-89, it is not clear what Medicaid restrictions

will be placed on their services.

Forty-five States allow services provided by

physician-supervised office staff (e.g., registered

nurses) to be reimbursed as a physician service. So,

for example, an adolescent’s visit for a routine

allergy shot given by a physician’s nurse can be

covered under Medicaid as a physician office visit.

Seventeen States exclude physician-supervised

speech and other ancillary therapists from the

Medicaid program (see table 16-13).

States use a variety of other regulations to govern

Medicaid coverage of physician-supervised health

providers. Almost half of the 49 States that covered

physician-supervised services in 1989 required that

the physician be on the premises. Six States required

that the physician have direct contact with the

patient. Other States used different definitions of

physician supervision.

Clinic Services, Including Those of SchoolLinked Health Centers72—Although States are not

required by Federal law to cover clinic services

under Medicaid, all but three do (Mississippi, Rhode

Island, and Wisconsin). States may limit the types of

clinics whose services they cover and may include or

exclude school-linked health centers, community

mental health centers, and substance abuse clinics,

among others.73

In 1989, only two States--Connecticut and Illinoispermitted school-linked health centers to be authorized Medicaid clinic providers. Even though they are

not specifically cited as qualified clinics in a State

Medicaid plan, however, school-linked health centers in the other 48 States may receive Medicaid

reimbursement. Some of them may receive Medicaid reimbursement because they have been set up as

a satellite to an outpatient hospital department or

other type of clinic (e.g., rural health clinic or a

community health center). School-linked health

centers may also receive Medicaid reimbursement

through physicians or other qualified providers,

mote that services provided by psychiatrists are subject to separate limitations in 13 States; see discussion of coverage for mental health and substance

abuse treatment below.

TIFor a &xussion of school-l~ed health centers, see ch. 15, ‘ ‘Major Issues Pertainhg to the Delivery of Primary and Comprehensive HAth Cae

Services to Adolescents, ” in this volume.

VzC/inic sem”ces me defined under Medicaid to include preventive, diagnostic, therapeutic, rehabilitative, or p~iatiVe itemS Or SerViCeS tht~

provided to outpatients under direction of a physician or dentist without regard to whether the clinic itself is administered by a physician (69). Clinics

providing covered services may provide general health care services or may focus on specific Sen?ices, for example, mental health senices (69).

Tssee Ch. 15, ‘‘MaJorlssues p ti~ to the Delivery of Primary and Comprehensive Health Services to Adolescents,” in this volume for mom details

on the fucing of school-linked he+ilttt centers.
Chapter 16--Financial Access to Health Services ● ///-105

Table 16-13-Coverage of and Restrictions on Physicians’ and Physician-Supervised Services

in State Medicaid Programs, 1989

Physician-supervised care

Other practitioners

Limits on Prohibited (e.g., physician assistants,

State office visitsa

settings Off ice nursesa

ancillary therapists)a b

Alabama . . . . . . . . . . . . . . . . . . . . . . . . . .

Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . .

Arkansas . . . . . . . . . . . . . . . . . . . . . . . . .

California. . . . . . . . . . . . . . . . . . . . . . . . .

Colorado . . . . . . . . . . . . . . . . . . . . . . . . .

Connecticut . . . . . . . . . . . . . . . . . . . . . . .

Delaware . . . . . . . . . . . . . . . . . . . . . . . . .

District of Columbia . . . . . . . . . . . . . . . . .

Florida . . . . . . . . . . . . . . . . . . . . . . . . . . .

Georgia . . . . . . . . . . . . . . . . . . . . . . . . . .

Hawaii . . . . . . . . . . . . . . . . . . . . . . . . . . .

Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Illinois . . . . . . . . . . . . . . . . . . . . . . . . . . .

Indiana . . . . . . . . . . . . . . . . . . . . . . . . . . .

Iowa . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kansas . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kentucky . . . . . . . . . . . . . . . . . . . . . . . . .

Louisiana . . . . . . . . . . . . . . . . . . . . . . . . .

Maine . . . . . . . . . . . . . . . . . . . . . . . . . . .

Maryland . . . . . . . . . . . . . . . . . . . . . . . . .

Massachusetts . . . . . . . . . . . . . . . . . . . .

Michigan . . . . . . . . . . . . . . . . . . . . . . . . . .

Minnesota . . . . . . . . . . . . . . . . . . . . . . . .

Mississippi . . . . . . . . . . . . . . . . . . . . . . .

Missouri . . . . . . . . . . . . . . . . . . . . . . . . . .

Montana . . . . . . . . . . . . . . . . . . . . . . . . . .

Nebraska . . . . . . . . . . . . . . . . . . . . . . . .

Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . .

New Hampshire . . . . . . . . . . . . . . . . . . .

New Jersey . . . . . . . . . . . . . . . . . . . . . . .

New Mexico . . . . . . . . . . . . . . . . . . . . . . .

New York . . . . . . . . . . . . . . . . . . . . . . . . .

North Carolina . . . . . . . . . . . . . . . . . . . .

North Dakota . . . . . . . . . . . . . . . . . . . . .

Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Oklahoma . . . . . . . . . . . . . . . . . . . . . . . . .

Oregon . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pennsylvania . . . . . . . . . . . . . . . . . . . . . .

Rhode Island . . . . . . . . . . . . . . . . . . . . .

South Carolina.. . . . . . . . . . . . . . . . . . . .

South Dakota... . . . . . . . . . . . . . . . . . . .

Tennessee . . . . . . . . . . . . . . . . . . . . . . . .

Texas . . . . . . . . . . . . . . . . . . . . . . . . . . .

Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Vermont . . . . . . . . . . . . . . . . . . . . . . . . .

Virginia . . . . . . . . . . . . . . . . . . . . . . . . . .

Washington . . . . . . . . . . . . . . . . . . . . . . .

West Virginia . . . . . . . . . . . . . . . . . . . . . .

Wisconsin . . . . . . . . . . . . . . . . . . . . . . . . .

Wyoming . . . . . . . . . . . . . . . . . . . . . . . . .

12 visits/year

—

12 visits/yearc

—

—

—

.

—

—

—e

—

—

—

—e

—

12 visits/year

—

12 visits/year

—e

1 visit/day

1 visit/day

—

—

12 visits/year

—

—

—

—e

18 visits/year

—

—

—

24 visits/yearf

—

IO visits/month

4 visits/month

2 visits/day

—

—

18 visits/year

—

24 visits/year

—

l visit/day

—0

—

I visit/day

1 visit/day

—

—

—

—

School, day care

—

—

—

—

School,day care,

and other

School, day care,

and other —

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

School

—

—

—

School, day care

—

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

No

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

No

Yesd

Yes

No

Yes d

No

No

No

No

Yes

Yes

No

No

Yes

Yes

Yesd

Yesd

Yesd

No

Yesd

Yes

Yesd

Yes

No

Yesd

Yesd

Yes

No

Yes

Yesd

Yes

Yesd

Yes

No

No

Yesd

No

Yes

Yes

Yesd

Yes

Yesd

No

Yesd

Yesd

No

Yes

Yes

KEY: —= None;Yes.covered; No.notcmvered.

aEp.sDT tisltsarenot subjecttolimits.

bOBRA-89ma~at~ State Med~aidcoverage ofcertified pediatric andfamily nurse practitioners starting July f,19W.

cFora~ physichn and hospital outpatient services.

donlysomelmensed Practitioners covered under physician supervision.

epfior authorization is rwuirad afteracertain numbarofvisits have been made.

fForall@ys~ian, hospital outpatient, and dinicservices.

SOIJRCE: P,McManus,H.Fox, P. Newacheck,etal.,unpublished datafrom a1989surveyofState Medicaidprograms,supportadbyagrant (#MCH463500)

fromthe Bureauof Maternal and Child Health and Resources Development and the Bureau of Health Care Delivery and Assistance, Health

Resources and Services Administration, Public Health Service, U.S. Departmentof Health and Human Services, Rockville, MD,1989.
III-106 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

including nurse practitioners, that practice at the

clinic, as long as the State does not restrict billing in

a school setting. Five States (Arkansas, District of

Columbia, Florida, Utah, and Wisconsin) prohibit

Medicaid reimbursement for physician services

provided in school settings (see table 16-13).

It is not clear to what extent school-linked health

centers have established the billing systems necessary to collect Medicaid reimbursement. Numerous

administrative obstacles have been cited by some

school-linked health centers trying to bill Medicaid

for their services, including: difficulty in establishing eligibility of students and obtaining their Medicaid numbers; problems in obtaining provider certification; delays in the reimbursement process and low

reimbursement rates; and problems maintaining

patient confidentiality (161).

Hospital Outpatient Service--State Medicaid

programs are required to cover preventive, diagnostic, therapeutic, rehabilitative, or palliative services

provided in a hospital outpatient setting by or under

the direction of a physician or dentist. In 1989, seven

States imposed some limit on the annual number of

hospital outpatient visits, ranging from 3 to 30 visits

per year (see table 16-14). Florida set a $1,000

ceiling on outpatients and Oklahoma and the District

of Columbia restricted daily outpatient visits to one

and two per day, respectively. More than half (i.e.,

27) of the States require prior authorization for some

hospital outpatient services and 13 States impose

ceilings on mental health or ancillary services, such

aS physical, occupational, and speech therapies.

Mental Health Care74--States have considerable flexibility in establishing the nature and extent of

mental health services available to Medicaid recipients (66). As in private health insurance coverage,

mental health care provided under Medicaid is often

constrained by separate and more stringent limits on

cost and utilization. The incentives in private mental

health benefits to hospitalize patients rather than use

nonhospital settings for care also appear to exist in

Medicaid. Some argue that Medicaid payment

policies appear to discourage less costly treatment

alternatives because Medicaid reimbursement rates

come closer to covering costs for inpatient care than

for outpatient services (63).

Inpatient Mental Health Care—Mental health

stays in general hospitals are covered by Medicaid

programs in all the States (69). Coverage of inpatient

stays in freestanding psychiatric facilities is available for children and adolescents under age 21 in 38

States (almost three out of four) (80),75 but only 10

of these 38 States permit residential treatment

centers and other special psychiatric facilities that

are not specifically certified as psychiatric facilities

by the Joint Commission on Accreditation of

Healthcare Organizations to be reimbursed under

Medicaid. Inpatient mental health treatment, regardless of the setting, is typically subject to separate,

stricter limits on length of stay compared with care

for “physical” health problems. Federal law requires precertification that inpatient services are

necessary and can be reasonably expected to improve the patient’s condition so that ultimately such

services will no longer be necessary (69).

Partial Hospitalization—Partial hospitalization

is an often important way of allowing adolescents

with mental health problems to spend longer amounts

of time (usually 4 hours per day) in a treatment

setting (19). Eighteen States cover partial hospitalization, most with no day limits. Some States do not

permit partial hospitalization in freestanding psychiatric facilities (19).

Outpatient Mental Health Care—How Medicaid

covers outpatient mental health care depends on

whether services are provided in a hospital outpatient setting, clinic, or physician or other health

provider’s office. In 40 States, mental health visits

are covered in a general hospital outpatient setting

and are usually subject to visit or dollar limits and

prior authorization requirements. Twenty-one States

cover outpatient mental health services in psychiatric hospitals. Few States restrict the type of therapy

used (i.e., individual therapy).

As noted earlier, all but three States cover clinic

services. Community mental health centers can

74A more de~~ review of State Medicaid coverage of mental health and substance abuse will be available in m upmming repofi pl’ep=~ by FOX,

McManus, Wicks, et al., for the AlcolIo~ Drug Abusep and Mental Health A&rm.I “ “stration in the U.S. Department of Health and Human Services (22).

The sections on mental health and substance abuse presented here are based largely on a summary of this report.

75~e 38 Smtes ~~ab+ ~lq ArkxIs~, GliforK@ Colorado, Connecticut, District of Columbi& Hliwl@ IUiflOis, rndiu IOw4 -X,

Kentucky, Jmuisx Maine, Maryland, Massachusetts, Michigaq Minnesota, Missou@ MonW Nebrask New Jersey, New York North Caroli.q

North DakoQ Ohio, Oklahoma, Oregom Pennsylvan@ Rhode Island, South Carolixq ‘Ikmessee, Utah+ Vermont Washington West VirginiA and

Wisconsin.
Chapter 16--Financial Access to Health Services . III-107

Table 16-14-Coverage of and Restrictions on Hospital Outpatient Services in

State Medicaid Programs, 1989°

Separate limits for some Prior

Limits on services (e.g., mental health,

State

authorization

basic coverage ancillary therapies) requiredb

Alabama . . . . . . . . . . . . . . . . .

Alaska . . . . . . . . . . . . . . . . . . .

Arkansas . . . . . . . . . . . . . . . .

California .............,..

Colorado . . . . . . . . . . . . . . . .

Connecticut . . . . . . . . . . . . . .

Delaware . . . . . . . . . . . . . . . .

District of Columbia . . . . . . .

Florida . . . . . . . . . . . . . . . . . . .

Georgia . . . . . . . . . . . . . . . . . .

Hawaii . . . . . . . . . . . . . . . . . . .

Idaho . . . . . . . . . . . . . . . . . . . .

Illinois . . . . . . . . . . . . . . . . . . .

Indiana . . . . . . . . . . . . . . . . . .

Iowa . . . . . . . . . . . . . . . . . . . . .

Kansas . . . . . . . . . . . . . . . . . .

Kentucky . . . . . . . . . . . . . . . .

Louisiana . . . . . . . . . . . . . . . .

Maine . . . . . . . . . . . . . . . . . . .

Maryland . . . . . . . . . . . . . . . .

Massachusetts. . . . . . . . . . .

Michigan . . . . . . . . . . . . . . . . .

Minnesota . . . . . . . . . . . . . . .

Mississippi . . . . . . . . . . . . . .

Missouri . . . . . . . . . . . . . . . . .

Montana . . . . . . . . . . . . . . . . .

Nebraska . . . . . . . . . . . . . . . .

Nevada . . . . . . . . . . . . . . . . . .

New Hampshire . . . . . . . . . .

New Jersey . . . . . . . . . . . . . .

New Mexico . . . . . . . . . . . . .

New York . . . . . . . . . . . . . . . .

North Carolina. . . . . . . . . . .

North Dakota . . . . . . . . . . . .

Ohio . . . . . . . . . . . . . . . . . . . . .

Oklahoma ... ..... ...0...

Oregon . . . . . . . . . . . . . . . . . .

Pennsylvania . . . . . . . . . . . .

Rhode Island . . . . . . . . . . . .

South Carolina . . . . . . . . . . .

South Dakota . . . . . . . . . . . .

Tennessee . . . . . . . . . . . . . . .

Texas . . . . . . . . . . . . . . . . . . .

Utah . . . . . . . . . . . . . . . . . . . . .

Vermont . . . . . . . . . . . . . . . . .

Virginia . . . . . . . . . . . . . . . . . .

Washington . . . . . . . . . . . . . .

West Virginia . . . . . . . . . . . . .

Wisconsin . . . . . . . . . . . . . . .

Wyoming . . . . . . . . . . . . . . . .

Total . . . . . . . . . . . . . . . . . . . .

3 visits/year — —

— x x

12 visits/yearc

—

— —

x

x

x

x

x

—

— —

—

2 visits/day

$1,000/year

— —

—

x

x

—

— —

— —

— x — — —

x

x

—

—

— —

—

x

—

—

—

—

—

— —

—

—

x

x

x

x

x

—

x

x

x

x

x

x

—

— —

— —

6 visits/year —

—

—

—

—

—

12 visits/year

—

x

—

x

—

x

—

—

24 visits/yeard

— — —

— x x

l visit/day — —

x

x

x

—

—

— x —

—

—

—

30 visits/year —

x

—

x

x

Xe

—

—

—

—

x

x

—

—

—

—

x—

—

9 13 27

aHospitalo~patient limits do not apply to services provided under EPSDT.

bp~orauthoflzation rquires advame approval forsome~r~~s ~~onafinding ofm~ical necessity.

cAJ]outpat~ent hospital and physician servkm.

dAlioutpatient hospita~clin&, and physician services.

epriorauthorizatlon requiredto exceed aiirnit.

SOURCE:P. McManus, H. Fox, P. Newacheck, etal, unpublished data from a 1989 survey of State Medicaid

programs, supported by agrant (# MCH-063500) from the Bureau of Maternal and Child Health and

Resources Development and the Bureau of Health Care Delivery andAssistance, Health Resourcesand

Services Administration, Public Health Service, U.S. Department of Health and Human Services, Rockville,

MD, 1989.
III-108 . Adolescent Health-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

qualify as Medicaid clinics and may provide adolescents the same wide range of mental health services

that might be available in a hospital outpatient

setting, but in a somewhat less institutionalized

atmosphere (19). Benefits in this setting may include

assessment/diagnosis; individual, group or family

therapy; psychological testing; medication monitoring; and crisis intervention. In 1989, 38 States

covered outpatient care provided in a community

mental health center; 24 States allowed care in a

private mental health center. Services are typically

subject to prior authorization or ceilings on visits or

dollars spent.

Eligible Providers—Although all States cover

physician care, in one out of four States, visits to

psychiatrists are subject to separate and more

restrictive office visit limits that range from 12 to 48

visits per year. Many State Medicaid programs

confine their outpatient mental heath benefits to

services provided by or under the supervision of

psychiatrists.76 Almost half of all States do not cover

nonphysician mental health providers, such as psychologists and clinical social workers, even if their

services are provided under a psychiatrist supervision. State Medicaid programs that cover independent psychologists usually restrict reimbursement to

an outpatient office or clinic setting. Independent

clinical social workers are reimbursed by Medicaid

only in Massachusetts and Montana.

One survey of State mental health coverage found

that 38 State Medicaid programs allowed at least two

mental health visits per week at either a hospital

outpatient or clinic setting (19). Of these 38 States,

most covered weekly visits to psychiatrists, most

offered partial hospitalization, and some provided

psychologists’ services; none reimbursed all three.

Substance Abuse Treatment-As in mental

health care, States often set strict limits on Medicaid

benefits for substance abuse treatment.

Inpatient Substance Abuse Treatment—All but

four States cover alcoholism and drug treatment

services in a general hospital inpatient setting.

Thirty-four States that cover mental health stays in

psychiatric facilities also allow treatment for substance abuse. As for mental health care, however,

only 10 of these States allow substance abuse

Photo credit: Sasha Bruce Youth Network, Inc., Washington, DC

Almost half of all State Medicaid programs do not

cover nonphysician mental health providers, such as

psychologists and clinical social workers, even if their

services are provided under a psychiatrist’s supervision.

treatment in residential treatment centers and other

special psychiatric facilities that are not certified by

the Joint Commission on Accreditation of

Healthcare Organizations. As many as two-thirds of

all States providing substance abuse inpatient care

restrict coverage to detoxification only. Five States

cover partial hospitalization for treatment of substance abuse usually with restrictions on length of

stay.

Outpatient Substance Abuse Treatment—Thirty

States cover visits to an outpatient hospital department for substance abuse, usually subject to limits

on utilization and cost. Twelve States cover outpatient treatment in drug or alcohol abuse clinics.

Care may also be covered in community mental

health centers.

Physician Reimbursement and Participation

Under Medicaid

Even if a poor adolescent holds a Medicaid card

that represents a rather rich package of potential

health benefits, finding a private physician willing to

see Medicaid patients can be a significant problem,

especially among some medical specialties and in

certain geographic areas (73). Low payment rates,

76Nonphysici~ men~ hdth providers fa~ similar restrictions in the Medicare program. with one ex~ption (a ~irement Of the WbUS Budget

Reconciliation Act of 1987 (Public Law 100-203) that stipulates direct payment of psychologists providing services in community mental health centers),

Medicare does not allow direct payment of psychologists or any other nonphysician mental health provider (18).
Chapter 16-Financial Access to Health Services . /1/-109

Table 16-15-Factors Cited by Pediatricians as “Very Important” to

Decision To Participate in Medicaid

Percent of pediatricians citing factor

as very important

1978 1983 1989 Percent change

Factors N = 814 N = 791 N = 940 1978-89

Low payments . . . . . . . . . . . . . . . . . . . . . . . . . . . 59.7 66.5 70.9” 1 8.8%

Unpredictable payments . . . . . . . . . . . . . . . . . . 41.3 52.4 53.4” 29.3

Complex regulations . . . . . . . . . . . . . . . . . . . . . . 38.6 46.3 47.5’ 23.1

Payment delays . . . . . . . . . . . . . . . . . . . . . . . . . . 34.1 34.8 43.4” 27.3

Covered services . . . . . . . . . . . . . . . . . . . . . . . . . 26.1 31.0 39.8’ 52,5

Program regulations . . . . . . . . . . . . . . . . . . . . . . 29.4 32.8 38.8” 32,0

Paperwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.7 35.8 38.7b14.8

Broken appointments . . . . . . . . . . . . . . . . . . . . . 29.0 31.1 30.2 4.1

Type of patient . . . . . . . . . . . . . . . . . . . . . . . . . . NA 14.8 12.9 -12.8

Few Medicaid eligibles . . . . . . . . . . . . . . . . . . . . NA 5.0 4.3 –14.0

NA- not available.

aP<o,ol.

bP<o.05.

SOURCE: B. Yudkowsky,J.Cartland, and S. FlinL ’’Pediatrician Participation inMedicaid:’ Pediafrics8~4):567-577,

1990. Reprinted with permission.

administrative burdens, and other factors often

discourage physicians from participating in Medicaid.

While research has shown that national physician

surveys probably overstate the rate of physician

participation in Medicaid, data from these surveys

do help identify the specialties and geographic areas

where participation is relatively low (73). Overall

participation is particularly low among two specialties that are particularly important to adolescents,

obstetrics/gynecology (OB/GYN) and psychiatry.

Although current data are not available, in 1984 only

60 percent of psychiatrists and 72 percent of

OB/GYNs accepted any Medicaid patients at all

(73). Given that in recent years many OB/GYNs

have withdrawn from obstetrics practice because of

malpractice concerns, their Medicaid participation

may have declined as well, especially for high-risk

patients (52).

A recent survey conducted by the American

Academy of Pediatrics found that the proportion of

pediatricians saying that they were willing “to see

at least some Medicaid patients’ declined from 85

percent in 1978 to 77 percent in 1989 (87). Fortyfour percent of the surveyed pediatricians reported

that they either had refused or limited their availability to care for children with Medicaid coverage in

1989.

Administrative difficulties involved in filing

claims for Medicaid reimbursement has consistently

been shown to result in lower Medicaid physician

participation (52). In the American Academy of

Pediatrics survey, pediatricians were asked to identify which factors were ‘‘very important” reasons

for choosing not to participate or to limit their

participation in Medicaid. More than 70 percent

cited ‘‘low reimbursement’ and roughly half also

noted “unpredictable payments’ and ‘‘complex

regulations’ as a deterrent to their willingness to

treat Medicaid children (see table 16-15).77 Other

studies have shown that physicians may find that

Medicaid patients require more time and support

than others and that they are less likely to follow

medical advice (69).

Federal Medicaid rules do not impose specific

physician payment methods on State Medicaid

programs; Federal rules require only that Medicaid’s

physician payment level not exceed that paid by the

Medicare program for the elderly and that it remain

high enough to ensure reasonable access (75).

Medicare sets physician payment levels at the 75th

percentile of the customary charges in a given locale.

Most Medicaid programs use fixed fee schedules

that are unrelated to provider charges (69). Medicare

permits physicians to bill the patient for charges

higher than the Medicare rate, but Medicaid does not

allow this. Medicaid reimbursement rates not only

vary widely by State but are often far lower than

?7B=aux of ~rovldem’ obvious ve5t~ ~ter=t iII hprovhgpayment mtes, provider surveys inquiring about ‘lOW refibursement’ should ~ view~

with some caution.
III-11O . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

what Medicare reimburses providers. In 1986, for

example, maximum Medicaid payment levels for

brief followup visits ranged from $6.00 in New

Hampshire to $28.41 in Alaska (see table 16-16). As

a proportion of local Medicare payment rates,

Medicaid fees for followup visits varied from 33

percent in Michigan to 125 percent in Tennessee

(69).

Until recently, there has been little effort by the

Federal Government to monitor the effect of State

Medicaid payment policies on access to care and the

availability of qualified providers (75). OBRA-89

took several steps to address this concern. It

incorporates into statute the Medicaid regulation

requiring that Medicaid payments for all practitioners be ‘‘sufficient to enlist enough providers so that

care and services are available under the plan at least

to the extent that such care and services are available

to the general population in the geographic area”

(11). Yet it should be noted that HCFA staff have

described this regulation as an unenforceable “feel

good rule” because adequate access is not clearly

defined and there is no objective standard for

measuring conformity with the law (20). However,

States must submit annual plans specifying Medicaid payment rates for obstetrical and pediatric

services for the Secretary’s review, and in 1992

average Medicaid payments for specific obstetric

and pediatric procedures must be reported.

OBRA-89 also directed the Physician Payment

Review Commission to examine the adequacy of

physician payment, physician participation, and

access to care by Medicaid beneficiaries and report

to Congress by July 1, 1991. In its initial background

report to Congress, the Physician Payment Review

Commission concluded that despite recent research

focusing on access to care by the uninsured, little

attention has been devoted to those individuals

already eligible for Medicaid (75). The Physician

Payment Review Commission also found that although available studies rely on old data, almost all

conclude that higher Medicaid fees result in greater

physician participation in the program, even though

they used different sources of data (e.g., surveys v.

claims records), definitions of participation, and

estimation procedures, and appear to apply to all

medical specialties (75).

Estimated Effects of Employer Mandates

and Medicaid Expansions on the

Number of Adolescents Without

Health lnsurance78

‘‘Employer mandates’ and Medicaid expansions

have been among the numerous legislative proposals

suggested to reduce the number of people who lack

health insurance in this country. Employer mandates

require employers to offer group health insurance

policies and pay a significant amount of the premiums for all employees who work more than a

specified number of hours per week. Proposals to

expand Medicaid require that categorical eligibility

requirements be relaxed and/or that income eligibility limits be increased, thereby requiring or encouraging all States to make Medicaid available to all

those eligible below certain income levels.

Numerous factors determine the effects of an

employer mandate. Who is included in an employer

mandate is especially important. How many hours

per week must a person work to be considered an

employee? Does coverage begin on the first day of

employment or after a waiting period? Are the

self-employed included? Are employee dependents

covered? Will small firms be exempt? What level of

benefits must be provided? How much must the

employer contribute to the premium?

Similarly, the effect of an expansion in Medicaid

depends on a number of policy decisions. For

example, what is the minimum eligibility income

level? Are the changes in eligibility mandatory or

optional for the States? Are two-parent families with

workers eligible or must one parent be absent

unemployed?

Estimated Effects of Employer Mandates

The following assumptions were used by OTA

or

in

estimating the effect of an employer mandate on the

number of uninsured adolescents:

. The self-employed are exempt. All other ‘‘permanent’ employees who work more than the

required number of hours per week are covered

(i.e., with no exemptions for firm size or

industrial classification).

T8~e es~tes p~sented here were developed by R. Kronick for OTA, under contract to tiegie Corporation of New York Md the @me@eCouncil

on Adolescent Development, and are based on U.S. Census Bureau’s March 1989 Current Population Survey data (45).
Chapter 16--Financial Access to Health Services . III-111

Table 16-16-Comparison of Medicaid and Medicare Reimbursement Rates for a

Brief Followup Visit to a Physician Specialist, 1986

Brief followup office visit (CPT code 90040)

Medicaid Medicare Medicaid as

maximum maximum

State

percent of

payment allowable charge Medicare

Alabama . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

. — . —— —

Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Arkansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Colorado . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Connecticut . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Delaware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

District of Columbia . . . . . . . . . . . . . . . . . . . . . . .

Florida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hawaii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Illinois . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Indiana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

lowa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kentucky . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Louisiana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Maine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Maryland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . .

Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Minnesota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mississippi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Missouri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Montana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nebraska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

New Hampshire . . . . . . . . . . . . . . . . . . . . . . . . .

New Jersey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

New Mexico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

New York . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

North Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . .

North Dakota.. . . . . . . . . . . . . . . . . . . . . . . . . . .

Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Oklahoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Oregon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pennsylvania . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rhode Island . . . . . . . . . . . . . . . . . . . . . . . . . . . .

South Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . .

South Dakota . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tennessee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Vermont . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Virginia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Washington . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

West Virginia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Wisconsin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Wyoming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Simple average . . . . . . . . . . . . . . . . . . . . . . . . .

NA- notavailable.

NOTES: a) Medicaid fees reflect statewide average maximums as reported toHCFA. It is not known which, ifany,

States havedifferentmaximums indifferentpartsoftheState. Medicarefeesreflecthighestallowablecharge

anywhere in State.

b) Connecticut fee refiects maximum payment for general practitioner value forspedalists isunavailable.

District of Columbia fee includes Maryland suburbs.information on Nevada feas available only for partof

Siate.

$11.70

28.41

12.00

11.04

11.75

8.80

12.66

20.00

10.00

15.60

13.25

10.50

11.50

17.30

NA

15.00

13.00

10.69

8.00

10.50

8.00

7.75

15.75

11.55

10.00

11.30

16.30

15.82

6.00

9.00

11.50

7.00

13.10

8.20

12.00

11.00

11.07

13.00

14.00

9.50

12.00

18.00

NA

9.92

8.00

6.30

13.92

10.00

16.23

16.30

$12.43

$20.70

24.70

14.40

30.00

15.50

24.80

21.00

25.00

24.80

15.00

16.50

14,60

25.00

16.50

30.00

16.70

16.50

16.30

NA

22.00

NA

23.50

NA

NA

20.70

14.70

16.30

24.70

12.40

20.60

17.20

20.60

16.50

12.40

20.60

20.70

18.50

25.00

20.63

14.62

12.40

14.40

24.75

12.40

12.40

NA

17.70

16.50

18.10

14.40

$18.56

56.5%

115.0

83.3

36.8

75.8

35.5

60.3

90.9

40.3

104.0

80.3

71.9

46.0

104.8

81.8

78.8

65.6

NA

47.7

NA

33.0

NA

NA

48.3

76.9

100.0

64.0

48.4

43.7

66.9

34.0

79.4

66.1

58.3

53.1

59.8

52.0

67.9

65.0

96.8

125.0

NA

80.0

64.5

NA

78.6

80.6

89.7

113.2

67.0%

SOURCE: U.S. Congress,Library ofCongress,Congressional Research Service, MedicakfSource Book.’Background

DaiaandArra/ysLs(Washington, DC: U,S. Government Printing Offica,1988), pp.450-451.
///-112 . Adolescent Health-–Volume III: Crosscutting Issues in the Delivery of Heaith and Related Services

Table 16-17-Extending Health Insurance to Uninsured Adolescents:a Potential Effect of

Three Employer Mandates on Uninsured Adolescents

Number of uninsured Additional number Additional Number of uninsured

adolescents covered covered by changing number covered adolescents not

Uninsured adolescents’ Total number by a mandate covering mandate to cover by changing covered by a mandate

living arrangement of uninsured employees who work employees who work mandate to covering employees who

parent’s work status adolescents in 1988a at least 30 hours/wk at least 25 hours/wk 18 hours/wk work at least 18 hour/wk

Living without parents . . . . . . . . . . 862,000 126,000 11,000 32,000 693,000

Parent is self-employed . . . . . . . . . 455,000 7,000 2,000 15,000 432,000

Parent is not working . . . . . . . . . . . 413,000 5,000 0 3,000 405,000

Parent working fewer than

26 weeks per year . . . . . . . . . . . 236,000 4,000 0 3,000 229,000

Parent working 26 weeks per

year or more . . . . . . . . . . . . . . . . 2,645,000 2,404,000 78,000 112,000 51,000

Total . . . . . . . . . . . . . . . . . . . . . . . . . . 4,611,000 2,546,000 90,000 165,000 1,810,000

(100.0%) (55.2%) (2.0%) (3.6%) (39.3%)

aln 1988 abut 4.6 million ado[e~nts ages 10 to 18-15 percent overall-were without health insurance.

SOURCE: R. Kronick, Adjunct Professor, University of California, San Dieao, CA, calculations baeedon US. Department of Commerce, Bureau of the Census,

●

●

●

March 1989 Current Population Surve~ putdic use files, 1990~

Employees working 26 weeks or more in the

preceding year are considered “permanent”

workers and are covered under the mandate.

The effects of the employer mandate are

estimated using three different assumptions

about the number of hours of work per week at

which employees are covered: 18 hours, 25

hours, and 30 hours.

Adolescents who do not live with their parents

are not covered as dependents under the mandate; however, all other unmarried adolescents

age 18 or younger are covered by the mandate

if their parents were covered as well.

If the employer mandate requires employers to

offer health insurance to all employees who work at

least 30 hours a week, OTA estimates that approximately 2.55 million uninsured adolescents, or 55

percent of all adolescents currently without health

coverage, would become insured (see table 16-17).

Reducing the hourly work threshold from 30 hours

a week to 25 or 18 hours a week does increase the

number of uninsured adolescents who would be

covered by health insurance, but its effect is

relatively minimal (at least within the range of 18 to

30 hours a week). If the hourly work threshold is

reduced to 25 hours per week, for example, an

additional 90,000 adolescents (2 percent of all those

uninsured) would be covered by health insurance. If

the work threshold is 18 hours a week, an additional

165,000 adolescents (or 4 percent of all uninsured

adolescents) would be covered.

Estimated Effects of Medicaid Expansions

Proposals to expand Medicaid may either mandate that States broaden Medicaid eligibility or

allow States that option. If the current categorical

eligibility requirement of a “deprivation factor’ is

maintained, the potential for an expansion in Medicaid to cover significant portions of uninsured adolescents is severely limited.

If all adolescents living with one parent whose

income is below the Federal poverty level were

covered by Medicaid, approximately 621,000 of the

4.6 million adolescents without health insurance

would be covered (see table 16-18). Even if States

were required to extend eligibility standards to all

such adolescents, however, it is doubtful that all

would enroll. In fact, many of the 8 percent of

uninsured adolescents who were in single-parent

households in 1987, with incomes below 50 percent

of poverty, were already eligible to receive Medicaid

benefits.

If categorical eligibility requirements were

dropped, and all adolescents with family incomes

below a specified standard were made eligible for

Medicaid, then significant portions of the adolescents without health insurance could be covered by

a Medicaid expansion. If Medicaid covered adolescents in families with incomes below 100 percent of

poverty, for example, more than 38 percent of

currently uninsured adolescents would be covered

(see table 16-18). An additional 20 percent of

uninsured adolescents would be included if the

income standard was raised to 149 percent of poverty.
Chapter 16 Financial Access to Health Services . ///-113

Table 16-18-Extending Health Insurance to Uninsured Adolescents:a

Potential Effect of Medicaid Expansions on Uninsured Adolescents

Estimated number (percent) of uninsured

adolescents covered by the Medicaid expansion,

by adolescent’s living arrangement

Living with Living with two

Medicaid income eligibility Ievela b one parent parents or living alone Total

Below 50% of poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316,000 405,000 721,000

(7%) (9%) (16%)

50 to 99% of poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305,000 700,000 1,005,000

(7%) (15%) (22%)

100 to 149% of poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292,000 639,000 931,000

(6%) (14%) (20%)

150 to 199% of poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168,000 426,000 594,000

(4%) (9%) (13%)

200°/0 of poverty and above . . . . . . . . . . . . . . . . . . . . . . . . . 284,000 1,077,000 1,361,000

(6%) (230/o) (300/0)

Total number of uninsured adolescents

covered under expansion . . . . . . . . . . . . . . . . ........1 ,365,000 3,246,000 4,611,000

Overall percentage of uninsured adolescents

covered by expansion . . . . . . . . . . . . . . . . . . . . . . . . . . . . (300/.) (70%) (1000/0)

aln 1988 abut 4.6 million actolescent~l 5 percent overall+vere without health insurance.

bAssume~ that ~11 ~ole=ents in famili= with incomes below the specified amount would ~ cover~ by Med~id

SOURCE: R. Kronick, Adjunct Professor, University of California, San Diego, CA, calculations based on U.S.

Department of Commercs, Bureau of the Census, March 1989 Current Population Survey public use files,

1990.

Table 16-19-Extending Health Insurance to

Uninsured Adolescents:a Potential Effects of

Various Combinations of Employer Mandates and

Expansions in Medicaid on Uninsured Adolescents

Percent of currently uninsured

adolescents who would be insured

under the indicated combination of

an employer mandate and Medicaid

expansion

Employees included

No in the mandatec

Medicaid income employer (no. of hours worked weekly)

eligibility y Ievelb mandate 30 hours 25 hours 18 hours

No expansion . . . . . . . . . . . . 00/0 5 5 % 5 7 % 61 %

Below 50%

of poverty . . . . . . .......16 68 69 72

Below 100%

of poverty . . . . . . .......37 78 79 81

Below 150%

of poverty . . . . . . .......57 86 87 88

Below 200%

of poverty . ...........,70 90 91 92

aln 1988, about 4.6 million adolescents-15 percent overall-were Mthom

health insurance.

b~sumesthat all a~les~nts in families with incomes below the spedfid

amount would be covered by Medicaid.

~he employer mandates assume that all workers excluding the setf -

employed (and their dependents), who work more than the indicated

number of hours for at least 26 weeks during the precading year, would be

covered.

SOURCE: R. Kronick, Adjunct Professor, University of California, San

Diego, CA, calculations based on U.S. Department of Commerce, Bureau of the Census, March 1989 Current Population

Survey public use files, 1990.

. .

Combined Approach: Employer Mandate

With a Medicaid Expansion

OTA estimates that if employers were required to

provide health insurance to all workers who worked

at least 18 hours a week and if Medicaid were made

available to all adolescents in families with incomes

below 200 percent of the poverty level, then only

8 percent of adolescents without health insurance

would remain uninsured (see table 16-19). An

employer mandate that included employees who

worked at least 30 hours per week combined with a

Medicaid expansion that included all adolescents

below 100 percent of poverty would leave 22 percent

of currently uninsured adolescents without health

insurance.

Most of the adolescents left out by the combination of an employer mandate and Medicaid expansion are children of the self-employed. If the

self-employed were included under a “combination” mandate, nearly all currently uninsured adolescents would be covered.

Of the proposals evaluated, clearly the single

greatest impact on uninsured adolescents would

come from an employer mandate.
III-114 . Adolescent Health–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Conclusions and Policy Implications

Adolescents Without Health Insurance

In 1988, about 4.6 million U.S. adolescents-or

one out of seven overall--lack a key ingredient to

access to health care: health insurance coverage.

That health insurance coverage and ability to pay

may determine when, or if at all, someone seeks

medical services is well established. It has also been

shown that while people with incomes below the

Federal poverty level have significantly fewer physician contacts than others in the same state of health,

Medicaid coverage can counter these effects of

poverty. Yet one out of three poor adolescents ages

10 to 18 is not covered by the Medicaid program.

And few adolescents except those who are pregnant

have benefited from recent Medicaid expansions.

Family income is clearly the most important determinant of health insurance status. But many adolescents in nonpoor families, including a significant

proportion with working parents, also lack health

insurance. Adolescent children of parents who work

for small firms or are self-employed are especially at

risk; approximately one out of four is uninsured, and

adolescents in this group account for more than half

of all uninsured adolescents. Overall, the percentage

of the nonelderly population without health insurance is particularly high in the South and West,

although only in eight States do 90 percent of

residents have health insurance.

Ninety-four percent of adolescents ages 10 to 18

live with one or both parents, and the majority of

them are covered by a parent’s employer-sponsored

health plan. But there is increasingly worrisome

evidence that escalating health insurance costs are

threatening coverage of adolescents and other dependents of the working insured. More workers than

ever before are required to pay a higher share of

insurance premiums to cover their dependents, and

some receive no financial ‘contribution from their

employers for family benefits. The U.S. General

Accounting Office recently found that, for lower

income families, the high cost of family coverage

can lead to decisions to forego dependent coverage

altogether (67). In 1989, premiums for employersponsored health insurance for family coverage rose

18 percent and cost, on average, more than $260 per

month; parents paid an average share of $55 to $81

per month depending on the type of plan. Deductibles and coinsurance requirements for covered

benefits typically add annual out-of-pocket costs of

up to $2,000 per family for ‘‘physical’ health

problems; cost-sharing for mental health care and

uncovered services can be an additional expense.

Recent surveys of employers reflect their growing

concern about the cost burden of covering their

employees’ dependents. Many employers report that

they intend to increase their employees’ share of

premium costs, deductibles, and copayments, Some

employers plan to cut benefits for dependents.

Most approaches to resolving the dilemma of the

uninsured have focused on the overall nonelderly

population, and no attention has been given to

addressing the health coverage needs of adolescents

in particular. Numerous commissions and studies

have looked at a wide range of remedies to improve

the plight of the uninsured including national health

insurance proposals, employer mandates to provide

health benefits to workers and their dependents,

Medicaid expansion and reform, tax reform, and

regulatory reform of employee health benefit plans

and private health insurance (3,17,37,56,74). OTA

does not endorse any particular approach but examined the effects on adolescents of combining two

generic proposals: 1) an expansion in Medicaid to

cover all adolescents whose families have incomes

below the Federal poverty level and 2) a mandate to

employers to provide health benefits to all workers

(and their families) working at least 30 hours

weekly. Such an approach would insure approximately 78 percent of uninsured adolescents ages 10

to 18.

At a minimum, the Federal Government should

consider efforts to prevent any erosion in employersponsored health benefits for adolescent dependents,

especially for critical health care needs such as

treatment of acute and chronic illnesses, mental

health care, substance abuse treatment, maternity

care and related services (including family planning), vision and dental care, and rehabilitative

services. Congress could act to maintain current

private health insurance benefits for adolescent

dependents by prohibiting employer-sponsored

health plans from providing more limited benefits to

health plan participants (i.e., subscriber or dependent) based on age or coverage status.

As private health insurance benefits have not been

developed or assessed with respect to the special

needs of the adolescent population, Congress could

also support an effort to develop a model health

insurance benefit for adolescents.
Chapter 16--Financial Access to Health Services .111- 115

Adolescents With Private Health Insurance

Although adolescents with private health insurance have a wide range of benefits, their health plans

may not meet some crucial adolescent health needs.

Health benefits surveys show that 90 percent or more

of employees with employer-based group health

coverage have health benefits for hospital room and

board, surgical services, physician visits, diagnostic

X-ray and laboratory procedures, and outpatient

prescription drugs. Mental health and substance

abuse benefits are also available in most plans, but

they are subject to separate and more stringent

limitations than for “physical’ problems. Preventive services, including basic immunizations and

routine health assessments, are usually not covered

for adolescents by private health plans, with the

exception of health maintenance organizations. Most

privately insured adolescents do not have basic

dental, hearing, and vision benefits.

Approximately one-third of privately insured

adolescents are not covered for maternity-related

services because of a loophole in the Pregnancy

Discrimination Act of 1978 (Public Law 95-555)

that allows employers not to cover maternity care for

adolescent daughters of employees in their health

benefit plans. Congress should consider amending

the act to close this loophole.

While it is not clear that physical and mental

health care should be covered in precisely the same

manner, there is evidence that current mental health

benefits may lead to inappropriate hospitalization of

adolescents and that the preferred approach to

treatment, community- and family-based care, is

often strictly limited or not covered at all. In

addition, recent surveys of employers who provide

health benefits indicate that coverage of mental

health and substance abuse treatment for adolescent

dependents may be in jeopardy. Inpatient treatment

costs for mental health and substance abuse for

adolescents are often substantially higher than for

adults, and employers are finding that a rising share

of their claims dollars are going towards the mental

health and substance abuse care of their workers’

children. As a result, many employers and health

insurers are now reconsidering how and whether to

cover mental health and substance abuse treatment

for dependents. In fact, a recent survey of corporate

benefits decisionmakers found that more than half

predicted restricting or excluding coverage for

dependent mental health or chemical dependency

illnesses. Congress could support an effort to

develop a model health insurance benefit for mental

health and substance abuse treatment for adolescents. It could also act to prevent any future erosion

of benefits for adolescent dependents by requiring

equivalent benefits for mental health and substance

abuse for all recipients of employer-sponsored

health benefits regardless of age or coverage status

(i.e., subscriber or dependent).

Little is known about the extent to which private

health insurance reimburses nonphysician providers

who are often key players in adolescent health

settings, such as school-based clinics. How nurse

practitioners, psychologists, clinical social workers,

and drug addiction counselors are paid for their

services can be critical to the development of

additional low-cost community adolescent health

care resources. Although many States mandate

private health insurance coverage of some nonphysician providers, especially psychologists, social workers, nurse practitioners, and clinical nurse midwives,

it is not clear how many health insurance plans allow

for direct payment for their services since a substantial proportion of employment-based health coverage is free from State insurance regulation. The

quality of care provided by nurse practitioners and

clinical nurse midwives within their areas of competence is equivalent to that provided by physicians,

and these caregivers can be cost-effective substitutes

for physicians in delivering many services (72).

Under OBRA-89, State Medicaid programs are now

required to cover certified pediatric and family nurse

practitioners to the extent that they are legally

authorized by State law to provide services even if

they are not practicing under the supervision of, or

associated with, a physician or other provider.

Medicaid also mandates coverage of clinical nurse

midwife services. Congress could act to mandate

private insurance coverage of nurse practitioners and

clinical nurse midwives to boost the availability of

personnel to treat adolescents and the financial

viability of school-linked and other adolescent

health centers.

Adolescents in the Medicaid Program

The Medicaid program may be more aptly described as a confederation of 50 State programs.

Although Federal guidelines determine broad eligibility and coverage criteria, each State designs and

manages its own Medicaid program. Consequently,

eligibility requirements, services offered, utilization
Ill-1 16 . Adolescent Health-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

limits, and provider payment policies vary widely

among the States, How well Medicaid covers poor

adolescents depends to a large extent on these

State-specific features.

Medicaid is a joint Federal-State entitlement

program and its costs are shared by Federal and State

Governments. The Federal share in each State’s

Medicaid program ranges from 50 to 80 percent, and

in fiscal year 1990 total expenditures were projected

to total approximately $70.5 billion. Federal funds

account for 56.9 percent of total Medicaid program

expenditures, an estimated $40.2 billion in fiscal

year 1990. Although actual data on Medicaid

expenditures for adolescents are not available,

HCFA estimates that adolescents ages 10 to 18 made

up 17.1 percent of Medicaid enrollment and 6.9

percent of overall Medicaid expenditures in fiscal

year 1988.

One reason that so many poor adolescents are not

covered by Medicaid is that eligibility has generally

been linked to participation in the AFDC cash

welfare program. AFDC eligibility hinges on not

only whether family income and resources fall

within the State’s AFDC limits but also, with few

exceptions, whether the family has a so-called

‘‘deprivation factor’ (i.e., at least one parentis dead,

disabled, continually absent from the home, or, as of

October 1990, in two-parent families whose principal breadwinner is unemployed), In many cases, the

States have failed to adjust the AFDC income

standards for inflation and, consequently, the average income threshold as a percentage of the Federal

poverty level has been eroded substantially, from

71 percent in 1975 to 47 percent in January 1990.

OTA estimates that if AFDC categorical requirements were dropped and all adolescents with family

income below 100 percent of poverty were eligible

for Medicaid, then approximately 1.7 million poor

adolescents (38 percent of those currently uninsured) would be affected. If the current categorical

requirement of a‘ ‘deprivation factor” is maintained,

the potential for an expansion in Medicaid to cover

significant portions of poor., uninsured adolescents is

severely limited. If all adolescents in single-parent

households with incomes below 100 percent of

poverty were covered by Medicaid, OTA estimates

that approximately 621,000 adolescents would be

covered. Congress could expand Medicaid by mandating State benefits to all adolescents through age

18 with family incomes up to 100 percent of poverty

or include, as it has for children up to age six, all

adolescents up to 133 percent of poverty.

As part of OBRA-89, Congress significantly

expanded adolescents’ and other children’s access to

Medicaid-covered services by its reform of the

EPSDT program. Under EPSDT, States are mandated by Federal law to periodically screen Medicaideligible adolescents for any illnesses, abnormalities,

or treatable conditions and refer them for definitive

treatment. The OBRA-89 amendments dramatically

broadened Medicaid coverage of children and adolescents by essentially eliminating any State Medicaid limitations on diagnosis or treatment for any

health condition identified during the course of an

EPSDT screen as long as the services are within the

limits of Federal Medicaid guidelines and are

deemed medically necessary. The potential for

providing comprehensive health services using EPSDT

will not be fully realized, however, if adolescent

Medicaid recipients do not get screened. Although

the program has been shown to improve children’s

health and reduce health care costs, use of EPSDT

services is extremely low, especially in rural areas.

In fiscal year 1988, average program expenditures

were only $9 per Medicaid enrollee age 20 and

younger, and were directed largely towards younger

children. HCFA estimates that while, in fiscal year

1988, average per enrollee expenditures for EPSDT

screening were $15 per child under age 5, they were

only $4 for adolescents ages 10 to 14 and $3 for

adolescents ages 15 to 18. Congress could act to

provide direct subsidies to EPSDT outreach programs that make effective efforts to involve adolescents in EPSDT.

Even if a poor adolescent holds a Medicaid card

that represents a rather rich package of health

benefits, finding a private physician willing to see

Medicaid patients can be a significant problem

especially among some medical specialties and in

certain geographic areas. Low payment rates, excessive administrative burdens, as well as other factors

often discourage physicians from participating in

Medicaid. Overall participation is particularly low

among two specialties that are particularly important

to adolescents, OB/GYN and psychiatry. OBRA-89

directed the Physician Payment Review Commission to examine the adequacy of physician payment,

physician participation, and access to care by

Medicaid beneficiaries and report to Congress by

July 1, 1991. In considering potential Medicaid

physician payment reform resulting from the Physi-
Chapter 16--Financial Access to Health Services . ///-117

cian Payment Review Commission effort, Congress

could give high priority to providers involved in

direct service to adolescents.

Conflict Between Confidentiality

and Insurance Reimbursement 79

Even if appropriate benefits are available, adolescents who are concerned about confidentiality may

be reluctant to seek care from providers if their

private health plan requires parents to submit a claim

for reimbursement (as most do). An adolescent with

Medicaid coverage who must present a parent’s

Medicaid card to gain access to care faces the same

dilemma. It may be important to evaluate the

feasibility of direct funding of some particularly

sensitive adolescent health services, such as pregnancy testing and early prenatal care, mental health

and substance abuse counseling.

●

●

●

●

Summary of Policy Implications

Congress could act to maintain current private

health insurance benefits for adolescent dependents by prohibiting employer-sponsored

health plans from providing more limited

benefits to health plan participants (i.e., subscriber or dependent) based on age or coverage

status. It could also support an effort to develop

a model health insurance benefit for adolescents.

Congress could consider amending the Pregnancy Discrimination Act of 1978 (Public Law

95-555) to close the loophole that allows

employers not to cover maternity care for

adolescent daughters of employees in their

health benefit plans.

Congress could support an effort to develop a

model health insurance benefit for mental

health and substance abuse treatment for adolescents. It could also act to prevent any future

erosion of benefits for adolescent dependents

by requiring equivalent benefits for mental

health and substance abuse for all recipients of

employer-sponsored health benefits regardless

of age or coverage status (i.e., subscriber or

dependent).

Congress could act to mandate private insurance coverage of nurse practitioners and clinical nurse midwives to boost the availability of

personnel to treat adolescents and the financial

●

●

●

●

viability of school-based clinics and other

adolescent health centers.

Congress could expand Medicaid by mandating

State benefits to all adolescents through age 18

with family incomes up to 100 percent of the

Federal poverty level or include, as it has for

children up to age 6, all adolescents up to 133

percent of the poverty level.

Congress could act to provide direct subsidies

to EPSDT outreach programs that make effective efforts to involve adolescents in EPSDT.

Congress could give high priority to providers

involved in direct service to adolescents in

considering any potential Medicaid physician

payment reform that results from the Physician

Payment Review Commission’s OBRA-89-

mandated effort to examine the adequacy of

physician payment, physician participation,

and access to care by Medicaid beneficiaries.

Congress could consider direct funding of some

particularly sensitive adolescent health services, such as pregnancy testing, early prenatal

care, and mental health and substance abuse

counseling.

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No. 3, HCFA Pub. 45-5, Washingto~ DC, April 1990.

U.S. Department of Health and Human Services, Health Care

Financing AdministratiorL Division of Intergovernmental Affairs,

Medicaid Services State by State, HCFA Pub. No. 02155-90

(Washington DC: U.S. Government Printing Offlce, October

1989).

U.S. Department of Health and Human Services, Health Care

Financing Administration, Office of the Actuay, unpublished

HCFA-2082 data on Medicaid expenditures and enrollment in

fiscal year 1988, Baltimore, MD, June 1990.

U.S. Department of Health and Human Services, Public Health

Service, Agency for Health Care Policy and Resmck Nursing

Strategies To Encourage Medical Screening of Poor Children To

Be Tested, Research Activities No. 127 (RockviIle, MD: March

1989).

U.S. Department of Labor, Bureau of Labor Statistics, Employee

Benefits in State and Local Governments, 1987, Bulletin 2309

(Washington+ DC: U.S. Government Printing Office, May 1988).

U.S. Department of Labor, Bureau of Labor Statistics, Employee

Benefits in Medium and Large Firms, 1988, Bulletin 2336

(Washingto~ DC: U.S. Govemment Printing Office, August

1989).
III-120 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

85. U.S. Preventive Services Tifik Fome, Guide to Clinical Preventive Review 40:773-838, 1988.

Services” (Baltimore, MD: Williams & Wilkens, 1989). 87. Yudkows@, B., CarUand, J., and Flint, S., “PediatricianParticipa86. Weithow L., “Mental Hospitalimtion of Troublesome Youth: An tion in Medicaid: 1978 to 1989,” Pediatrics 85(4):567-577, 1990.

Analysis of Skyrocketing Admission Rates,” Stanford Luw
Chapter 17

CONSENT AND CONFIDENTIALITY IN

ADOLESCENT HEALTH CARE

DECISIONMAKING
Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

Law Pertaining to Consent and Confidentiality in Adolescent Health Care Decisions . . . . . . . . . . 123

Parental Consent Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Exceptions to the Parental Consent Requirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Exceptions Arising From Juvenile and Family Courts’ Jurisdiction Over Abused and

Neglected Minors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

Exceptions Related to the Status and Characteristics of Individual Minors . . . . . . . . . . . . . . . 126

Exceptions for Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Exceptions for Specific Types of Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Confidentiality and Parental Notification Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

Parental Notification Requirements for Health Services Provided to “Emancipated,”

“Independent,” or “Mature’ Minors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Parental Notifcation Requirements for Emergency Health Services . . . . . . . . . . . . . . . . . . . . . 131

Parental Notifcation Requirements for Specific Types of Health Services . . . . . . . . . . . . . . . 131

The Impact of Law Requiring Parental Consent and Notification on Minors’ Access to

Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

Minors’ Competency To Make Health Care Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

Ambiguities in Legal Definitions of Consent and Competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

What Constitutes Effective Legal Consent to Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . 139

What Constitutes Legal Competency To Make Health Care Decisions . . . . . . . . . . . . . . . . . . . 139

Empirical Research on Minors’ Competency To Make Health Care Decisions . . . . . . . . . . . . . . 141

Findings of the Core Group of Empirical Studies on the Age-Competence Relationship in

Health Care Decisionmaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Findings of Other Studies on the Age-Competence Relationship in

Health Care Decisionmaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Findings of Studies on How Variables Other Than Age Affect Adolescents’ Health Care

Decisionmaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

Implications for Public Policy of Empirical Research on Minors’ Competence . . . . . . . . . . . . . 148

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

Chapter 17 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Boxes

Box Page

17-A Professional Ethical Standards Relevant to Consent and Confidentiality............,... 136

17-B. A Conceptual Framework To Aid Public Policymakers in Formulating Policy Related

to the Allocation of Authority for Adolescent Health Care Decisionmaking . . . . . . . . . . . . . 151

Table

Table Page

17-1. Summary of Seven Core Empirical Studies on the Age-Competency Relationship in

Health Care Decisionmaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Chapter 17

CONSENT AND CONFIDENTIALITY IN ADOLESCENT

HEALTH CARE DECISIONMAKING1

Introduction

Who should decide whether an adolescent is

provided health services, what health services are

provided, and how health services are provided? The

adolescent? The adolescent’s parents or legal guardian? Health professionals? The state? And who

should decide whether adolescents’ communications with health professionals and health care

records are to be treated as confidential?

The question of how authority for adolescent

health care decisionmaking should be allocated has

been much debated—and is far from being settled.

The body of law that determin es how this authority

is allocated-including the extent of parental involvement in adolescent health care decisionmaking—

is summarized in this chapter. That body of law is

large and complicated and is not always clear or

consistent, in part because it is an amalgam of

decisions of State and Federal courts, statutes passed

by Congress and State legislatures, and regulations

issued by executive departments and agencies.

The common law rule-to which there are many

notable exceptions identified in this chapter—is that

parental consent is generally required for the medical or surgical care of a minor child (i.e., a son or

daughter who has not reached the age of majority,

either age 18 or 19, depending on the State). The

rationales for parental consent requirements are

several. One rationale is that minors lack the

capacity to make their own health care decisions and

need to be protected from their own improvident

decisionmaking. The legal presumption that minors

are incompetent rests at least in part on an assumption of courts and legislators that minors as a class

lack the requisite capacity to make health care

decisions for themselves. Recently, the factual

validity of that assumption has been increasingly

criticized on the ground that it inequitably denies

minors in middle or late adolescence-many or most

of whom may actually have the requisite decisionmaking capacity-the power to make their own

decisions about services. Several empirical studies

that challenge the legal presumption about the

incompetency of minors to make health care decisions are summarized in the second part of this

chapter.

It is important to recognize, however, that concerns about adolescents’ competency to make decisions are not the only rationale for parental consent

requirements. Several other rationales for such

requirements are reviewed in the discussion that

follows, among them the state’s interest and families’ interest in encouraging family involvement in

minors’ lives and health care providers’ interest in

being able to receive compensation for the services

they provide to minors.

How the law should allocate authority for making

decisions about adolescent health care has traditionally been a matter for the individual State governments to determine, but the allocation of authority is

or can be controlled or influenced to some extent by

the Federal Government acting through the Federal

courts, Congress, and Federal agencies. If it chose to,

Congress could increase the Federal Government’s

role in the formulation of more uniform or coherent

policies pertaining to the allocation of authority for

adolescent health care decisionmaking. That and

other possibilities are discussed, and a conceptual

framework for public policy formulation in allocating authority for adolescent health care decisionmaking is presented, in the concluding section of

this chapter.

Law Pertaining to Consent and

Confidentiality in Adolescent

Health Care Decisions

The large and complicated body of law that

determin es the allocation of authority for adolescent

l~s c~pter is based on a February 1990 background PaPer entitl~ “Adolescent Health Care Decisionmaking: The Law and Public Policy, ”

prepmed for OTA’s Adolescent Heahh Project under contract to the Carnegie Council on Adolescent Development by J. Gittler, M. Quigley-Rick, and

M.J. Saks. That background paper has been published separately in its entirety, including extensive legal citations, and is available from the Carnegie

CounciI on Adolescent Development, WashingIon, DC, or from OTA.

-III-123 -
III-124 . Adolescent Health-—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

health care decisionmaking is summarized below. 2

Much of the law focuses on the nature and extent of

parental involvement in adolescent health care

decisionmaking, including whether an adolescent’s

parents must consent to the delivery of health

services to the adolescent and whether an adolescent’s parent must be notified of the adolescent’s

decision to obtain health services or of the adolescent’s actual receipt of health services.

As noted in the introduction, the body of law that

determines the allocation of authority for adolescent

health care decisionmaking is not always clear or

consistent, in part because it is an amalgam of

principles and rules drawn from different areas of

law (e.g., tort law, contract law, family law, and

constitutional law) and different jurisdictions, and in

part because it consists of decisions of Federal and

State courts, statutes passed by Congress and State

legislatures, and regulations issued by executive

departments and agencies. For at least some adolescents, a lack of information about what services they

can or cannot receive without parental consent or

notification may be a barrier to their seeking or

receiving certain types of health services. For other

adolescents, the barrier may be the substance of the

laws requiring parental consent or notification rather

than confusion about what the law allows.

Parental Consent Requirements

Anglo-American law draws a sharp distinction

between adults and minors, and it is well established

that minors have fewer rights and more restrictions

on their liberty than adults (27,33). It is also well

established that parents have a right to care, custody,

and control of their minor children (83). Perhaps not

surprisingly, therefore, the common law rule is that

parental consent is generally required for the medical or surgical care of a minor child.3 The age of

majority is determined by individual States. Currently, the age of majority is set at age 18 in every

State but Alaska, Nebraska, and Wyoming, where

the age is 19. States can modify the age of majority

to confer upon minors rights normally reserved for

adults, and five States (Alabama, Kansas, Rhode

Island, South Carolina, and Oregon4

) have enacted

statutes that specifically authorize minors who have

reached a designated age—ranging from 14 to

16---to consent to health care.

The parental consent requirement reflects the

application to minors of the tort law doctrine of

informed consent, as well as principles under

contract law. As discussed later in this chapter, the

legal doctrine of informed consent is based on the

premise that every person has the right to determine

what is done to his or her own body. The doctrine of

informed consent holds, therefore, that physicians

and surgeons have a duty to give their adult patients

the information necessary for making an informed

and voluntary choice concerning medical treatment

or surgery; the failure by a physician or surgeon to

obtain informed consent from a patient may give rise

to a civil liability and an award of damages.5 In

addition, under contract law, the relationship between a doctor and an adult patient is usually

considered a contractual relationship. Among the

essentials of any contract are competent parties.

Traditionally, minors have been deemed incompetent as a matter of law to give informed consent to

medical and surgical care and incompetent to enter

into binding contracts, including contracts with

physicians and surgeons. Thus, parental consent has

been required for provision of health services to

minors.

The rationales for parental consent requirements

in the area of health care are several. One of the main

rationales for the parental consent requirement—

based on the assumption that minors lack the

requisite capacity to make health care decisions—is

the need to protect minors from their own improviZAII.hou@ me fWus of MS OTA Report is on ‘‘adolescents” defined as individuals ages 10 to 18, the law regards 10- to 18-year-olds not a

“adolescents” but as either “minors” or “adults.” Since 18-year-olds are legally considered adults in all but three States, most of the issues about

adolescent health care decisionmaking raised in this chapter pertain to adolescents ages 17 and under.

Ssee, for emple, Bonner v. Mor(Jn, 75 App. D.C. 156, 126 F.2d 121, 123 (D.C. Ck. 1941); Rogers v. Sells, 178 Okla. 103,61 p.2d 1018 (1936);

Browning v. Hogan, 90 W. W 568, 111 S.E. 492 (1922). See Institute of Judicial Administration and Americaa Bar Association, Juvenile Justice

Standards Project, Standards Relating to Rights of Minors (47); G.D. Dodsoni “Legal Rights of Adolescents: Restrictions on Libexty, Emancipation%

and Status Offenses” (33); and R. Bennett, “Allocation of Child Medical Care Decision-Making Authority: A Suggested Interest Analysis” (19).

4A~. CODE $ zz-g~ (1984); ~Wt STAT. ANN. $ 38- 123b (1986); R.I. GEN. LAWS &j 23-4. 6- I ( 1985); S.C. CODE ANN. $ 20-7-280 (hW.

Co-op. 1985); OR. REV. STAT. $109.640 (1981).

5~e law of tons protects ~erWm ag~st UMuthoriZiM bOdiIy invasion. Bodity contact with a patient by a physician or surgeon ~tiout the Patient’s

consent constitutes technical battery, which is a tort (53).
Chapter 17—Consent and Confidentiality in Adolescent Health Care Decisionmaking ● 1//-125

dent decisionmaking. 6 Accepting for the sake of

argument that minors in fact need protection from

their own improvident decisionmaking, there remains the question of why parents have been legally

authorized to make health care decisions on behalf

of their minor children. There appear to be two

operative premises in this regard: 1) that parents, in

contrast to their minor children, possess the intelligence, maturity, and experience needed for adequate

and appropriate health care decisionmaking; and 2)

that parents usually have an identity of interest with

their minor children and will act in their best

interests. In at least some situations, parents and

their adolescent children do not have an identity of

interest, and sometimes their interests may conflict.7

It is precisely such situations that give rise to

concerns that parental consent or notification requirements may create barriers to adolescents’

seeking or receiving certain types of health services.

Another rationale for the parental consent requirement—apart from the need to protect minors from

their own improvident decisionmaking--is a belief

that the parental consent requirement promotes

family autonomyg and privacy and promotes parental authority9 and control of minor children. Family

autonomy and parental authority, in turn, are often

viewed as fostering the stability and cohesiveness of

the family as an institution and of individual family

units. The U.S. Supreme Court has commented in a

series of decisions on the importance of family

autonomy and parental authority, and the Court has

extended Federal constitutional protection, albeit

not absolute protection, to family autonomy and

parental authority .10 The parental consent requirement also seems, at least somewhat, to be designed

to protect parents from financial liability arising

from the provision of health services, without their

consent, to their children and to ensure providers of

the availability of a payment source for the services

they provide to minors.

Exceptions to the Parental Consent

Requirement

Over the years, the number of exceptions to the

parental consent requirement applicable to the

health care of minors has grown significantly.

Exceptions to the parental consent requirement,

described below, tend to fall into four categories:

● exceptions arising out of the jurisdiction of

juvenile and family courts over abused and

neglected minors,

. exceptions related to the status and characteristics of individual minors (e.g., emancipated,

independent, or mature minors),

61n dea]ing with issues of consent to health care for minors, State courts and lower Federal courts have consistently expressed concern about the

decisionmaking capabilities of minors. In Bonner v. Moran, 75 App. D.C. 156, 126 F.2d 121, 122 (1941), for example, the court stated: “In deference

to common experience, there is general recognition of the fact that many persons by reason of their youth are incapable of intelligent decisions, as a result

of which public policy demands legal protection of their personal as well as their property rights. ’ In recent yearn, the U.S. Supreme Court, in dealing

with issues concerning access of minors to contraceptives and abortions and the civil commitment of minors, has similarly expressed concern about the

decisionmaking capabilities of minors. For example, in Parhum v. JR., 442 U.S. 584, 602, 603 (1978), the court stated: “Most children, even in

adolescence, simply are not able to make sound decisions, including their need for medical care or treatment. ’ See also Bellotti v. Baird, 443 U.S. 622,

633,640 (1978), reh. denied, 444 U.S. 887 (1979); Planned Parenthood of Missouri v. Danforth, 428 U.S. 52,91 (1976) (Stewart, J., concurring); Carey

v. Population Services International,431 U.S. 678,709 (1977) (Powell, J. concurring); Carey v. Population Services international, supra at 714 (1977)

(Stevens, J. concurrin g).

TFor a f~er discussion of how the interests of an adolescent, the adolescent’s parents, the state, and health providers my differ, see box 17-B fi

the concluding section of this chapter.

8Fami/y ~ulonomy refers t. non~te~erence by the s~te in the right of families to make impoI_WN decisions concerning f~ily life ~d f~ilY

members. A tradition of family autonomy is deeply imbedded in Anglo-American law and can be traced back to Roman law, the JudeO-Christian tradition,

and Anglo-Saxon customary law. Family autonomy is often but not always equated with parental authority (42).

gparenta/ ~uthorim refers t. the deference of the s~te t. the right Of p~ents to m~e childrefig decisions (42). At common law, minor children

.

were in effect the chattels or property of their paren~ who had virtually the unfettered right to rear them as they saw fit. Over time, minor children

increasingly have been recognized as having independent rights (45), yet they are still largely subject to the authority of their parents.

lqn a line of dmisions over 50 Yms, the U,S. Supreme Court has held that parents have a Federal COnStitUtiOrMl tight to dkmt the upbringing of thek

children free from state intemention in the absence of a constitutionally acceptable justifkation for such intewention. The Court’s most notable decisions

in this regard are Meyer v. Nebraska, 262 U.S. 390 (1923); Pierce v. Society of Sisters, 268 U.S. 510 (1925); Prince v. Massachusetts, 321 U.S. 158

(1944); and Wisconsin v. Yoder 406 U.S. 205 (1972). See also Ginsburg v. New York 390 U.S. 629,634 (1968), reh. denied, 391 U.S. 971 (1973). [n

another line of decisions, the U.S. Supreme Court has afforded minors some of the same constitutional rights that adults are afforded in areas that do

not directly implicate parents’ right to direct the upbringing of their children. See, for example, In re Gaulr, 387 U.S. 1 (1967); Tinker v. Des Moines

Independent Communiry Schoo/ Dism’cf, 393 U.S. 503 (1969); and GOSS v. bpez, 419 U. S., 565 (1975). in recent years, the U.S. Supreme Court has

begun to confront conflicts between a parent’s asserted right to direct the upbringing of his or her minor child and the minor’s assertion of his or her

own independent rights and has issued several decisions involving actual or potential parent-child conflicts with respect to the access of minors to

contraceptives and abortions and the civil commitment of minors. Taken as a whole, however, the results and rationales of the Supreme Court’s decisions

do not reflect a coherent approach to such conflicts.
III-126 . Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

. exceptions for health emergencies, and

* exceptions for specific health problems and

services (e.g., services related to sexual activities, drug and alcohol abuse, or mental health).

As noted in the discussion that follows, some of the

exceptions apply to certain categories of minors

regardless of their age, and others are directed at or

affect primarily adolescent minors. For a number of

exceptions to parental consent requirements for

specific health problems, as will be discussed later,

there are now in place parental notification requirements.

Exceptions Arising From Juvenile and

Family Courts’ Jurisdiction Over Abused and

Neglected Minors

In all States, juvenile and family courts have

jurisdiction over minors of all ages who have been

abused or neglected. Exercising this jurisdiction,

juvenile and family courts have traditionally had the

power to intervene to secure health services for

minors whose parents refuse to consent to the

provision of services if the parents’ refusal is

deemed medical neglect. The basis for judicial

intervention under State juvenile and family court

acts in such instances is the state’s parens patriae

power. In many instances where medical neglect is

alleged, the parents’ refusal to consent to care is

based on religious convictions. Judicial intervention

typically occurs only when a minor’s life is or will

be threatened because of lack of care.

Exceptions Related to the Status and

Characteristics of Individual Minors

Two major types of exceptions to the parental

consent requirement are related to the status and

characteristics of individual minors:

. exceptions for ‘‘emancipated’ minors and

‘‘independent’ minors, and

● exceptions for ‘‘mature’ minors.

Exceptions for “Emancipated” and “Independent” Minors-Emancipation is a somewhat

murky and confused area of the law,ll but generally

speaking, ‘‘emancipated minors’ are minors who

have been legally freed from the control and

authority of their parents. Under the common law

doctrine of emancipation, courts-without explicit

statutory authorization-may use various factors in

determining whether a minor’s emancipation has

taken place. Emancipation may be found to have

occurred in accordance with an express agreement

between a minor’s parents and the minor or may be

implied from the acts of the minor’s parents and the

minor. The main indicia of emancipation implied

from the acts of the parties are a minor’s marriage,

a minor’s induction into the armed services, a

minor’s establishment of a home away from that of

his or her parents, a minors’ economic independence

from his or her parents, and a minor’s age (50).

Emancipation under common law may be complete

or partial and may or may not result in a minor’s

having the right to consent to health services.

About half of the States have enacted statutes that

provide for court-ordered emancipation of minors or

specify that certain designated acts by a minor’s

parents, a minor, or both constitute emancipation.

Some of these statutes explicitly state that emancipation under these statutes removes the disabilities of

minority, including the requirement of parental

consent to health services. Thus, minors emancipated under these statutes have the right to consent

to health services.

A substantial number of States have enacted

statutes that authorize minors who have attained

varying degrees of independence to consent to

health services but that do not use the term ‘emancipation’ or “emancipated’ minors. Over half of the

States have ‘‘independent minor’ statutes that allow

minors who are parents to consent to health care for

themselves and/or their children; about half of the

States have statutes that allow married minors to

consent to health care; and some States have statutes

that allow independent minors in other categories

(e.g., minors living apart from their parents and

managing their own financial affairs, minors in the

military, minors who are high school graduates) to

consent to health services.

Emancipated minor and independent minor exceptions to the parental consent requirement affect

minors who have achieved complete or substantial

independence from their parents, so they primarily

affect adolescent minors. The focus of these exceptions is the minor’s independence, not the minor’s

capacity to make health care decisions. These

1 I For discussions of tie Ofigfi ad development of ernancipatio~ see H.H. Clark, The LUW oflhmtestic Relations in the United States (27); F. Cady,

“Emancipation of Minors” (24); and S. Katz, W. Schroeder, and L. Sidman, “Emancipating Our Children-Corning of Age in hgal America” (50).
Chapter 17—Consent and Confidentiality in Adolescent Health Care Decisionmaking .111-127

exceptions seem to reflect legislative judgments that

a minor who is not part of a functioning family, or

whose parents exercise little or no control over him

or her, is in a better position to make health care

decisions than the minor’s parents.

Exceptions for “Mature” Minors-The ‘‘mature minor’ exception to the parental consent

requirement has been enunciated primarily by courts

rather than by State legislatures. This exception was

recognized by State courts beginning in the early

1900s. According to one authority, the factors

supporting a determination of a minor’s maturity for

purposes of health care decisionmaking in these

decisions are as follows:

(1) the treatment is undertaken for the benefit of

a minor rather than a third party; (2) the particular

minor is near the age of majority; (3) the minor is

considered to have sufficient mental capacity to

understand fully the nature and importance of

medical steps proposed; (4) the procedures are

characterized as less than major, ’ not serious’ or

not overly ‘ ‘complex’ (75).

Recently, the mature minor doctrine has been

applied by the U.S. Supreme Court in decisions

dealing with the right of a minor to family planning

services and abortion services (see discussion below).

Only a few States have mature minor statutes. Three

States (Arkansas, Mississippi, and New Hampshire12) have enacted statutes that explicitly authorize mature minors to consent to health services, and

two States (Idaho and Nevada13) have enacted

statutes that are somewhat ambiguous but could be

construed to constitute mature minor consent statutes.

The mature minor exception to the parental

consent requirement is based on a rejection of the

presumption of minors’ incompetency and the underlying assumption that minors as a class lack

decisionmaking capacity; this exception allows for

individualized determinations of minors’ actual

decisionmaking capacity. Because it pertains to

mature minors, this exception to the parental consent

requirement probably most often applies to minors

in middle and late adolescence.

Exceptions for Health Emergencies

In health emergencies, medical or surgical care

may be furnished to minors without parental consent. The emergency exception to the parental

consent requirement was originally enunciated by

the courts. More than half of the States now have

statutes that codify the exception. Some of the State

statutes simply authorize emergency care of a minor

without parental consent; others state that a physician or other health professional who treats a minor

in an emergency without parental consent is relieved

from liability; and still others provide that a minor

may consent to emergency care.

Exceptions for Specific Types of Health Services

Exceptions to the parental consent requirement

for specific health problems or specific types of

services fall into three major categories:

● exceptions for health services related to sexual

activities,

● exceptions for health services related to drug

and alcohol abuse, and

● exceptions for mental health services.

Exceptions for Health Services Related to

Sexual Activities—Exceptions to the parental consent requirement for health services related to sexual

activities are of three general types: 1 ) exceptions for

health services related to venereal,14 sexually transmitted, and infectious diseases and acquired immunodeficiency syndrome (AIDS); 2) exceptions for

family planning services and abortion services; and

3) exceptions for pregnancy-related health services. 15

Exceptions for Health Services Related to Venereal, Sexually Transmitted, and Infectious Diseases

and AIDS-Almost all States have enacted legislation that specifically allows minors to consent to or

to receive services for a venereal or sexually

transmitted disease without parental consent, More

12~. CODE A~, $ 2@9_~z(7) (1987); ~SS. CODE A~ ~ 41_41.3@) (Supp, 1988); NH, MV. STAT, ANN. $ 318-B:12a (1984).

13~~0 CODE $39-4302 (198 S); ~V, MV, $TAT. $ ]Z90SO(Z) (1987). But s= ~V. REV, STAT. $ 129.oso(1” ) (] 987),

141n common usage, the term ‘‘venereal disease’ has been replaced by ‘‘sexually transmitted disease’ (see ch. 9, ‘ ‘AIDS and Other Sexually

Transmitted Diseases: Prevention and Services, ‘‘ in Vol. H. However, because some State statutes use the older term venereal disease, it is included here.

15~e effectiveness of semim~ related t. adolescents’ sexwl behavior+,g, se~ices for tie prevention and heament of AIDS and other sexually

transmitted diseases, family planning sewices, and pregnancy-related services-is discussed in Vol. II in ch. 9, ‘ ‘AIDS and Other Sexually Trammitted

Disemes: Prevention and Services,’ and ch. 10, ‘‘Pregnancy and Parenting: Prevention and Sewices. ’
III-128 . Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

than two-thirds of the States have enacted legislation

that specifically allows minors to obtain without

parental consent health services for “venereal disease’; about one-quarter of the States have a statute

that allows services without parental consent for

‘‘sexually transmitted disease. ’ A few States have

a statute that allows minors to obtain services

without parental consent for ‘‘infectious, contagious, communicable and reportable diseases” (or

some variant thereof). None of the State statutes just

mentioned expressly covers testing for infection

with human immunodeficiency virus (HIV), the

virus that causes AIDS, but some of them may cover

or could be interpreted to cover HIV testing. A few

States have statutes that expressly authorize minors

to consent to or to receive HIV testing without

parental consent.

Most of the State statutes just mentioned allow

minors of any age to consent to services or to receive

services for the diseases specified without parental

consent, although others specify that minors must be

12 or 14 to consent to these services. The fact that

these statutes impose either no age limit or a very

low age limit for minors to consent to or to receive

services for these diseases without parental consent

appears to stem from a legislative recognition that

society has a critical interest in facilitating and

encouraging access to health services to reduce the

spread of disease among its citizens.

Exceptions for Family Planning Servicesl6 and

Abortion Services-Restrictions on access to family

planning services and abortion services by adolescents are governed by Federal constitutional law as

interpreted by the U.S. Supreme Court and the lower

Federal courts, and the Supreme Court is the final

arbiter of what is constitutionally permissible and

impermissible when it comes to State-imposed

restrictions-including parental consent and notification requirements-on the provision of family

planning services and abortion services to minors.

In the landmark 1965 case Griswold v. Connecticut [38 1 U.S. 479 (1965)] and in Eisenstadt v. Baird

[405 U.S. 438 (1972)], the U.S. Supreme Court held

that an individual has a constitutionally protected

“right to privacy” under the 14th amendment

encompassing decisions with respect to the use of

contraceptives. 17 In the 1977 case Carey v. Population Services International [431 U.S. 678 (1977)],

the U.S. Supreme Court established that minors as

well as adults have a constitutionally protected right

to privacy with respect to the use of contraceptives .18

A little under half of the States have statutes

providing that minors may obtain without parental

consent what are variously described as contraceptives, birth control services, or services for the

prevention of pregnancy. Some of these statutes

impose restrictions on minors obtaining these

services without parental consent (e.g., that the

minor be of a certain minimum age, be referred from

a designated source, possess a certain maturity and

intelligence, or be likely to suffer detrimental health

consequences if the services are not provided).

Many of them explicitly exclude or have been or

could be interpreted as excluding abortion from the

services that minors may obtain.

In the landmark 1973 decision Roe v. Wade [410

U.S. 113 (1973)], the U.S. Supreme Court held that

the constitutional right to privacy encompassed a

woman decision about whether to have an abortion

and invalidated State criminalstatutes prohibiting

nontherapeutic abortions at any stage of pregnancy.

At the same time, however, the Court ruled that a

State did have legitimate interests (e.g., in safeguarding maternal health, in maintaining proper

medical standards, and in protecting human life) that

could justify State regulation of the performance of

abortions .19

Since 1972, the Supreme Court has issued several

decisions that have extended to minors at least some

constitutional protections with respect to the right to

lsFamz/y planning ~ewice~ we ~ntra~ptivcs anct other birth control services, with the exceptions of sterilization ~d dXMtiOn.

11’~ Gn”~o/d V. co~~ec~c~r [381 U.S. 479 (1965)], the U.S. Supreme Court held that State regulation of use of contraceptives by m~d WSOUS

invaded “the zone of privacy created by several constitutional guarantees” and struck down as unconstitutional a State statute prohibiting the use of

contraceptives by married persons. In Eisenstudt v. Baird [4Q5 U.S. 438 (1972)], the Court held that unmarried as well a.. married persons had a right

to privacy with respect to contraceptive use.

18~ Carq ~. population ~ewices~nz,ernatioW/ [431 U.S. 678 (1977)], the Supreme COW spec~Ically held unconstitutional a state statute prohibiting

the sale or distribution of contraceptives to minors. The Court indicated that ‘State resrnctions inhibiting privacy rights are valid only if they sme any

significant State interest . . . that is not present in the case of an adult. ”

l~e Supreme co~ ~~~ Roe v, Wtie titd~g me fwst ~ester of pRgIImcy, a Sute may rquirc ofdy that the abortion be performed by

a licensed physiciu that after the fwst trimester, a State may ‘‘regulate the abortion procedure in ways that are reasonably related to maternal health;”

and that once the fetus is “viable,’ a State may “regulate, even proscribe, abortion except where it is necessary in appropriate medical judgmen~ for

the preservation of life or health of the mother” [410 U.S. at 164-65].
Chapter 17-Consent and Confidentiality in Adolescent Health Care Decisionmaking .111-129

AD

Photo credit: U.S. Congress, Office of Technology Assessment

Laws related to the allocation of authority for decisions

about the provision of health services to minors have

historically been the province of State legislatures, State

courts, and State administrative agencies, but the U.S.

Supreme Court decides whether State laws adhere to

the requirements of the U.S. Constitution.

have an abortion. 20 The U.S. supreme Court has not

held a parental consent requirement for a minor’s

abortion to be unconstitutional per se. It has ruled,

however, that a minor’s parents cannot be given an

absolute veto of a minor’s decision to undergo an

abortion; any parental consent requirement for a

minor’s abortion must be coupled with the availability of a ‘‘judicial bypass’ procedure, under which a

minor can secure court approval for an abortion if

she can demonstrate to the court that she is mature

enough to make the abortion decision or that the

abortion would be in her best interests. The Court

has also indicated that the judicial bypass procedure

must ensure a confidential and expeditious proceeding. In the wake of the Supreme Court Roe v. Wade

decision and related decisions, about one-quarter of

the States have enacted statutes requiring parental

consent to abortion for minors. Some of these State

statutes have been invalidated or are currently being

challenged on Federal constitutional grounds, however, so not all of the statutes are currently being

enforced.

It is important to emphasize that Federal constitutional law concerning the permissible scope of State

regulation of abortion as interpreted by the U.S.

Supreme Court is in flux. The Supreme Court’s

decision in the 1989 case Webster v. Reproductive

Health Services [109 S. Ct. 3040 (1989)] appears to

give the States greater leeway in restricting abortions and at the same time casts 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.

Exceptions for Pregnancy -Related Health Services—

Over half of the States have statutes specifically

authorizing minors to consent to pregnancy-related

health services (e.g., testing to determine pregnancy,

prenatal care, and delivery services). Since these

consent statutes are directed at pregnant minors, they

are in effect adolescent consent statutes.

Exceptions for Health Services Related to Drug

and/or Alcohol Abuse21—All but five States (Alaska,

Arkansas, Oregon, Utah, and Wyoming) and the

District of Columbia have statutes specifically

authorizing minors to consent to drug- and/or

alcohol-related health services or to receive such

services without parental consent. Two-thirds of the

States have statutes covering health services related

to both drug and alcohol abuse and dependency;

other States have statutes covering health services

related to drug abuse or alcohol abuse but not both.

The majority of State statutes that allow minors to

obtain treatment for drug and alcohol abuse without

parental consent do not impose minimum age

requirements, although some of them pertain only to

minors who have reached a designated age—ranging

from 12 to 16 years of age.

~otable Supreme Court decisiom dealing with parental consent to a minor’s abortion include PZunrred Parenthood of Missouri’ v. Danfimh [428

U.S. 52( 1976)], In Be/kmi v. Baird (Bellotti II) [443 U.S. 622(1979)], Cify ofAkron v. Akron Centerfir Reproductive Healfh, Inc. [462 U.S. 416 ( 1973)],

and Planned Parenthood Association v. Ashcrofi [462 U.S. 476 (1983)].

ZIFor a discussion of health services related to drug and alcohol abuse, S= ch. 12, “Alcohol, Tobacco, and Drug Abuse: Prevention and Services, ’

in Vol. II.
111-130. Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

State statutes that create an exception to the

parental consent requirement with respect to services for drug or alcohol abuse would appear to

represent an acknowledgment on the part of State

legislatures of the seriousness of drug and alcohol

abuse problems among *adolescent minors. They

would also appear to be the product of a concern on

the part of State legislatures that minors may not

obtain care related to such abuse if they have to

secure parental consent for such care, because

‘‘communications’ between parents and minors

regarding alcohol or drug abuse may ‘‘be strained or

nonexistent” (81).

Exceptions for Mental Health Services22— A

little under half of the States have statutes that allow

some minors to obtain outpatient mental health

services without parental consent. These statutes

typically impose age restrictions and pertain only to

adolescent minors. Underlying these statutes appears to be a legislative realization that a parental

consent requirement might deter some adolescent

minors who have mental health problems from

seeking needed treatment because of a reluctance to

reveal such problems to their parents.

Inpatient mental health services for minors present special problems in the area of consent. The

involuntary commitment of a person to a mental

institution or facility results in the deprivation of that

person’s liberty, so certain safeguards are in place

(e.g., substantive criteria for commitment and procedures pertaining to due process) to ensure that such

commitment is necessary. For voluntary commitment, however, such safeguards are not mandated,

and as a concomitant of the parental consent

requirement for the provision of health services to

minors, parents have sometimes been allowed to

make a ‘‘voluntary commitment’ of a minor child

to a mental institution or facility, regardless of the

minor’s desire or need for services.

In Parham v. J.R. [442 U.S. 584 (1979)], the U.S.

Supreme Court rejected the contention that an

adversary hearing was required to decide whether a

minor may be committed by his or her parents in

order to protect the minor, but held that the risk of

error in the parental decision to commit a minor to

a mental health facility was sufficiently great as to

call for an inquiry by a neutral fact finder to

determine whether the statutory criteria for admission were met. About two-thirds of the States now

have statutes that allow parents to make a voluntary

commitment to a mental health facility of a minor

child. These statutes vary substantially in the safeguards they provide against inappropriate use of

hospitalization or institutionalization to manage

‘‘troublesome’ minor children who do not have

severe mental health problems.23 According to one

analysis, “In general, . . . minors are significantly

less able than are adults to resist mental hospitalization sought for them by others” (85).

About half of the States have statutes that

authorize minors to apply for admission as an

inpatient to a mental institution or facility without

parental consent. Most of these statutes impose

minimum age limits, the most common being 16

years of age or older. Finally, a few States have

statutes that require both the minor’s consent and a

parent consent for inpatient mental health services.

Confidentiality and Parental Notification

Requirements

It has long been accepted that the confidentiality

of the relationship between a physician and patient,

as well as of the relationship between other types of

health care providers and their patients or clients, is

essential to a patient’s trust in a health care provider

and to a patient’s willingness to supply information

candidly (68). Courts and legislatures have established a physician-patient privilege to protect the

confidentiality of communications between physicians and their patients and have established similar

privileges to ensure the confidentiality of communications between other types of health care providers

and their patients or clients (29). Furthermore, there

is a developing case law imposing liability on

physicians for unauthorized disclosure of confidential information about their patients (8) (although all

health care professionals are required by law to

disclose information in situations where there is a

strong societal interest in disclosure-e. g., in the

reporting of cases of suspected child abuse to the

public child welfare authorities (47)).

~Men~ he~th services for adolescents are reviewed in ch. 11, “Mental Health Problems: Prevention and Semices,” in Vol. Il.

23Some ~ople me concerned tit Ihc rising admission to psychiatric units of private hospitals are indicative of widespread misuse of commitment

to control “troublesome” minors (85). See ch. 11, “Mental Health Problems: Prevention and Services,” in Vol. II, for further discussion.
Chapter 17—Consent and Confidentiality in Adolescent Health Care Decisionmaking . ///-131

By and large, the confidentiality of the relationship between health service providers and minors

and the disclosure of confidential information by

health service providers to the parents of minors or

other third parties are not addressed in case or

statutory law. Requirements that parents be notified

of a minor’s decision to obtain health services or of

the minor’s actual receipt of health services, however, have in fact become a‘ ‘legal’ issue. In carving

out exceptions to the requirement for parental

consent to the provision of health services to minors,

courts and legislatures have sometimes-though not

always—replaced the parental consent requirement

with a parental notification requirement.

The justifications for requiring that the parents of

minors be notified of the decisions of their minor

children to obtain health services are essentially the

same as---or at least very similar to-the justifications for requiring that parents consent to health

services for minor children. One justification for

parental notification requirements is to ensure that

parents play an appropriate “guiding role” in

counseling their minor children about health care

decisions—a role assumed to be needed given the

presumed incompetency of minors to make health

care decisions based upon minors’ assumed lack of

decisionmaking capacity.

24 Another major justifica--

tion is to bolster parental direction and control of

their minor children and thereby to maintain the

family structure.25

Parental Notification Requirements for Health

Services Provided to “Emancipated,”

“Independent,” or “Mature” Minors

The prevailing pattern in the many State statutes

that authorize ‘‘emancipated minors’ to obtain

health services without parental consent is for these

statutes to be silent concerning parental notification;

only a few of these statutes contain various kinds of

parental notification provisions. The same prevailing pattern is found in States’ ‘‘independent minor’

statutes and ‘‘mature minor’ statutes.

Parental Notification Requirements for

Emergency Health Services

The prevailing pattern in the many State statutes

that create an exception to the parental consent

Photo credit: Los Angeles Free Clinic, Project Able

Courts and legislatures seem to regard parental

notification requirements as less burdensome for

adolescents than parental consent requirements, but it is

not clear that adolescents in conflict with their parents

make this distinction.

requirement in health emergencies is for the statutes

to have no provisions concerning parental notification; only a handful of these statutes have some sort

of parental notification provisions.

Parental Notification Requirements for Specific

Types of Health Services

Many parental notification provisions appear in

State statutes that create exceptions to parental

consent requirements by allowing minors to consent

to health services related to sexual activities, health

services for drug and alcohol abuse, or mental health

services (see discussion of these exceptions above).

Although the legislatures and courts appear to regard

the requirement of parental consent as more onerous

from the standpoint of an adolescent than the

requirement of parental notification, it is not clear

that adolescents distinguish between parental consent and notification requirements. According to

one observer, it is ‘‘immaterial to the adolescent just

when parents learn (before or after the fact of

treatment) or how parents learn (by mandatory

consent, by notification, or by inadvertent disclosure

through parental reading of the health record)” (43).

—

XSW, for exmple, HL. V. ~ar~e~on, 45o U.S. 398 (Burger, J.) (Powell, J. concurring); HL. V. A4atheson 42025 (Stevens, J. conc~ng); ~d BD.

Hofrnzq “The Squeal Rule: Statutory Resolution and Constitutional Implications--Burdening the Minor’s Right of Privacy” (44).

~See, for example, M- Bo~! “Dispensing Birth Control in Public Schools: Do Parents Have a Right To Know?” (23).
///-132 . Adolescent Health-–Volume ///: Crosscutting Issues in the Delivery of Health and Related Services

Notification Requirements for Health Services

Related to Sexual Activities-Parental notification

requirements related to health services involving

sexual activities pertain to the three major categories

of services mentioned earlier: 1) health services

related to venereal, sexually transmitted, and infectious diseases and acquired immunodeficiency syndrome (AIDS); 2) family planning services and

abortion services; and 3) pregnancy-related health

services.

Notification Requirements for Health Services for

Venereal, Sexually Transmitted, and Infectious Diseases and AI.. S-The many State statutes that

authorize minors to obtain testing and treatment for

venereal, sexually transmitted, or infectious diseases

without parental consent generally do not require

parental notification. A few States have statutes that

specifically state that services for these diseases may

be furnished to minors without parental notification;

nearly one-third of the States have statutes that give

health professionals general discretion to notify

parents or discretion to notify parents under certain

specified circumstances; nearly two-thirds of the

States have statutes that contain no parental notification provisions; and one State has a statute that

mandates parental notification under limited conditions.

The relatively small number of State statutes that

permit minors to be tested and treated without

parental consent for infection with HIV (the virus

that causes AIDS) generally do not require parental

notification. A few States have statutes with provisions giving health professionals general discretion

to notify or discretion to notify parents under

specified circumstances; one State has a statute that

contains no parental notification provision; and one

State has a statute requiring confidentiality unless a

minor’s HIV test results are positive, in which case

parental notification is required.

Notification Requirements for Family Planning

Services and Abortion Services---Only a few of the

State statutes that permit minors to consent to family

planning services without parental consent have

provisions pertaining to parental notification of the

minor’s application for receipt of such services, and

nearly all of these provisions allow but do not

compel parental notification. As of mid-1990, the

U.S. Supreme Court had not directly addressed the

constitutionality of parental notification requirements that involve parents in a minor’s decision

about obtaining family plannin g services.

In 1983, the U.S. Department of Health and

Human Services unsuccessfully attempted to promulgate Federal regulations requiring that family

planning clinics receiving Federal funds under Title

X of the Public Health Service Act26 notify parents

of unemancipated minor children when contraceptives were prescribed.27 These regulations-issued

pursuant to a congressional amendment to the

authorizing statute for the Title X family planning

program that provided that ‘‘[t]o the extent practical,

entities which receive grants or contracts under this

subsection shall encourage family participation in

projects assisted under this section” [42 U.S.C. §

300(a) (1982 )]—aroused a great deal of controversy

and were the subject of litigation in the Federal

courts. Ultimately, two Federal courts enjoined the

Department from implementing the regulations.28

Although the issue of parental notification has

also generated a great deal of attention in relation to

minors’ access to abortions, the U.S. Supreme Court

has not dealt extensively with parental notification

in cases involving abortion services for minors. In

the 1981 case H.L. v. Matheson [450 U.S. 398

(1981)], however, the Supreme Court sustained the

constitutionality of a State statute requiring a

physician to notify “if possible” the parent of a

minor upon whom an abortion is to be performed as

applied to a minor living with and dependent on her

parents; the Court left open the question of whether

the statute would be constitutional as applied to

emancipated or mature minors.

In Hodgson v. Minnesota [110 S.Ct. 2926 (1990)],

handed down in June 1990, the Supreme Court

26For tier discussion of the Title X family pl arming program, see ch. 10, ‘‘Pregnancy and Parenting: Prevention and Semices,’ in Vol. II and ch.

19, “The Role of Federal Agencies in Adolescent Healti’ in this volume.

zv~e reWlatlon provid~ tit 10 &lys after prescribing a contraceptive drug or device for a minor, the fmy p-gclinic must notify tie ~or’s

parent [45 CFR $ 59.5(a) (12)(i)(A)].

2s~e CoWof ApW~s for tie se~l~d Ciraitheld that tie 1981 amendment to Title X did not authorize the regulation mandating ParenW notfi~tion

[New York v. Heckler, 719 F.2d 1191 (2d Cir. 1983)]. The Court found that Congress did not intend to require parental notification but merely to

encourage parental involvement. The Court of Appeals for the Disrnct of Columbia held that the regulation requiring parental notilcation was

inconsistent with congressional intent with respect to Title X [Pkzrmed Parenthood Federation of America v. Heckler, 712 F.2d 650 (D.C. Cir. 1983)].
Chapter 17—Consent and Confidentiality in Adolescent Health Care Decisionmaking .111- 133

struck down as unconstitutional a section of a

Minnesota statute requiring that both parents of an

unemancipated minor be notified before she undergoes an abortion, except under very limited circumstances. However, the Court upheld the constitutionality of a section of the statute providing for the same

two-parent notification requirement with the addition of a ‘‘judicial bypass” procedure. In a contemporaneous decision, Ohio v. Akron Center for

Reproductive Health [110 S. Ct. 2972 (1990)], the

Court upheld the constitutionality of an Ohio statute

making it a crime for a physician or other person to

perform an abortion on an unmarried, unemancipated minor unless: 1) there was timely notice to one

of the minor’s parents, her guardian, or custodian; 2)

the minor’s parents, guardian, or custodian had

consented to the abortion; 3) a juvenile court had

issued an order authorizing the minor to consent to

the abortion, thereby bypassing parental notification

for consent; or 4) judicial inaction under certain

circumstances constitutes constructive authorization

for the minor to consent.

A little under one-quarter of the States have

statutes requiring parental notification of a minor’s

abortion decision. In the wake of the Webster ruling,

there has been increased debate as to whether

parental notification of abortions involving minors

should be required,29 and the Supreme Court’s

decisions as to the constitutionality of the two State

statutes just mentioned may furnish an impetus for

additional State legislative activity aimed at requiring parental notification in the case of a minor’s

decision to have an abortion.

Notification Requirements for PregnancyRelated Health Services-The many State statutes

that authorize minors to obtain pregnancy-related

health services without parental consent generally

do not require parental notification. One State has a

statute that explicitly provides that prenatal care may

be furnished without parental notification; somewhat under one-third of the States have statutes that

have no provisions regarding parental notification;

and about one-fourth of the States have statutes that

provide for parental notification at the discretion of

health professionals.

Notification Requirements for Health Services

Related to Drug and/or Alcohol Abuse-The

many State statutes that allow minors to obtain

health services for drug and/or alcohol abuse without parental consent exhibit considerable variation

when it comes to parental notification provisions--

and this variation makes generalizations difficult.

Some of these State statutes are silent as to parental

notification; some of the statutes require that a

minor’s drug or alcohol abuse treatment be kept

confidential under specified circumstances; some of

the statutes leave parental notification up to the

discretion of the health professional or to the

discretion of the health professional under certain

specified circumstances; a few State statutes require

parental notification attempts; and a few of the

statutes require parental notification or require

parental notification under certain specified circumstances.

In 1987, the U.S. Department of Health and

Human Services issued a final rule for federally

funded alcohol and drug abuse programs that

prohibits such programs from notifying a minor’s

parent of the minor’s application for treatment

without the minor’s written consent to notification in

States where State law permits minors to obtain

alcohol or drug abuse treatment without parental

consent [42 CFR, Part 2 § 2.14 (1989)]. This

prohibition covers, among other things, the disclosure to a minor’s parent of patient identifying

information for the purpose of obtaining financial

reimbursement; however, ‘‘these regulations do not

prohibit a program from refusing to provide alcohol

or drug abuse treatment until a minor consents to the

disclosure necessary to obtain reimbursement. . .“

[42 CFR, Part 2$2.14 (1989)]. In States where State

law requires parental consent to alcohol or drug

abuse treatment, the rule states that the fact of a

minor’s application for treatment may be communicated to the minor’s parent only if: a) the minor has

given written consent; or b) the minor ‘‘lacks the

capacity for rational choice’ regarding such consent

(e.g., because of extreme youth or physical condition) and the minor’s ‘‘situation poses a substantial

threat to the physical well-being of the minor or

other person’ that may be alleviated by parental

notification [42 CFR, Part 2 § 2.14 (1989)].

Notification Requirements for Mental Health

Services-The many State statutes under which

minors can consent to mental health services or

2

9 See C. Collins, “Abortion Focus Shifting to Teenagers” (30); New York Times, “Kamsas Is Urged To Curb Abortion” (70); New York Times,

“Virginia Senators Stall Bill To Curb Abortion” (71).
///-134 . Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Photo credit: Joe M. Sanders, American Academy of Pediatrics

Laws requiring parental consent and notification in the

provision of health services to adolescents do not affect

adolescents’ access to services unless there are

conflicts or potential conflicts between adolescents,

their parents, and health care professionals.

receive mental health services without parental

consent vary in terms of parental notification requirements. The majority of State statutes that allow

minors to consent to outpatient mental health

services are silent as to parental notification, and the

remainder of statutes specify that mental health

treatment should be confidential, specify that notification is at the discretion of health professionals, or

mandate parental notification under designated limited conditions. The majority of State statutes that

allow minors to consent to inpatient mental health

services similarly do not have parental notification

provisions, and the remainder provide for parental

notification at the discretion of health professionals,

or provide for notification under certain circumstances. Perhaps not surprisingly, inpatient mental

health statutes are more likely than outpatient

statutes to require or permit parental notification.

The Impact of Law Requiring Parental

Consent and Notification on Minors’

Access to Health Services

What is the impact of law requiring parental

consent to health services for minors or requiring

parental notification of the provision (or intended

provision) of health services to minors? More

specifically, what is the impact of parental consent

and notification requirements on minors’ access to

health services and on minors’ utilization of health

services?

Several factors affect the impact of legally mandated parental consent and notification requirements

on minors’ access to and utilization of health

services. One factor is whether--and if so, to what

degree--there are actual or potential conflicts

between minors, the parents of minors, and health

professionals in the making of health care decisions

involving the minor. As noted earlier, laws requiring

parental consent and notification do not become

critical, or even relevant, unless there are such

conflicts. In some cases, the way a health professional presents information to a minor and the

minor’s parents and what kind of relationship he or

she has with them may have a decisive influence on

the nature and extent of such conflict. If a health

professional has knowledge, skills, and experience

regarding the management of potential conflicts,

some conflicts may well be avoided (43,77).

On the other hand, some conflicts between

minors, their parents, and health professionals over

health care decisions affecting the minor are probably unavoidable. There is some evidence that actual

or potential conflicts do occur in a significant

number of cases involving decisions about the

provision of family plannin g and abortion services

to adolescent minors .30 What is not known, however,

is whether-and if so, to what degree--actual or

potential conflicts occur in cases involving decisions

about other health services that minors, particularly

adolescent minors, may want or need.

Another factor that affects the impact of legally

mandated parental consent or notification requirements for the delivery of health services to minors is

whether--and if so, to what degree--wealth care

providers comply with these requirements in providing health services to minors. Laws might be

expected to evoke compliance, carrying with them

as they do sanctions for violations and constituting

as they do a societal declaration that certain conduct

is right or wrong. Clearly, however, laws differ in

their effectiveness. Noncompliance with parental

consent or notification laws on the part of health

professionals might occur because the professionals

misunderstand or do not know the legal requirements. Noncompliance might also occur because the

legal requirements, at least as applied to particular

factual situations, are at odds with the ethical

?OSec, for ~Wple, Brief for petitio[le~ at 1623 Hodgson v, Minnesota [853 F.2d 1452 (8th Cir. 1988) (en Me), appeal fikd @.S. Feb. 3, 1989)

(NO. 88-11257), 110 S.Ct. 400 (1989)1.
Chapter 17—Consent and Confidentiality in Adolescent Health Care Decisionmaking .111-135

standards as expressed in statements by professional

organizations of their profession (see box 17-A) or

with their personal ethical values and norms. OTA

is unaware of any empirical studies and data

concerning compliance and noncompliance with

legally mandated parental consent or notification

requirements that would permit valid conclusions

about the extent of compliance and noncompliance

among health service providers.

To the extent that legally mandated parental

consent and notification requirements are adhered to

by health professionals, the issue arises of whether—

and if so, to what degree-such requirements may

operate as barriers to adolescents’ access to needed

health services. As noted earlier, it is not clear that

adolescents distinguish between parental consent

and notification requirements. With parental consent

and notification requirements in place, one possible

scenario is that a substantial number of parents of

adolescents would frequently and strongly object to

the provision to their children of at least some health

services-for example, family planning or other

services associated with sexual activity, services for

substance abuse, and services for mental health

problems. A possibly related scenario is that a large

number of adolescent minors would be unwilling to

reveal to their parents their need for health servicesor at least their need for certain services associated

with sexual activity, drug or alcohol abuse, or mental

health problems—and therefore would delay or be

deterred from seeking these services entirely.

Several empirical studies concerning the impact

of parental consent and notification requirements

indicate that such requirements-at least in the case

offamily planning and abortion services--do create

barriers to adolescents’ access to and utilization of

services (21,22,25,26,28,78,79,87,88). What cannot

be said with certainty, however, is whether the

findings of these studies of the impact of parental

consent and notification requirements on adolescents’ access to family planning and abortion

services can be extrapolated to other types of health

services.

One other point related to evaluating the impact of

parental consent and notification requirements is

deserving of mention. Even if the laws in a given

jurisdiction do not require that a parent consent to

health services for a minor and/or that the parent be

notified of the provision or intended provision of

Photo credit: March of Dimes Birth Defects Foundation

In the case of family planning and abortion services,

studies have found that parental consent and

notification requirements pose a significant barrier

to adolescents’ access to and utilization of services.

Quite probably, such requirements also pose similar

barriers to adolescents’ access to other types of

services (e.g., mental health treatment, drug abuse

treatment, alcohol abuse treatment).

health services to a minor, health care providers—

both institutional providers (e.g., hospitals, clinics,

and health maintenance organizations) and individual providers--may as a matter of policy or practice

refuse to provide services to minors without parental

consent and/or notification. One of the main reasons

that health care providers may refuse to provide

services without parental consent is probably financial--i.e., providers may be concerned that a minor

will be unable to pay for services provided and that

the minor’s parents will not pay for services because

they have not consented to or been notified of the
111-136. Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Box 17-A--Professional Ethical Standards Relevant to Consent and Confidentiality

A central principle of medical ethics is that “a physician may not reveal the confidences entrusted to him in

the course of medical attendance. . . unless he is required to do so by law or unless it becomes necessary in order

to protect the welfare of the individual or the community” (9). Many organizations of physicians, nurses,

psychologists, social workers, and other professionals engaged in providing health services to adolescents have

issued or approved professional ethical standards that similarly stress the importance of maintaining confidentiality

between the health professional and the patient or client being served but at the same time acknowledge that legal

obligations and the welfare of the individual and the community may take precedence over confidentiality

(2-4,6,7,9-16,65-67).

Few of the ethical standards issued or approved by organizations of health professionals speak directly to issues

of consent and confidentiality as they arise in the provision of health care to adolescents. A conference sponsored

by the American Academy of Pediatrics in 1981 sought to address that problem. Conference participants from a

variety of disciplines agreed that the following principles should govern consent and confidentiality m adolescent

health care:

●

●

●

●

●

●

●

●

●

●

●

●

With respect to adolescence, there exists an enduring need to balance delicately the relative rights and needs

of minors to confidential health services with the relative rights and responsibilities of parents toward their

offspring.

Adolescents should have access to needed health services.

Adolescents, unless fairly adjudged incompetent, should participate in decisions pertaining to their health.

The concept of “mature minor” and the capacity of that individual to consent is recognized.

Even when adolescents seek health care on their own consent, they should be encouraged to involve their

parents, unless there is compelling reason not to do so. (In that case, often an alternative adult adviser/relative

is appropriate.)

Chronologic age is not a suitable yardstick to determine an adolescent’s maturity and capacity to give

informed consent. Development criteria are far more telling, as applied on an individual basis.

Adolescents generally should be entitled to confidentiality in their own health care, and that presumption

should be overridden only by good reason.

Parental notification should be encouraged but not be made mandatory in the provision of adolescent health

care, especially inasmuch as the absence of guaranteed confidentiality could deter many young persons from

seeking and receiving necessary services.

Adolescents should have the same right of access to their health care records as do adults unless there is

compelling reason to the contrary.

Disclosure of health data to third parties, such as health insurers, should only be with parents’ informed

consent and/or that of adolescents if it pertains to care they have received on their own. As a general rule,

adolescents should retain the right to consent to such disclosure with or without parental participation, and

even if the adolescent did not originally consent to the health care, unless there is a compelling reason not

to.

Health providers and third-party repositories periodically should review data collected during an

individual’s minority to reassess its relevance, expunging data no longer needed.

To protect adolescents, they should be provided with some record as to where their health information was

sent, when it was sent, and for what purpose (5).

In 1989, the American College of Obstetricians and Gynecologists (ACOG) issued a policy statement setting

forth the most extensive ethical standards pertaining to consent and confidentiality in adolescent health care to date.

The statement, which has since been approved by the American Academy of Family Physicians, the American

Academy of Pediatrics, the NAACOG (the Organization for Obstetric, Gynecologic, and Neonatal Nurses), and the

National Medical Association, provides as follows:

1. Health professionals have an ethical obligation to provide the best possible care and counseling to respond

to the needs of their adolescent patients.

2. This obligation includes every reasonable effort to encourage the adolescent to involve parents, whose

support Can, in many circumstances, increase the potential for dealing with the adolescent’s problems on

a continuing basis.

3. Parents are frequently in a patient relationship with the same providers as their children or have been

exercising decisionmaking responsibility for their children with these providers. At the time providers
Chapter 17—Consent and Confidentiality in Adolescent Health Care Decisionmaking .111- 137

establish an independent relationship with adolescents as patients, the providers should make this new

relationship clear to parents and adolescents with regard to the following elements:

a. The adolescent will have an opportunity for examination and counseling apart from parents, and the same

confidentiality will be preserved between the adolescent patient and the provider as between the

parent/adult and the provider.

b. The adolescent must understand under what circumstances (e.g., life-threatening emergency) the

provider will abrogate this confidentiality.

c. Parents should be encouraged to work out means to facilitate communication regarding appointments,

payment, or other matters consistent with the understanding reached about confidentiality and parental

support in this transitional period when the adolescent is moving toward self-responsibility for health

cam.

4. Providers, parents, and adolescents need to be aware of the nature and effect of laws and regulations in their

jurisdictions that introduce further constraints on these relationships. Some of these laws and regulations

are unduly restrictive and in need of revision as a matter of public policy. Ultimately, the health risks to

the adolescents are so impelling that legal barriers and deference to parental involvement should not stand

in the way of needed health care (7).

The ACOG policy statement and American Academy of Pediatrics conference principles encourage parental

involvement in adolescent health care decisions but do not endorse the current legal requirements of parental consent

and notification. The support of health professionals serving adolescents for that statement and principles indicates

that many of these professionals are-at least in theory-more willing than most courts or legislatures have been

to grant adolescents autonomy in health care decisionmaking and to afford protection to the confidentiality of the

relationship between a provider of health services and an adolescent patient or client. Furthermore, at least one

empirical study suggests that health professionals are willing to support these ideas in practice (60).

A question that remains is how helpful existing standards in the form of statements by professional

organizations are in resolving the kinds of ethical problems that professionals encounter in providing health services

to adolescents. The following situations, compiled by a national authority on adolescent medicine, are illustrative

of potential conflicts between interests of the adolescent, the adolescent’s parents, and the state (77):

●

●

●

●

●

A 16-year-old boy is discovered to have a malignant bone tumor. Appropriate treatment requires amputation

of his leg. His parents consent to the surgery but he refuses. He will accept all other forms of treatment but

would ‘rather die with both legs than survive as a cripple! Do you operate without the consent of the boy?

Do you seek a court order against the wishes of the boy?

A 17-year-old boy is admitted to the intensive care unit with multiple fractures and disorientation. He was

the driver of an automobile involved in a collision in which three passengers were killed. As part of the

evaluation of his state of consciousness you determine that his blood alcohol level is well above the legal

limits for intoxication. Do you share this information with his family in explanation for his confusion? Do

you share this information with the authorities who are investigating this fatal accident?

A 16-year-old girl is brought to care by her mother who is concerned about her daughter’s poor school

performance and disruptive behavior. In your private interview with the girl, she confides that she is smoking

marijuana a few nights each week The girl feels that her current problems relate to the unrealistic

expectations of her mother regarding performance and behavior. She insists that the confidentiality of her

interview be respected and that the information about her drug use not be shared with her mother. Do you

tell the mother anyway? What if the mother specifically asks, “Is my daughter using drugs?” The mother

requests that a portion of the urine sample collected for routine analysis be sent for drug testing. Do you

accede to this request?

A 15-year-old girl returns with her parents to discuss her recently diagnosed pregnancy. Her parents are

certain that the only acceptable course of action is to terminate the pregnancy. The girl is adamant in her

refusal to consider an abortion. What do you do?

A 16-year-old girl is brought for evaluation by her mother because of a complaint of abdominal pain.

Physical examination and laboratory evaluation reveal a vaginal discharge secondary to gonorrhea. The girl

admits to multiple brief intimate relationships over the past few months. She states that her mother would

“kill her” if she found out. You know the family and the mother is a bit of a tyrant with a quick temper.

What do you tell the mother?

Continued on next page
///-138 . Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

provision of services. 31 Another reason may be of decisionmaking capacity; however, the legal

providers’ concern that the effectiveness of the

services provided will be reduced by lack of parental

involvement or belief that the effectiveness of the

services provided will be enhanced by parental

involvement.

Minors’ Competency To Make

Health Care Decisions

As noted at the beginning of this chapter, individuals traditionally have been treated as legally

competent or incompetent for purposes of health

care decisionmaking on the basis of their age rather

than a determination of their actual capacity for

decisionmaking. As a general rule, the law presumes

that adults are competent to consent to health care

and that minors are incompetent. The legal presumption that minors as a class are incompetent to consent

to health services rests at least in part on the

assumption that minors as a class lack the requisite

decisionmaking capacity. The legal presumption

that adults are competent is rebuttable under some

circumstances upon a factual showing of actual lack

presumption that minors are incompetent is not

rebuttable by a factual showing of actual presence of

decisionmaking capacity in the absence of legislatively or judicially sanctioned rules permitting such

a showing.

The factual validity of assumptions that minors

lack the requisite capacity to make health care

decisions has been increasingly challenged.32 Accordingly, the presumption that minors are incompetent to make health care decisions has been increasingly subject to criticism on the ground that it

inequitably denies minors in middle or late adolescence-some of whom actually have the requisite

decisionmaking capacity-the power to make their

own determinations about obtaininghealth services

(82). Since assumptions concerning minors’ lack of

health care decisionmaking capacity seem largely to

reflect the intuition of judges and legislators rather

than hard evidence, it is important to identify

empirical research bearing upon the validity of these

assumptions and to evaluate whether such research

supports modification or elimination of the pre311f a Pmmt kco=nt~ to h~th servicm for his or her minor chil~ the parent is usually f-cially liable for the services. If a parent hM not

consented to health services for the minor child, however, the parentis usually not f-idly liable unless the services are determined to be “necessary.’

If the parentis not f~cially liable, lhc health c= provider may attempt to collect from the minor ch.il~ but collection may prove ~lcult beeause

the minor may have the power to disaffii the contract for services or may have insufficient f~ial resources to pay for the services. As noted at the

beginning of this chapter, one of the rationales for the parental co~ent requirement seems to be to assure providers of the availability of a payment source

for their services.

nsw, for ex~ple, G. Melton, “C’hildren’s Consent: A Problem in Law and Social Science” (61).
Chapter 17-Consent and Confidentiality in Adolescent Heatth Care Decisionmaking . III-139

sumption that minors are incompetent to make their

own health care decisions,

Empirical research bearing on the competency of

minors to make health care decisions was reviewed

by OTA’s contractors and is discussed below.

Before turning to that research, however, it is

necessary to examine two definitional issues: frost,

what constitutes effective legal consent to health

services; and second, what constitutes legal competency to make such consent.

Ambiguities in Legal Definitions of

Consent and Competency

What Constitutes Effective Legal Consent

to Health Services

As alluded to at the beginning of this chapter, the

tort law doctrine of informed consent requires

physicians and surgeons to obtain from their patients

informed consent for medical treatment or surgery;

failure to obtain informed consent may give rise to

civil liability .33

The informed consent doctrine has been developed in judicial opinions and codified by legislation

and does not readily lend itself to a concise

summary. Nevertheless, one leading tort law authority has summarized the doctrine as follows:

The informed consent doctrine is based on

principles of individual autonomy, and specifically

on the premise that every person has the right to

determine what shall be done to his own body.

Surgeons and other doctors are thus required to

provide their patients with sufficient information to

permit the patient himself to make an informed and

intelligent decision on whether to submit to a

proposed course of treatment or surgical procedure.

Such a disclosure should include the nature of the

pertinent ailment or condition, the risks of the

proposed treatment or procedure, and the risks of any

alternative methods of treatment, including the risks

of failing to undergo any treatment at all. Thus,

although the procedure is skillfully performed, the

doctor may nevertheless be liable for an adverse

consequence about which the patient was not adequately informed.

In addressing the perplexing question of whether

the patient needed to know about a particular

undisclosed risk in order to make an informed

decision, the courts often speak in terms of the

materiality of the risk: the doctor’s duty is to disclose

all risks which are ‘‘material. The extent of this

duty to disclose has traditionally been based upon a

professional medical standard-whether physicians

customarily inform their patients about the type of

risk involved, or whether a reasonable physician

would make the disclosure in the circumstance,

Since the use of a professional standard paternalistically leaves the right of choice to the medical

community, in derogation of the patient’s right of

self-determination, a number of recent cases have

defined the duty in terms of the patient’s need to

know the information-based on whether a reasonable person in the patient’s position would attach

significance to the information.

In addition to proving the doctor’s failure to

provide sufficient information, on whatever standard, the plaintiff must also establish a causal link

between the nondisclosure and his harm, by proving

that he would not have undergone the treatment had

he known of the risk of harm that in fact occurred.

. . . [Citations omitted] (53).34

Rationales for the informed consent doctrine are

to promote the patient’s autonomy and protect the

patient’s right of self-determination (64), to protect

patients against depersonalized authoritarian medical treatments, and to encourage rational decisionmaking (59). It is important to note that focus of the

doctrine as it has been articulated and applied is on

the duty of health professionals to disclose information to an individual. The focus has not been on the

individual’s actual understanding of the information

disclosed.

What Constitutes Legal Competency

To Make Health Care Decisions -

The legal concept of competency has a very long

history and is central to existing laws governing

health care decisionmaking with respect to adolescents. On the one hand, as noted earlier, the

well-established legal requirement that parents must

consent to the provision of health services for their

minor children is partially an outgrowth of the

presumption that minors are incompetent (which in

turn is based on assumptions of their lack of

decisionmaking capacity). To some extent, judicial

33T0 be legally effective, conwnt to health care sewices must be both 4’kfOrmed’ ~d also be ‘ ‘vol~tarY. ’ The concept of voluntariness is not well

defined (17).

34 For &ussion of tie development of tie ~om~ consent doc~e, s= p.s. Appclba~ C.w, IJdz, and A. Meiscl, Informed Consent: figa/

Theo~ and Clinical Practice ( 17); for a State-by-State analysis of the application of the informed consent doctrine, see AJ, Rosoff, Informed Consent:

A Guide for Health Care Providers (73).
III-140. Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

and statutory parental notification requirements

applied to minors are also derived from this presumption and assumption. On the other hand,

‘‘mature minor’ and some other exceptions to the

parental consent requirement, as discussed earlier in

this chapter, represent a rejection of the presumption

of minors’ incompetence (and underlying assumptions of their lack of decisionmaking capacity) as

applied to some minors under certain circumstances.

Unfortunately, neither the courts nor the legislatures in this country have furnished much guidance

as to the content and meaning of competency in the

context of health care decisionmaking. The U.S.

Supreme Court has most fully articulated its assumptions concerning the minors’ lack of health care

decisionmaking capacity (which underlie the presumption of minors’ incompetency to make health

care decisions) in decisions dealing with minors’

rights to obtain contraceptives and abortions without

parental involvement and in decisions dealing with

the civil commitment of minors by parents (see

discussion above). A thread that runs through these

Supreme Court decisions is the Court’s concern that

minor children do not possess the intelligence,

maturity, and experience that their parents possess.

Another thread that runs through these decisions is

the Court’s concern that minors are not capable of

making informed and voluntary decisions. The

Court’s specific concerns in this regard are that

minors may not understand or appreciate the short-or

long-term consequences of their decisions, that they

may be susceptible to interpersonal pressures in

making decisions, and that they may make unwise

decisions detrimental to their welfare.

 Courts-and, to a lesser extent, legislatures—

have probably come closest to enunciating a standard for determining the competency of minors to

make health care decisions in connection with

exceptions to parental consent requirements for

‘‘mature’ minors (see discussion above). The standard for judging competency in these cases is

essentially whether the minor is capable of understanding the nature and consequences of proposed

medical or surgical treatment and procedures. Unfortunately, however, this standard for determining

a minor’s competency provides little real assistance

for its application in particular cases.35

Recognizing the need to define with more specificity a criterion for determining whether a person,

including an older minor, is competent to make

health care decisions, the President’s Commission

for the Study of Ethical Problems in Medicine and

Biomedical and Behavioral Research noted that

three general criteria have been used to determine if

a patient lacks capacity to make health care decisions: the outcome of the decision, the status or

category of the patient, and the patient’s fictional

ability as a decisionmaker.

The outcome approach-which the Commission

expressly rejects-bases a determination of incapacity primarily on the content of a patient’s decision.

Under this standard, a patient who makes a health

care decision that reflects values not widely held or

that rejects conventional wisdom about proper health

care is found to be incapacitated.

Using the status approach, certain categories of

patients have traditionally been deemed incapable of

making treatment decisions without regard to their

actual capabilities. Some of these categories of patients—such as the unconscious--correspond closely

with actual incapacity. But other patients who are

presumed to be incapacitated on the basis of their

status may actually be capable of making particular

health care decisions. Many older children, for

example, can make at least some health care

decisions, mildly or moderately retarded individuals

hold understandable preferences about health care,

and the same may be true in varying degrees among

psychotic persons.

The third approach to the determination of incapacity focuses on an individual’s actual functioning in decisionmaking situations rather than on the

individual’s status. This approach is particularly

germane for children above a certain age variously

described as from seven to mid-teens. . . . .

The Commission recommends that determinations of incapacity be guided largely by the functional approach, that individuals not in certain basic

categories (such as under the age of 14, grossly

retarded, or comatose) should be assumed to possess

decisionmaking capacity until they demonstrate

otherwise, and that incapacity should be found to

exist only when people lack the ability to make

decisions that promote their well-being in conform35see, for exmple, G.B. Melton, “Legal Regulation of Aborliou Unintended Effects” (62).
Chapter 17—Consent and Confidentiality in Adolescent Health Care Decisionmaking . ///-141

ity with their own previously expressed values and

preferences. [Citations omitted] (72).36

The failure of courts and legislatures to furnish

much guidance as to the content and meaning of

competency in terms of health care decisionmaking

has had important implications for the strategies

adopted in empirical studies of the capacity of

minors to make health care decisions. Because

courts have not provided operational definitions of

legal standards for minimally competent decisionmaking, researchers have been unable to use an

operational definition of competency corresponding

to the legal definition. Thus, researchers seeking to

test the validity of the law’s presumption that adults

are competent and minors are incompetent to make

health care decisions have had to resort to an

alternative strategy-namely, comparing decisionmaking by minors to decisionmaking by adults (i.e.,

individuals age 18 and over). Since adults are

presumed by the law to be competent, adults’

decisionmaking capabilities implicitly set the standard against which the decisionmaking capabilities of

minors are to be judged. If the decisionmaking of

minors and adults were found to be indistinguishable, the argument for lowering the age of legally

effective consent would be strengthened, although

other considerations would have to be taken into

account as well. Virtually all of the empirical

research on the competency of minors to make

health care decisions reviewed by OTA’s contractors recognizes that the standard of comparison is the

decisionmaking ability of adults.

Empirical Research on Minors’ Competency To

Make Health Care Decisions

To review the empirical research on the competency of minors to make health care decisions,

OTA’s contractors selected a core group of seven

empirical studies that address the cognitive development of minors and tested whether minors differ

from adults in their ability to make health care

decisions (1,1 8,48,49,55,56,86). Those core studies,

which are listed in table 17-1, share the following

characteristics:

●

●

●

●

they involve health care decisionmaking;

they involve participants whose ages span or

overlap the range of 10 to 18 years;

they involve comparison groups with at least

some subjects legally considered adults-i. e.,

age 18 or over37 (although no adult participants

in the core studies were older than 25 and most

were 21 or younger); and

they appear to be methodologically adequate.

In addition to the core group of studies, a few

other studies that lack one or more of the features

just mentioned but nevertheless provide insight into

decisionmaking by minors were reviewed (40,51,57,

58,76). Some of these other studies address decisionmaking domains not addressed in the core group of

studies (e.g., legal decisionmaking); and some of

them deal with the effect on decisionmaking of a

variable or variables other than age (e.g., the

differential vulnerability of minors and adults to

social influence of peers, family, or professionals).

Findings of the Core Group of Empirical Studies

on the Age-Competence Relationship

in Health Care Decisionmaking

The findings of the core group of seven empirical

studies on the age-competence relationship in health

care decisionmaking reviewed by OTA contractors are summarized in table 17-1 and discussed in

more detail below. These core studies generally

found few differences in health care decisionmaking

as a function of age for adolescents as young as 14

or 15 years of age. It is important to note that most

of the core studies did not collect information on

decisionmaking by adults older than 25, and most of

the core studies did not collect information on

decisionmaking by adolescents under age 13 (i.e.,

ages 10 to 12).

Lewis, 1980--The 1980 study by Lewis compared hypothetical pregnancy decisions for 42 unmarried minors (ages 13 to 17) and young adults

(ages 18 to 25) awaiting the results of pregnancy

tests in a clinic (55). Those who learned they were

pregnant would be faced with the decision whether

to have an abortion or deliver a child. All 42

36see ~lsO L,H. ROth, A, Mclse., ~d C.W. Lldz, < ‘Tests Of Competence To Consent to Treatment’ (74), (The vtiOUs legal, medical ~d pSyChia~C

tests of competency being utilized may be categorized as: evidencing a choice, ‘‘reasonable’ outcome of choice, choice based on 4 ‘rational’ reasons,

the ability to undemtand, and actual understanding.)

~TA~ noted ~revlou~]y, this OTA Repo~ fom~es on ~ndivJd~ls ages I () ~ough 18. ~g~]y, 1 &ye~-ol& ~ Ccm.sickrtxl adults in au but three s~t~

(where the age of majority is 19). In the studies comparing decisio nmaking capabilities of adults and minors listed in table 17-1, therefore, 18-year-olds

are regarded as adults.
III-142 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Table 17-1—Summary of Seven Core Empirical Studies of the Age-Competency Relationship in

Health Care Decisionmaking

Influence of age on decisionmaking

studya Sample Decision domain No differences Differences found

Lewis, 1980 N=4 2

Ages 13-17 V. 18-25

Possibly pregnant, unmarried females; diverse

socioecnomic statuses;

urban California

Lewis, 1981 N = 108

Ages 12-19

(grades 7-8,10 and 12)

Middle to upper socioeconomic status; 87% expected to attend college;

San Francisco

Weithorn and Campbell, 1982 N=96

Ages 9, 14, 18, 21

Half male, half female;

white; middle socioeconomic status; younger

groups, Long Island; older

groups, Washington, DC

Belter and Grisso, 1984 N=6 0

Ages 9, 15, 21

Ail males; predominantly

white; middle-class; average to above average

IQ

Kaser-Boyd et al,, 1985 N =62

Ages 10-13 v. 14-20

Behaviorally disordered,

emotionally disturbed,

learning disabled; some

with, without prior therapy experience; 70% middle socioeconomic

status, 20% low-mid, 10%

low; mostly white, 16

nonwhite; 670/. male;

probably LA.

Pregnancy: knowledge

of law, source of advice,

reasons for choice

Cosmetic surgery,

choice of custodial parent, research: on acne

medication, on “mind”

choice of treatment alternatives for diabetes, epilepsy, enuresis, depression; risks, benefits, etc.

Recognizing and protecting against violations of

patients’ rights by a professional

Psychological treatment;

risks, benefits

In knowledge of laws; in

number of types of people consulted; in advice

expected; in consideration of childrearing ability; in hypothetical advice giving.

In consulting with peers

or parents; in revising

attitudes in light of new

information.

In expression of a decision preference or

choice of treatments

among 14-,18-, 21-yearolds; in reasons for

choice (except as noted);

in factual understanding

and appreciation of prob

Iems/consequences (except as noted).

In recognition or protection of patients’ rights

between 15-and 21 -yearolds who were briefed

about such rights.

In identifying risks [Author’s note: ns were too

small in some instances

to complete chi-sq]; in 8

benefit dimensions.

The 18- to 25-year olds

were more likely to consult a professional; consider their own ability to

care for a child. The

13- to 17-year olds were

more likely to consider

impact of a child on their

parents; to consider possibility of deformity; and to

perceive decision as externally determined.

With increasing age, there

was increasing probability of mentioning risks,

future consequences,

and desirability of consulting an independent

specialist, as well as caution against persons with

vested interests,

The 9-year-olds differed

from other groups on

treatment choices for depression; they were more

likely to choose inpatient treatment. In reasons for choices, 9-yearolds differed from other

groups; 14-year-olds differed on epilepsy. In factual understanding of the

condition and appreciation of the consequences,

9-year-olds differed from

all others.

The 9-year-olds showed

less recognition of patients’ rights violations

and failed to protect their

own rights more often than

the other two groups.

Nonsignificant trend for

10- to 13-year-olds to say

did not know if risks existed. In benefits, 14- to

20-year-olds thought

psychotherapy helped

you learn new things. The

14- to 20-year-olds used

more abstract concepts

in describing benefits.
Chapter 17—Consent and Confidentiality in Adolescent Health Care Decisionmaking .111- 143

Table 17-1—Summary of Seven Core Empirical Studies of the Age-Competency Relationship in

Health Care Decisionmaking—Continued

study’ Sample

Kaser-Boyd et al., 1986 N = 75

Ages 10-19

Adolescents with mild to

severe learning and

behavioral problems;

mostly upper middle

socioeconomic status,

Iow to mid socioeconomic

status; mostly white, 14

nonwhite; probably l-A.

Ambuel, 1989 N = 75

Ages 13-21

All females; diverse racial, economic, and religious backgrounds

. . . . .

influence of age on decisionmaking

Decision domain No differences Differences found

Psyological treatment;

risks, benefits, and irrelevant considerations

Broad range of knowledge, affect, decision

conflict around

unplanned pregnancy

In distinguishing risks, None

benefits, and irrelevant

considerations; in treatment decision vignettes.

In cognitive or volitional Females ages 13 to 15

competence (except who did not consider aboramong females ages 13 tion scored lower on the

to 15 who did not con- measure of volitional com

sider abortion an alter- petence and most measnative). ures of cognitive competence.

aFull ~’tations are listed at the end of this chapter.

SOURCE: Office of Technology Assessment, 1991, adapted from J. Gittler, M. tiigley-Rick, and M.J. Saks, “Adolescent Health Care Decisionmaking: The

Law and Public Policy,” prepared under contract to the Carnegie Council on Adolescent Development for the Office of Technology Assessment,

U.S. Congress, Washington, DC, February 1990.

participants were asked to respond to a hypothetical

question seeking advice for a person in that situation.

In terms of the decision as to whether to have a

child, this study found that the minors and young

adults did not differ from each other in terms of

knowledge of relevant laws, number or types of

people consulted, the advice anticipated from those

consulted, or considerations of childrearing ability

in giving advice to another person.

On the other hand, the young adults in the study

were more likely than the minors to want to consult

an independent professional and more likely to

consider their own childrearing abilities in deciding

whether or not to have a child themselves. The

minors were more likely to consider the impact of

their child on their own parents and gave more

weight to the likelihood of possible deformity of

their baby. Furthermore, the minors tended to

perceive the decision as being more externally

determined than as being within their own power to

make. (This perception may simply reflect the

minors’ life experience in other domains.)

Lewis, 1981—The 1981 study by Lewis asked

students ages 12 to 19 (grades 7-8, 10, and 12) what

advice they would give peers who were faced with

a variety of choices: cosmetic surgery, choice of

custodial parent, a research trial involving acne

medication, and research on ‘‘the mind’ (56). This

study found no age-related differences in advice the

participants said they would give regarding consultation with peers or parents and found no age-related

differences in participants’ revisions of attitudes in

the light of new information.

On the other hand, this study found that with

increasing age from 12 to 19, there was an increasing

tendency among participants to mention risks, future

consequences, and the desirability of consulting an

independent specialist (i.e., a specialist without

vested interests in the choice made), and there was

an increasing tendency to express caution about the

advice of persons with vested interests in the choice

made.

Weithorn and Campbell, 1982—The 1982 study

by Weithom and Campbell presented hypothetical

treatment dilemmas involving four health problems

(diabetes, epilepsy, enuresis, and depression) to

participants ages 9, 14, 18, and 21 and asked

participants what decisions they would make and the

reasons for those decisions (86).

This study found that groups of participants ages

14, 18, and 21 did not differ in their decisions or

reasons for decisions. Moreover, the decisions of

these participants did not differ from those recommended by health professionals for the problems in

question. Groups of participants ages 14, 18, and 21

also did not differ from each other on tests of factual
///-144 . Adolescent Health—Volume III: Crosscutting Issues in the Delivery of Health and Related Services

understanding of the health problems or appreciation of the consequences associated with various

options.

The group of 9-year-olds, this study found, did

differ in many ways from the older groups. The

9-year-olds were more likely than the older groups

to select inpatient treatment for depression. Indeed,

the study found an overall trend for younger

participants to be accepting of inpatient treatment

and older participants to reject it. The 9-year-olds

also differed from the older groups in the reasons for

their choices of treatment, in factual understanding

of the conditions, and in appreciation of consequences.

Belter and Grisso, 1984-The 1984 study by

Belter and Grisso studied the ability of 60 middleclass males ages 9, 15, and 21 to recognize a

violation of their rights as patients in a simulated

counseling session and to take steps to assert and

protect their rights against violations by the professional (18). The research procedure involved half the

participants at each age level receiving briefings on

the rights of patients (e.g., the rights to refuse

treatment, to know the reason for referral, to

withhold information, to refuse to allow tape recording of the session, and the rights of confidentiality

and access to records). In a subsequent session,

participants observed a videotaped counseling session and were asked at various points whether or not

a right was being violated and, if so, what they would

do to protect the right.

The Belter and Grisso study found that 15-yearolds did not differ from 21 -year-olds in their scores

on the recognition or protection of rights or in the

benefit they gained from the briefings about patients’ rights. On the other hand, this study found

that 9-year-olds showed significantly lower recognition of or asserted protection of rights than did the

15- or 21-year-olds, who did not differ from each

other.

Kaser-Boyd et al., 1985—The 1985 study by

Kaser-Boyd et al. compared behaviorally disordered, emotionally disturbed, and learning disabled

individuals ages 10 to 13 to those ages 14 to 20 in

their ability to assess risks and benefits of psychological treatment (48).

This study found that the 10- to 13-year-olds did

not differ from the 14- to 20-year-olds in the

identification of risks or evaluation of eight benefit

dimensions. A serious problem noted by the authors,

however, is that in some of these comparisons, the

numbers were too small to permit a significance test

to be performed. In terms of differences in decisionmaking as a function of age, this study found that

participants ages 14 to 20 identified more potential

benefits from psychotherapy and expressed the

perceived benefits in more abstract terms than

participants ages 10 to 13.

Kaser-Boyd et al., 1986--The 1986 study by

Kaser-Boyd et al. asked 75 adolescents ages 10 to 19

with mild to severe learning and behavior problems

to distinguish among risk and benefit factors, as well

as irrelevant considerations, with respect to a

hypothetical decision to acceptor refuse psychotherapy (49). One might regard the decisionmaking

ability of a group of adolescents with problems such

as these as immediately suspect, but in fact a group

such as this may be the right group of adolescents to

be testing, because it is adolescents with problems

such as theirs who might actually be asked to decide

whether to accept psychotherapy. Although this

study does provide comparisons in decisionmaking

among younger and older study participants up to 19

years of age, it does not provide comparisons

between subjects with and subjects without the

problems mentioned.

In any event, this study found no differences in

decisionmaking as a function of age. Participants

ranging in age from 10 to 19 years of age showed no

differences in distinguishing risks, benefits, and

irrelevant considerations, or in the psychological

treatment decisions they made.

Ambuel, 1989—The 1989 study by Ambuel

collected and analyzed data from 75 socioeconomically diverse females ages 13 to 21 who suspected an

unplanned pregnancy and were visiting a medical

clinic for a pregnancy test (1). This study is

noteworthy for combining a real-world setting in

which research participants faced a potentially

serious and stressful decision with extensive and

careful measurement of attitudes, affect, and cognition.

The study found that-apart from females ages 13

to 15 who said they excluded abortion as an

option—participants showed no age-related differences in three measures of cognitive competence

(thoroughness of consideration of consequences,

number of reasons considered, and quality of the
Chapter 17—Consent and Confidentiality in Adolescent Health Care Decisionmaking . ///-145

process and content of reasoning about pregnancy)

or in a measure of ‘‘volitional competence. ’

Females ages 13 to 15 who did not consider

abortion as an option (but no other groups of minors,

categorized either by age or attitude toward abortion) had significantly lower scores than adults age

21 and under on every measure of competence

except one measure of cognitive competence (the

number of reasons considered). This difference

suggests that females ages 13 to 15 who regard

abortion as a possibility have cognitive and volitional competencies similar to or indistinguishable

from those of young adult females, whereas females

age 13 and above whose competencies are lower

have ruled abortion out and are therefore not likely

to seek an abortion anyway.

Findings of Other Studies on the Age-Competence

Relationship in Health Care Decisionmaking

The finding of several studies that are not part of

the core group discussed above provide some

additional insight concerning age-related similarities and differences in health decisionmaking.

Lewis et al., 1977—A 1977 study by Lewis et al.

systematically observed the behavior of elementary

school children ages 5 to 12 in an innovative

program in two Los Angeles schools (58). That

program allowed children to decide when a health

problem required the attention of the school nurse,

to sign themselves out of class to see the nurse, and

to choose among treatment options presented to

them by the nurse. In short, the program allowed the

children the same freedom as adults in making their

own health care choices, and the children’s choices

had real consequences for treatment.

The authors of this study found that children in

their school’s self-activated health program made

sensible (even in adult terms) use of their power to

choose. It is interesting to note that the elementary

school children in this study are below the age at

which we would have any theoretical reason based

on developmental psychology to expect equivalence

between child and adult decisonmaking.

Lewis et al., 1978-A 1978 study by Lewis et al.

invited 213 elementary school children ages 6 to 9,

grouped in their classes, to become informed about

swine flu vaccine trials and to decide whether or not

to volunteer to participate (57). If a child did

volunteer, the consent of the child’s parents was

sought, and if granted, the child did participate in the

vaccine trial. Thus, the child’s decision had potential

real consequences.

This study found very few age-related differences

in the ability of classes of children to elicit information about the flu and the vaccine and about potential

risks and benefits of participation in a vaccine trial,

although one class of 6-year-olds did not elicit all the

relevant information it could have. It is important to

note that this study really measured group ability—

rather than individual ability-to elicit information

critical to making the decision to participate in

medical research. If, as seems likely, there is

significant variation in decisionmaking capacity

among individuals within age groups, then measuring group ability would tend to minimize differences

between age groups. In other words, assuming that

the percentage of individuals who could think of all

the questions to ask increases with age, then any of

these groups might as groups be able to ask all the

right questions and appear equally capable, while in

fact important developmental changes were occurring over time (as larger and larger percentages of

children in older classes would individually be able

to ask the appropriate questions). The basic question

before us pertains to the competence of minors as

individuals and the information-seeking of individuals that is more typical of the informed consent

process in our institutions. Still, it is striking that

even in a group of 6-year-olds, there are enough

group members that in all but one class all the

relevant information was elicited by the children.

Kazdin, 1986---A 1986 study by Kazdin had

parents and their severely disturbed children rate the

acceptability of different kinds and settings of

mental health treatment (51 ).38 This study found that

parents rated both outpatient treatment and hospitalization as more acceptable than their children did.

The parents rated hospitalization higher than outpatient treatment; the children rated them in the reverse

order. Furthermore, the strength of treatment was

positively correlated with acceptability for parents

and negatively correlated for children. According to

Kazdin, these differences may very well reflect

differences in the meaning of the treatments for

38 Special ~roblem$ fi the mea of Cement t. ment~ hed~ Services were discussed earlier in this chapter. For a discussion of various ment~ heal~

treatment settings available to adolescents, see ch. 11, ‘ ‘Mental Health Problems: Prevention and Services, ’ in Vol. II.
III-146 . Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

parents (e.g., relief) and children (e.g., abandonment).

Grisso, 1981—An important note of caution is

raised by a study that addresses not medical decisionmaking by minors but legal decisionmaking—

Grisso’s 1981 study of juveniles interrogated by

police, with particular attention to the decisionmaking of these youths in asserting or waiving their legal

rights (39). This study reminds us that minors

making decisions in different contexts and different

subsets of minors may show important differences in

decisionmaking as compared with adults.

This study found that 42 percent of arrested adults

chose not to answer police questions but that fewer

than 10 percent of arrested juveniles asserted their

right to remain silent-and virtually none of the

arrested juveniles under age 15 refused to answer

police questions. 39 As a group, juveniles under age

15 showed little comprehension of the Mirand a

warning40—so little comprehension in fact that their

decisions to assert or waive those rights had little

meaning. Furthermore, as many as half of the

juveniles ages 15 to 16 who had IQs below 80 or who

were black or in lower socioeconomic groups also

showed little comprehension of their legal rights and

the consequences of asserting or waiving their

rights. This study found that white juveniles who

had greater contact with juvenile courts and police

evinced improved understanding of Miranda rights,

but black juveniles who had such contact evinced

poorer understanding. Greater contact with police

and courts did, however, lead to greater understanding of the different roles of judges, lawyers, and

police.41

Findings of Studies on How Variables Other

Than Age Affect Adolescents’ Health Care

Decisionmaking

Variables other than age have important effects on

decisionmaking, and several studies involving some

of these other variables in the context of health

decisionmaking by minors are described below. The

studies reviewed here do not permit any definitive

conclusions about how variables such as gender,

socioeconomic status, race and ethnicity, intellectual skills, experience, condition severity, pressure

from peers or family, or skill training affect decisionmaking by minors. They do, however, point to

areas in which the gathering of additional data about

minors’ decisionmaking capacity would probably be

useful.

Gender-Only one core study reviewed by OTA’s

contractors specifically examined effects of gender

on decisionmaking. That study, the 1982 study by

Weithorn and Campbell, used equal numbers of

male and female participants and found no gender

differences in decisionmaking in hypothetical treatment situations (86). Two other studies that examined the effect of gender and were reviewed by

OTA’s contractors were the 1977 and 1978 studies

by Lewis et al. The 1977 study by Lewis et al.

reported that the patterns of utilization of health

services by elementary school boys and girls (ages

5 to 12) participating in their school’s self-activated

health program paralleled the utilization patterns of

adults—i.e., girls made more use of the services than

boys (58). The 1978 study by Lewis et al. reported

that elementary school boys and girls ages 6 to 9 did

not differ in the questions they asked after being

invited to volunteer for swine flu trials, but reported

both that boys volunteered less often than girls and

that girls more often than boys found themselves

unable to make a choice about volunteering.

Socioeconomic Status-None of the core studies

reviewed by OTA’s contractors examined the effect

of socioeconomic status on decisionmaking, but

decisionmaking by minors from different socioeconomic groups was compared in one of the other

studies they reviewed. That study, the 1977 Lewis et

al. study, found that the poorer elementary school

children (ages 5 to 12) in their school’s selfactivated health program made more visits to the

school health service than the more affluent children

(58). Furthermore, the poorer children saw their

health as more in the control of physicians, while the

more affluent children saw their health as being

more influenced by forces that they themselves

could control. None of the other studies OTA’s

contractors reviewed had enough minors from lower

socioeconomic strata to allow conclusions about

s~e us,supreme cow ~fo~d juv~es t. ~ competent to make their own decisions in this context ~d hM held such waiver of constitutio~

rights by minors to be valid [Fare v. Michael C., 442 U.S. 707 (1979)].

%e Miranda warning is the standard warning given to apprise criminal suspects of their constitutional rights in regard to custodial interrogation

by police--they have the right not tcl answer any questions and the right to the advice and assistance of an attorney.

AlFor a discussion of adolescents in the juvenile justice SyStem, wx ch. 13, “Delinquency: Prevention and Services, ’ in Vol. II.
Chapter 17-Consent and Confidentiality in Adolescent Health Care Decisionmaking .111-147

possible differences in decisionmaking related to

socioeconomic status.42

Race and Ethnicity--only one of the core

studies OTA’s contractors reviewed reported on the

effect of race or ethnicity on decisionmaking by

adolescents. That study, the 1986 Kaser-Boyd et al.

study among adolescents with mild to severe learning and behavior problems, reported that white,

non-Hispanic adolescents obtained higher scores on

the psychological treatment decision vignettes than

other participants; but only 14 of the 75 subjects in

this study were black or Hispanic (49). The 1977

Lewis et al. study reported that as white elementary

school children gained experience in their selfactivated health program, they increasingly saw

themselves as the decisionmakers, but that the same

shift did not occur for the black or Hispanic children

(58).

Intellectual Skills-Only one of the core studies

OTA’s contractors reviewed, the 1986 study by

Kaser-Boyd et al., compared participants with different intelligence or a comparable measure of

intellectual ability (49). This study found, unsurprisingly, that participants with poor reading comprehension scored less well on the decision tasks. A

point made earlier in this discussion was that there

seems to be considerable variation in decisionmaking ability of individuals within particular age

groups. This within-group variation could be due to

a variable that is more important to the quality of

decisionmaking than age. Intelligence or reading

comprehension may very well be that variable, but

few data on this topic have been collected.

Experience-Only two of the core studies OTA’s

contractors reviewed examined the effect of experience on decisionmaking. The 1986 study by KaserBoyd et al. found surprisingly that participants with

learning and behavioral problems who had had

experience with psychotherapy obtained lower

scores on the psychological treatment decision

vignettes than participants without such experience

(49). The researchers advanced several hypotheses

to account for this finding. The 1985 study by

Kaser-Boyd et al. found that participants with

learning, behavioral, and emotional problems who

had experience with psychotherapy were more likely

than participants who had no experience to assert

that psychotherapy had low risks and that participants who were currently referred to therapy saw

somewhat more benefits to psychotherapy than

participants who were not referred (48).

No other studies of which OTA is aware make

comparisons among experienced and inexperienced

decisionmakers. One would expect decisionmakers

experienced with the decision domain to show some

differences from those who are new to the decision

domain. Presumably, one advantage that older—

especially considerably older--decisionmakers have

is experience with the decision task, and presumably

some decisions benefit more from such experience

than others. More research on this topic would

probably be useful.

Condition Severity-Only one of the core studies OTA’s contractors reviewed examined the effect

of condition severity on competence to decide. This

study, the 1986 study by Kaser-Boyd et al., found

that participants not currently referred for psychological treatment and participants with moderate

behavior problems scored higher on the psychological treatment decision vignettes than participants

currently referred for psychological treatment and

participants with severe behavior problems, respectively (49).

Two of the other core studies provide a partial

answer to the question of whether the severity of a

condition that does not impair a decisionmaker’s

intellectual functioning affects decisionmaking, the

1982 study by Weithorn and Campbell (86) and the

1981 study by Lewis (56). These two studies, which

presented to participants several different treatment

dilemmas varying in seriousness, reported no systematic differences in decisionmaking as a function

of the seriousness of the condition.

Social Influence From Peers, Parents, or Professionals----one issue that often is raised, but

seldom studied with care, is the ability of minors to

make independent decisions not unduly influenced

by peers, parents, or professionals. As far as one can

tell, the issue of minors’ ability to make decisions

without undue influence from peers, parents, or

professionals has not even benefited from a thoughtful conceptual analysis of the questions that need to

be asked. When is a rejection of information from

and about others evidence of independent judgment,

‘$@or a f@er discussion of ISSueS pfl a.ining to the delivery of health and related services to adolescents living in poverty, as well as adolescents

in specific cultural subgroups, see ch. 18, “Issues in the Delivery of Semices to Selected Groups of .kioleseents, ” in this volume.
III-148. Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

and when is it a sign of irrationality? When is

sensitivity to the ideas and conduct of others

thoughtful open-mindedness, and when is it conformity? Does the tendency toward conformity vary

with the context? These and many other questions

remain to be answered.

None of the core studies OTA’s contractors

reviewed examined the relationship between age and

conformity to social influence in decisionmaking.

Available research on the general relationship of age

and conformity to social influence suggests the

relationship between age and conformity to social

influence is complex. The available research shows

inconsistent findings, which may be reconciled by

positing that conformity to social influence decreases from ages 7 to 11, then increases from ages

11 to 13, and then begins to decrease after that.43 A

1988 study by Scherer and Reppucci examined 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 (76). The Scherer and Repucci study found

that the more consequential the health problem and

invasive the treatment choices, the less the 14- and

15-year-olds yielded to parental pressure; the more

socially sensitive the condition, the more these

adolescents yielded to parental pressure.

Surely the amount of social conformity people

exhibit varies widely with the social situation and

setting as well as with the individual. In fact, it is at

least conceivable that developmental effects on

social conformity may actually be overshadowed by

situational variables. On the other hand, there may

be complex situation-by-development interactions.

Studies to examine that possibility have yet to be

done.

Skill Training-Only one of the core studies

OTA’s contractors reviewed examined the effect of

skill training on competence to decide. In the 1984

Belter and Grisso study, half the participants at each

age level received briefings on patient rights and half

did not. This amounts to specific trainingin on e

aspect of decisionmaking by patients (18). Unsurprisingly, participants who received briefings

showed significantly higher recognition and protection scores than participants who did not. The

15- and 21-year-olds both derived significant benefit from the briefing, but the 9-year-olds did not

derive any benefit. With the briefings, the 15-yearolds performed indistinguishably from the 21-yearolds in the recognition and protection of their rights

as patients.

None of the other core studies OTA’s contractors

reviewed involved special efforts to teach decisionmaking skills to minors. Some additional research

has addressed the question of whether decisionmaking skills can be taught. For example, a 1988 study

by Weinstein has prepared children for psychotherapy by using videotaped modeling (84), and a 1986

study by Haremes and Petersen has shown that sixth

grade children can be taught resistance to persuasion

and thereby taught to make more independent

decisions (41). These studies suggest that even if

minors were found to lack adult-level competence to

consent—which in general they have not been—it

might be possible to prepare minors to make

decisions that reflect a heightened level of competence.

Implications for Public Policy of Empirical

Research on Minors’ Competence

The studies that form the core of OTA’s review on

the age-competence relationship in health care

decisionmaking, though not great in number, do

provide at least some empirical support for the idea

that minors as a class-especially minors age 14 or

15 through age 17—have the same capacity to make

health care decisions as young adults. These empirical studies, therefore, challenge the traditional and

implicit assumption of the law that minors as a class

are unable to make health care decisions as well as

adults. Furthermore, the studies’ findings on this

point are consistent with a huge body of research on

cognitive development generally.44

Are the empirical studies reviewed in this chapter

sufficient to establish that adolescents as a group,

ages 14 or 15 and above, are competent to consent to

their own health care? Probably not. Beyond being

43see p. coS@o ad M, Shw, ‘cco~o~ty ~ ~ Fmction of Age ~vel” (32); ~d B. Bishop ad L. B~km~, “Developmen~ conformity’

(20).

~see D. Etid, “Concep@ orientation ShiftS in Children and Adolescents” (34); J. Flavell, The DeveIopmenrul Psychology of Jean Piagef (36)

and ‘‘An Analysis of Cognitive-Developmental Sequences” (37); B. Inhelder and J. Piaget, The Growth of Logical Thinking From Childhood to

Adolescence (46); D.P. Keating, “Thinking Processes in Adolescence” (52); G.B. MeltoL G.P. Koocher, and M.J. Saks, Chikiren’s Competence To

Consent (63); and E.D. Neimark and N. Lewis, “Development of Imgical Problem Solving: A One-Year Retest” (69).
Chapter 17—Consent and Confidentiality in Adolescent Health Care Decisionmaking ● //1-149

Photo credit: U.S. Congress, Office of Technology Assessment

Available empirical research challenges the traditional and

implicit assumption of the law that minors as a class are

unable to make health care decisions as well as adults.

rather few in number, the studies reviewed leave

gaps in the knowledge ideally needed for the

formulation of public policy pertaining to adolescents’ involvement in health care decisionmaking.

One limitation of the available studies is that most of

them did not examine minors’ decisionmaking

performance in situations sufficiently real and stressful to see what effects such situations may have on

their decisionmaking performance (although the few

that did examine this found the same pattern of

results as the other studies). Another limitation of

the available studies is that they generally compared

minors’ decisionmaking with the decisionmaking of

very young adults rather than with that of adults of

various ages. Still another limitation of available

studies is that they leave open several important

questions about the effects exerted on minors’

decisionmaking by factors such as socioeconomic

status, ethnicity, social influence, skill training, an d

experience, and how these might interact with the

age-competence relationship found in the generally

white middle-class groups studied. It is difficult to

know how well one may generalize from the groups

studied to the groups not studied.

Two basic responses can be made to the limitations of existing studies of minors’ health care

decisionmaking capabilities. One would be to carry

out studies designed to generate more complete data.

The other would be to make judgments as to whether

the pattern of findings of existing studies is firm

enough to expect them to carry over into untested

areas. Whatever is done, it is important to bear in

mind that there is considerable variation among

individual adolescents. Some of the empirical studies reviewed for this chapter note the great variation

of performance within age groups, but they do not go

beyond that. Because of individual variation in

decisionmaking capacity among adolescents, some

adolescents ages 14 and older do not, in fact, have

the requisite capacity to make health care decisions.

Even if the average minor of any given age group can

make health care decisions as well as the average

adult, if the variability is much greater among the

minors than it is among adults, then a large absolute

number of minors might fall below whatever the

standard of competence is.

The problem of individual variation in decisionmaking capacity within an age group can be dealt

with in various ways. One way would be for public

policymakers to require individualized determinations of competency by courts or even by health

professionals. Unfortunately, however, an approach

based on individualized determinations would open

the door to discriminatory and arbitrary determinations unless there were tests of decisionmaking

capacity that were reliable and valid and that could

be administered easily—and it is doubtful that there

are such tests.45 Moreover, individualized determinations can be quite expensive in terms of resources.

Another way of dealing with the problem of

individual variation in decisionmaking capacity

would be for public policymakers to establish a

rebuttable legal presumption of competence based

on chronological age that could be used by courts to

make individualized determinations of competence

d5some ob~emers ~ugge~t tit not one of tie ~su~ tests of ~mwtence reh~ on by tie law ad heal~ professional.% videnc kg a choice,

reasonableness of outcome of choice, ‘‘rational’ reasons, ability to understand, actual understanding-is or can ever be used consistently and that

changing circumstances and considerations modify the tests that the law or clinicians apply (74).
III-150. Adolescent Health-Volume ill: Crosscutting Issues in the Delivery of Health and Related Services

(31). 46 Thus, for example, public policymakers

could establish a legal presumption that any minor

age 14 or above is competent to make health care

decisions, but could also allow for the use of

evidence of an individual’s inability to make such

decisions to rebut that presumption.47

Finally, it must be noted that considerations of

minors’ health care decisionmaking capacity have

not been the sole determinant of the degree of

freedom minors have been granted with respect to

obtaining health services on their own. As pointed

out earlier in this chapter, the presumption that

minors are incompetent to make decisions about

health care based on assumptions about minors’ lack

of health care decisionmaking capacity is only one

of several rationales-albeit a major rationale--for

parental consent and notification requirements. It

also must be noted that only some of the recognized

exceptions to parental consent and notification

requirements are based on a rejection of this legal

presumption and underlying assumptions. In short,

the capacity of a minor to make health care

decisions may be a necessary but not a sufficient

condition for allowing a minor to obtain health

services on his or her own. Conversely, the lack of

capacity on the part of a minor to make health care

decisions may not preclude allowing the minor to

obtain health services without parental permission.

Conclusions and Policy Implications

This chapter began by asking how the law should

allocate authority for making decisions about an

adolescent’s health care among the adolescent, the

adolescent’s parents, health professionals, and the

state. It is important to emphasize that the way in

which the law allocates adolescent health care

decisionmaking authority does not become critical,

or even very relevant, unless the adolescent and one

or another of the parties just mentioned are in

conflict. As noted earlier, however, potential or

actual decisionmaking conflicts can and do sometimes occur. In the case of family planning and

abortion services and possibly other types of health

services that may be needed or wanted by adolescents, parental consent and notification requirements may sometimes pose barriers to access.

The ultimate responsibility for deciding how the

law should allocate authority for making decisions

about an adolescent’s health care rests with public

policymakers-legislators, judges, and administrators of public programs. If public policymakers are

to formulate appropriate public policy pertaining to

the allocation of authority for adolescent health care

decisionmaking, they must balance the interests of

adolescents, parents, health care providers, and the

state. 48 Balancing these interests is no easy task,

especially when the balancing has to be done in a

political environment in which policymakers must

rely on value judgments about which there is no

consensus. It is at least possible, however, that an

analysis of the interests of the various parties

involved can serve as a conceptual framework for

the development of clearer, more rational, and more

consistent policies. Such an analysis is presented in

box 17-B.

Laws related to the allocation of authority for

decisions about the provision of health services to

minors-individuals under age 18 in 47 States and

the District of Columbia, and under age 19 in 3

States—have historically been the province of State

legislatures, State courts, and State administrative

agencies. As noted in this chapter, existing State

laws governing parental consent and notification for

different types of health services vary widely from

State to State, and the laws of a particular State often

vary with respect to different types of services or

situations. For the most part, therefore, existing State

laws do not furnish clear and consistent answers to

the question of how authority for minors’ health care

decisionmaking is allocated.

Given the array of laws and regulations described

in this chapter, many adolescents-and perhaps

even providers—are probably uncertain about how

these laws and regulations pertain to them as

individuals. The involvement of the U.S. Supreme

Court and lower Federal courts in the allocation of

authority for decisions about family planning and

abortion services through their power to interpret the

‘See F.E. Zimrm‘ g, The Changing Legal World of Adolescence (90).

47s= ~e5id~t’s COremission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research Making Health Care

Decisions, Volume 1: Report (72).

~s~ R. Bennett, “~location of ~ld M@cd Care Deeision-Making Authority: A Suggested Interest Analysis” (19); L.S. Ewald, “Medicd

Decision-hlakin gfor Children: An Analysis of Competing Interests” (35); M.S. Wald, “ChiMren’s Rights: A Framework for Analysis” (82); Harvard

IAw Review, “Developments in the Law—The Constitution and the Family” (42); and F.E. Zimring, The Changing Lzgai World ofMolescence (90).
Chapter 17-Consent and Confidentiality in Adolescent Health Care Decisionmaking . /1/-151

Box 17-B—A Conceptual Framework To Aid Public Policymakers in Formulating Policy Related to

the Allocation of Authority for Adolescent Health Care Decisionmaking

A conceptual framework to aid public policymakers in formulating policy related to the allocation of authority

for adolescent health are decisionmaking can be supplied by analyzing the interests of the parties who maybe

involved in such decisionmaking-namely, the adolescent, the adolescent’s parents, the health care providers, and

the state. The essential issue to be considered in such an analysis is: Does the state have an interest or interests

derived from the interests of the adolescent, the adolescent’s parents, or healthcare providers-or does the state have

an independent interest-that would justify a particular allocation of authority for adolescent health care

decisionmaking via statutes, judicial decisions, or administrative regulations?

Interests of the Adolescent and the State-An adolescent has obvious interests in protecting his or her own

life and in maintaining good physicaI and mental health--interests that translate into an interest m timely access

to needed health services. The state, under its parens patriae power, also has an interest in protecting the life and

health of the adolescent and thus also has an interest in ensuring the adolescent’s access to needed health services.

The nature and extent of the adolescent’s interest-and by extension the state’s interest-in the adolescent’s access

to health services varies, depending on the type of service and circumstances. Clearly, the interest is greatest in the

case of health services that are needed to preserve life (e.g., emergency medical services for a seriously injured or

suicidal adolescent) and less in the case of health services that maybe viewed as desirable but are not necessary

to preserve or even to achieve or maintain health (e.g., cosmetic surgery). In situations where the adolescent’s life

or health maybe at stake, the adolescent’s interest in access to services should be paramount in any balancing of

interests to arrive at an appropriate allocation of the authority to make decisions concerning the provision of health

services to adolescents.

Given the interests of the adolescent and the state in ensuring that the adolescent has access to needed health

services, an issue that arises is whether-and if so, to what degree-legally mandated parental consent and/or

notification requirements create barriers to adolescents’ access to services. Several empirical studies have found that

such requirements do create barriers to adolescents’ access to and utilization of family planning and abortion

services (21,22,25,2628,78,79,87,88); the applicability of the findings of these studies to other types of services,

however, remains unclear. If policymakers are considering the advisability of allowing adolescents to make their

own health care decisions, a central concern becomes the competency of adolescents to make appropriate

determinations as to their need for services. Some empirical studies, which are reviewed in this chapter, suggest that

adolescents ages 14 or 15 and above have the same capacity to make health care decisions as young adults. It is

important to bear in mind, however, that these studies have a number of limitations. Furthermore, adolescents within

these age groups exhibit individual variation in decisionmaking capacity, and this variation itself has implications

for public policy.

Interests of the Adolescent’s Parents and the State-Parents and their minor children typically have

affectional and other ties, and the parents of most adolescents are likely to have an interest in ensuring that decisions

about the provision of health services for their adolescent child will benefit him or her. In some cases, however, an

identity of interest between an adolescent and the adolescent’s parents cannot be assume@ nor can it be assumed

that the parents will always act in the adolescent’s best interests in health care decisions affecting the adolescent.

Parents have responsibility for the care, support, and rearing of their minor children, and the parents of an adolescent

may have an interest in maintaining their authority over the adolescent. The parents also may have a more

generalized interest in protecting their family’s autonomy and privacy and in promoting their family’s stability and

cohesiveness.

The state may or may not have an interest in reinforcing parental authority. The state certainly has an interest

in having the parents continue to assume responsibility for their adolescent child, however, and if parental authority

is reduced, parents may be less willing to assume this responsibility. The state also has an interest in protecting

family autonomy and privacy, which are widely valued in American society, but the protection of family autonomy

and privacy is not necessarily the same as reinforcing parental authority. The state also has an interest in maintaining

family cohesiveness and stability, but this is not necessarily the same as reinforcing parental authority.

Interests of Health Care Providers—The interests of health care providers are seldom discussed or even

mentioned in discussions concerning the allocation of authority for adolescent health care decisionmaking.

Certainly, however, health care providers can be said to have an interest in providing services to adolescents that

Continued on next page
111-152. Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Box 17-B—A Conceptual Framework To Aid Public Policymakers in Formulating Policy Related to

the Allocation of Authority for Adolescent Health Care Decisionmaking-Continued

are consistent with their professional ethics (e.g., standards pertainingto confidentiality) and consistent with

accepted professional practices. Providers have an interest in being able to receive compensation for services they

provide. Providers also have a more narrow, but nonetheless significant interest, in clear and consistent laws to

enable them to avoid unintentional violation of these laws. It is not clear, however, whether or to what degree the

state has an interest m promoting or furthering these interests of health care providers.

Independent Interests of the State--Although, to some extent, the state’s interests maybe derived from and

substantially the same as those of the adolescent, the adolescent’s parents, and health care providers, the state also

has its own independent interests. Thus, the state has a clear independent interest in ensuring that adolescents are

tested and treated for sexually transmitteddiseases to prevent the spread of those diseases and thereby protect its

citizens from these diseases. To the extent that adolescent childbearing results in increased public expenditures for

health and human service programs that seine families started when the parents were adolescents (e.g., public

programs such as the Medicaid program, the Aid to Families With Dependent Children program, and the Food

Stamp Program) and to the extent that adolescent childbearing is associated with negative health, educational,

economic, and social consequences for these families,l the state may also have an independent interest in ensuring

access of adolescent to family planning services and abortion services.

Interests of the Various Parties Depending on the Types of Health Servtices Involved-The interests of the

adolescent, the adolescent’s parents, the state, and health care providers may well differ depending on the types of

health services involved-and the way the interests are balanced may well differ depending on the types of services

involved. Thus, analyzing the interests of the parties concerned may lead to rules regarding the proper allocation

of authority for adolescent health care decisionmaking that vary for different types of services. What this means for

policymakers is that while one set of rules may appropriately govern the allocation of decisionmaking authority for

general medical cam, another set of rules may appropriatelygovern the allocation of Decisonmaking authority for

family planning services, another set of rules may govern the allocation of this authority for mental health services,

and still another set of rules may govern the allocation of this authority for substance abuse treatment and

counseling.

l~OUS m&shave~~51ing8~*~~::=~ “ (38S4,80,89).FOI afurrherdiscusaion

ofrhis topic, sce ch 10, “PrcgxIancy and ~-*~~ . .

provisions of the U.S. Constitution may very well care decisionmaking. At least in theory, Congress

add to their uncertainties. One way of reducing

adolescents’ uncertainties, apart from moving laws

toward greater uniformity, would be to incorporate

information about the legal aspects of access to

health services for adolescents in health education

courses offered to adolescents in a State. Such

information would give adolescents the information

they need to make choices about whether or not to

seek care.

Responsibility for allocating authority for health

care decisionmaking now rests primarily with the

State courts and legislatures and Federal courts. If it

chose to, however, the U.S. Congress could play a

greater role in formulating public policies pertaining

to the allocation of authority for adolescent health

may enact legislation that would have the effect of

establishing particular substantive policies in this

area at the State and local level.49

One way for Congress to take on a larger role in

formulating public policies pertaining to the allocation of authority for adolescent health care decisionmaking would be to enact legislation conditioning

States’ receipt of Federal funds for specified purposes on the States’ having statutes or administrative

rules and regulations that incorporate particular

substantive policies with respect to health care

decisionmaking for and by adolescents. To OTA’s

knowledge, this approach has not been used by

Congress in this realm to date.

WAS ~ot~ ~m~er, tie U.S. Suw-e cow is tie f~~biter of wtit Sbte laws me permissible and impermissible under the U.S. Constitution.
Chapter 17—Consent and Confidentiality in Adolescent Health Care Decisionmaking . ///-153

An alternative way for Congress to expand its role

would be to enact legislation that requires federally

funded programs that support the provision of health

services for adolescents to adopt particular substantive policies with respect to the allocation of

authority for adolescent health care decisionmaking,

Congress authorizes and appropriates funds for a

variety of programs that provide reimbursement or

grants for adolescent health services-for example,

. the Medicaid program authorized under Title

XIX of the Social Security Act,

● the maternal and child health services block

grant programs authorized under Title V of the

Social Security Act,

● the family planning services and research

program authorized under Title X of the Public

Health Service Act, and

● the alcohol, drug abuse, and mental health

services block grant program authorized under

Title XIX of the Public Health Service Act.so

The Federal laws authorizing and appropriating

funds for these programs and the regulations and

rules issued by the agencies administering these

programs at the Federal level generally do not deal

directly with questions of whether adolescents must

have parental consent to participate in the programs,

whether parents must be notified of adolescents’

participation in the programs, or whether health care

records and communications between program service providers and adolescents are confidential vis-ávis their parents.51 In the absence of explicit directives from Congress or Federal agencies, the administrators of federally funded programs are free-so

long as they remain within the parameters imposed

by State law and Federal constitutional law—to

establish their own policies regarding parental

consent and notification requirements and the confidentiality of records and communications involving

minors.

If Congress were to legislate in the area of parental

consent and notification and confidentiality of

communications involving adolescents, it presumably would move laws governing matters such as

parental consent and notification toward greater

uniformity and coherence. Assuming for the sake of

argument that greater uniformity and coherence is

desirable, there remains the issue of what substantive policies Congress should adopt. That is a

political judgment-some people would undoubtedly support requiring or encouraging parental

involvement in decisions concerning health services

for adolescents and others would support giving

adolescents a substantial measure of autonomy in

such decisions. To help guide policy makers in

decisions governing the allocation of authority for

health care decisionmaking, further empirical research on the decisionmaking capabilities of adolescents and factors that may influence these capabilities (e.g., age, prior experience, situational factors,

intelligence) would probably be useful.

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Yorlq NY: Free Press/Macmillan, 1982).
Chapter 18

ISSUES IN THE DELlVERY OF

SERVICES TO SELECTED

GROUPS OF ADOLESCENTS

Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

Adolescents Living in Poverty: Issues in the Delivery of Health and Related Services . . . . . . . . . 159

Overview of the Number of Adolescents Living in Poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

Health Status of Poor Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Limitations of Data and Research on the Health of Poor Adolescents . . . . . . . . . . . . . . . . . . . . 165

Health Status of Adolescents by Family Income Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Access to Health Services by Poor Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Patterns of Health Care Utilization by Poor Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Barriers to Access for Poor Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Services and Interventions To Increase Access to Health Services Among

Poor Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Major Federal Programs Pertaining to Poor Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

ACTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

U.S. Department of Health and Human Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

U.S. Department of Agriculture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

U.S. Department of Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

Racial and Ethnic Minority Adolescents: Issues in the Delivery of Health and Related Services . . . 178

Overview of the Number of Racial and Ethnic Minority Adolescents . . . . . . . . . . . . . . . . . . . . . . 181

Health Status of Racial and Ethnic Minority Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

Limitations of Data and Research on the Health of Racial and

Ethnic Minority Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

Health Problems Experienced by Racial and Ethnic Minority Adolescents . . . . . . . . . . . . . . . 183

Access to Health Services by Racial and Ethnic Minority Adolescents . . . . . . . . . . . . . . . . . . . . . 187

Patterns of Health Care Utilization by Racial and Ethnic Minority Adolescents . . . . . . . . . . . 187

Services and Interventions To Increase Access to Health Services Among Racial and

Ethnic Minority Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Page

Major Federal Programs Pertaining to Racial and Ethnic Minority Adolescents . . . . . . . . . . . . . 191

U.S. Department of Health and Human Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192

U.S. Department of Agriculture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1%

U.S. Department of Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1%

U.S. Department of Justice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1%

Rural Adolescents: Issues in the Delivery of Health and Related Services . . . . . . . . . . . . . . . . . . . . 1%

Special Health Issues for Rural Adolescents . . . . . . . . . . . . . . . . . .*..*.*.* . . . . . . . . . . . . . . . . . . 1%

Limitations of Data andResearch on the Health of Rural Adolescents . . . . . . . . . . . . . . . . . . . 1%

Health Problem Experienced by Rural Adolescents . . . . . . . . .*.....** . . . . . . . . . ● *,....,. 197

Access to Health Services by Rural Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

Major Federal Programs Pertaining to Rural Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

Poor Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

Racial and Ethnic Minority Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● . . . . . . . 201

Rural Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

Chapter 18 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

Box

Box Page

18-A. Research on Resilient Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166

Figures

Figure Page

18-1. Number of U.S. Adolescents Ages 10 to18 and Number Living in Poor or

Near-Poor Families, by Race/Ethnicity, 1988 .,..*..* ..,***... . . . . . . . . . . . . . . . . . . ...,* 161

18-2. Socioeconomic Status of U.S. Adolescents Ages 10 to18, by Family Income

as a Percent of the Federal Poverty Level, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

l8-3. Family Incomes as a Percent of the Federal Poverty Level by

U.S. Adolescents’ Living Arrangements, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

18-4. Family Incomes as a Percent of the Federal Poverty Level by

U.S. Adolescents’ Race/Ethnicity, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

18-5. Projected Changes in the Racial and Ethnic Makeup of the U.S. Population,

All Ages, 1982 to 2080 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

18-6. Race/Ethnicity of U.S. Adolescents Ages 10 to 18, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

18-7. Projected Changes in the Racial and Ethnic Makeup of the U.S. Population

Under Age 18,1982 to 2080 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

18-8. Death Rates for All Causes for U.S. Adolescents Ages 10 to 14, by Race and Sex, 1987.. 184

18-9. Death Rates for All Causes for U.S. Adolescents Ages 15 to 19, by Race and Sex, 1987.. 184

Tables

Table Page

18-1. Reported Health Status of U.S. Adolescents Ages 10 to 18 by Family Income, 1988 . . . . . 167

18-2. Reported Restricted-Activity Days Among U.S. Adolescents Ages 10 to 18

by Family Income, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168

18-3. Reported Number of Hospital Discharges Among U.S. Adolescents Ages 10 to 18

by Family Income, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Chapter 18

ISSUES IN THE DELlVERY OF SERVICES TO

SELECTED GROUPS OF ADOLESCENTS

Introduction

OTA’s analysis of a wide variety of health

problems experienced by U.S. adolescents suggests

that the incidence and prevalence of many health

problems is greater among some groups of adolescents than others.1 There is also evidence that U.S.

adolescents’ access to health services is far from

uniform. As discussed elsewhere in this report, for

example, many adolescents in poor and near-poor

families are unable to obtain adequate health care

because they do not have health insurance.2

This chapter focuses on three broad groups of

adolescents and discusses some of the socioeconomic

and cultural factors that may affect their health and

access to health and related services. The three broad

groups of adolescents are as follows:

. adolescents living in poverty,

● racial and ethnic minority adolescents, and

. adolescents living in rural areas.3

Without trying to be comprehensive, the chapter

identifies some of the special health issues for

adolescents who are poor, members of racial or

ethnic minorities, or residents of rural areas. It also

discusses issues in the delivery of health and related

services to these groups of adolescents. Finally, it

describes Federal programs pertaining to poor adolescents, racial and ethnic minority adolescents, and

adolescents living in rural areas.

It is important to note that the analysis in this

chapter is severely limited by a lack of information.

In general, systematically collected and analyzed

information on socioeconomic and cultural factors

important to the appropriate and effective delivery of

health services is scarce. Where adolescents are

concerned, the problem is even worse.

Adolescents Living in Poverty:

Issues in the Delivery of Health

and Related Services

In 1988, more than 8 million U.S. adolescents

lived in a poor or near-poor family (see figure 18-1).

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 families whose income

falls below the Federal poverty level. Near-poor

families are families whose income falls between

100 and 149 percent of the poverty level.

According to data from the March 1989 Current

Population Survey, 26.7 percent of U.S. adolescents

in 1988 lived in poor or near-poor families (see

figure 18-2). About 17 percent of U.S. adolescents

age 10 through 18 in 1988 lived in families with

incomes below the Federal poverty level, and nearly

10 percent more lived in families with incomes

between 100 and 149 percent of the Federal poverty

level (106), This means that about 8.27 million of the

31 million U.S. adolescents in 1988 lived in poor or

near-poor families-about 5.3 million in poor families and about 3.0 million in near-poor families.4

The health and other effects of growing up poor or

near-poor are complex and not well understood

(154). Because poverty is often associated with low

educational level, substandard living conditions, an

inadequate social-support network, unemployment,

poor nutrition, risk-promoting lifestyle, 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 and

loTA~~ ~y~l~ of Sclwtti he~~ problems exp~enced by U.S. adolescents is presented in ChS. 5 throu@ 14 in VO1. II of this Report. For a S1.lmm W*

see app. B, “Burden of Health Problems Among U.S. Adolescents, ” in this volume.

~t is well established that health insurance coverage and ability to pay may det ermine when or whether a person in this country seeks health care

services (1 25,177). For further discussion of the fiiancial barriers to access confronted by U.S. adolescents, see ch. 16, ‘‘Financial Access to Health

Services, ‘‘ in this volume.

3clealy, some adolescents f~l into more ~ one of ~ese gToups. The mtiomle for diSCUSSing the grOUpS separately is to identi~ the unique

contribution of socioeconomic status, race and ethnicity, and rural residence to health and the delivery and receipt of health and related semices,

AThls ~culation is breed on the July 1, 1988, civilian population (21 1).

-111 -159-
III-160 . Adolescent Health–-Volume Ill: Crosscutting issues in the Delivery of Health and Related Services

Photo credit: Mark Charette, Washington, DC

Systematically collected and analyzed information on socioeconomic and cultural factors important to the appropriate and

Ineffective delivery of health services to U.S. adolescents is scarce.

supportive factors than their more advantaged peers.5

other words, cultural traditions, values, beliefs, and

Some observers have theorized, however, that "pov- practices can either dirninish or accentuate poverty’s

erty acts through the prism of culture” (84a). In negative effects. For the most part, systematic

5~e idea tit here is, ~ additio~ a “c~~e of pov~’ (121,145) has been controversial (74,93,273). ~ the 1*, ~wis miwed tit Wvem

is perpetuated because the children of low-income parents are socialized into a value system and set of behaviors that reduces their motivation to succeed

in the labor market (121). This thesis aroused controversy because it was seen as blaming the victims of poverty for their own fate. The structural

explanation (i.e., that persistent poverty in individual families and certain communities can be explained by such factors as the structure of the welfare

systeu the economic structure of low-paid jobs, and the location of jobs) has been a major alternative to the culture of poverty in explaining the

persistence of poverty (74,93). Wilson, among others, has recognized a relationship between certain aspects of eeonomic change (specifkdly, the loss

of manufacturing jobs in central cities) and the set of behaviocs, attitudes, and social perceptions of the impoverished communities particularly affeeted

by these aspects of change (273,273a), In this process, captured by the term “concentration effeets” (273a), “neighborhoods that have few legitimate

employment opportunities, inadequate job information networks, and poor schools not only give rise to weak labor force attachment but also raise the

likelihood that people will turn to illegal or deviant activities for income, thereby further weakening their attachment to the legitimate labor market. A

jobless family in such a neighborhood is influenced by the behavior, beliefs, orientations, and social perceptions of other disadvantaged families

disproportiomtely concentrated in the neighborhood” (73a). These attitudes, beliefs and behaviors affect behaviors related to the workforce and to

poverty (e.g., less investment informal education leads to less ability to obtain a job in the growing service seetor of the economy; the lack of marriageable

[i.e., employed] males is a factor in out-of-wedlock pregnancies and births). Wilson has limited discussion of concentration effects to the so-called

“underclass’ living in “urban ghettos,‘‘ in which an impoverished urban ghetto is a census tract in which at least 40 pereent of families live below the

Federal poverty level (273). Thus, any effects of of poverty on behaviors and values would apply ofdy to a relatively MITOW band of poor families (165a).

A full exploration of the vmying deftitions of the urban underclass (13,71,78,93,273,275) and other explanations of the persistence of poverty in selected

groups is beyond the scope of this Repofi. Interested readers are referred to the reeent volume edited by Jencks and Peterson for much of the latest thinbng

on these issues, including chapters cm the impact of living in an urban underclass neighborhood on out-of-wedIock adolescent pregnancy (93).
Chapter I8--Issues in the Delivery of Services to Selected Groups of Adolescents . //1-161

Figure 18-1—Number of U.S. Adolescents Ages 10 to 18 and Number Living in Poor or Near-Poora

Families, by Race/Ethnicity, 1988b

Millions of adolescents

32.5 ‘T5TiiT —

3 0

27.5

2 5

22.5

2 0

17.5

15

12.5

10

7.5

5

2.5

0

1

1

i

1

8.27

1,L

Total Whit e

b

1

= All adolescents

~ Adolescents

living in poor or

near-poor families

1I

4.84 I

Black

b Hlspani cc Asia nd American

Indian/

Alaska Native”

aPoor and near-poor are terms defined in relation to the F*ral poverty

level, a cash income level which varies with family size and the age of

family members. Poor families are families with incomes below the Federal

poverty level. Near-poor families are families w“th incomes fmm 100 to 149

percent of the Federal poverty level.

%his figure shows the approximate number of U.S. adolescents and

adolescents living in poor or near-poor families. The population estimates

for white and black adolescents are slight overcounts because they

include Hispanics, who are also shown separately.

f+ermns of Hispanic origin may ~ of any ram.

dAsia~pa~f~ IsIan&r includes Filipinos, Chinese, Wetnamase, Koreans,

Japanese, Asian-Indians, and “others.” The Census Bureau is unable to

calculate the number of Asian and Pacific Islanders who are ages 10

through 18 for periods beyond 1980. OTA’s rough estimate that there are

approximately 1.100 million Asian and Pacific Islanders ages 10 to 18 is

made by applying the estimated proportion of Asian and Pacific Islanders

who were ages 10 to 18 in 1980 (15.9 percent, derived by taking 9/17ths

of the proportion of the Asian and Pacific Islander population who were

under 18 in 1980 (30.2 percent)) to the estimated total population of Asian

and Pacific Islanders as of July 1, 1969. Better estimates of the 10- to

1 &year@IdAsian and Pacific Islander population of the United States will

be available from 1990 census statistics.

eB=use of the small number of American Indians and Alaska Natives

sampled for the Current Population Survey (CPS), and various limitations

of the survey design, the poverty estimates for this group have a large

standard error (that is, they may be unreliable). The proportion of

adolescents in families with incomes less than 150 percent of poverty

amid be between 41 and 61 percent (108). However, the high rate of

poverty among American Indians and Alaska Natives found through the

CPS is consistent with estimates from other sources (199).

SOURCE: Office of Technology Assessment, 1991, based on data from the following sources: Adolescent population counts: U.S. Department of

Commerce, Bureau of the Census, U.S. Population Estimates, by Age, Sex, Race, arrd Hispanic &“gin: 1989 Current Population Reports, Series

P-25, No. 1057, by F.W. Hollmann (Washington, DC: U.S. Government Printing Office, March 1990); S. Sue and N. Zane, “Health and Related

Services for Asian American Adokscents,” contract paper prepared for the Office of Technology Assessment, U.S. Congress, Washington, DC,

November 1989; F. Hollmann, Demographer, Bureau of the Census, U.S. Department of Commerce, personal communication cited in F. Butterfield,

“Asians Spread Across a Land, and Help Change It,” New York 77mes, Sunday, Feb. 24, 1991, p. 22. Number of adolescents living In poor or

near-poor families: R. Kronick, Adjunct Professor, University of California, San Diego, CA, calculations based on U.S. Department of Commerce,

Bureau of the Census, March 1989 Current Population Survey public use files, 1990.

investigations into whether and how variations in census of the entire U.S. population every 10 years.

socioeconomic status cause differences in health- The 1980 census included data on sex, race, and

related behaviors and attitudes have not focused on marital status from the entire enumerated population

adolescents (but see 103). Findings concerning the and more detailed information on income, educabeliefs and behaviors that characterize the average tion, housing, and other topics from a 20-percent

adults in a population mayor may not be applicable sample of the population (238a). The Bureau of the

to the adolescent children of those adults. Census also conducts the Current Population Survey, a monthly household survey of a sample of the

Overview of the Number of Adolescents civilian noninstitutionalized population, to obtain

Living in Poverty estimates of characteristics of the labor force, the

population as a whole, and various subgroups of the

Official estimates of the number of people living population. 7 Annual data on the number and characin poverty in the United States are available from the teristics of people living in poverty, based on income

Bureau of the Census within the U.S. Department of during the previous year, are obtained in the March

Commerce. 6 The Bureau of the Census conducts a supplement to the Current Population Survey (150,210).

Whe ot%cial gov ernment definition of poverty is based on cash income levels for families of different sizes. It was established in the mid- 1960s and

has not been modifkl substantially since then (150). Responsibility for changing poverty concepts and deftitions rests with the Office of Management

and Budget. The deftition of poverty has been the subject of numerous congressional hearings and reports (150,198). It is beyond the scope of this report

to address the questions that have been raised.

TA5 ~ homehold smey of the ~vilfi no~ti~tio~~d population, the Current Population Survey d~s nOt ticlude ~divid~s in ~titutiom

(e.g., correctional institutions, detention homes, and training schools for juvenile delinquent youths, homes for dependent and neglected childrerL homes

and schools for the mentally or physically handicapped, or homes for unwed mothers).
111-162 ● Adolescent Health–-Volume III: Crosscutting Issues in the Delivery of Health and Related Services

Figure 18-2-Socioeconomic Status of

U.S. Adolescents Ages 10 to 18, by Family Income

as a Percent of the Federal Poverty Level, 1988a

Income 300% of ,-

 - ‘----

poverty and above

13.45 million Income 150-299%

(43.4%) ‘ of poverty

#’ 9.24 million

(29.8%)

,‘\‘ ! ~,

Income less than

150% of poverty

(poor and near-poor)

8.27 million

(26.7%)

aFamily i~me is expressed in relation to the Federal poverty level. The

Federal poverty level is based on cash income levels for families of

different sizes. In 1968, the Federal poverty level was $9,431 for a family

of three.

SOURCE: Office of Technology Assessment 1991, based on R. Kronick,

Adjunct Professor, University of California, San Diego, CA,

calculations based on U.S. Department of Commeree, Bureau

of the Census, March 1989 Current Population Survey public

use files, 1990.

As shown in figure 18-3, the risk of being poor or

near-poor for U.S. adolescents is greatly related to

family composition. Adolescents living in motherheaded families without fathers and adolescents on

their own are at much greater risk of being poor or

near-poor than adolescents living with both parents

or their father only (13,106). In 1988, nearly

two-thirds of the adolescents who lived with their

mother only and two-thirds of the adolescents living

with neither parent (or married and living with their

parents 8

) lived in families with incomes that fell

below 150 percent of the poverty level. That same

year, about one-fourth of the adolescents in fatherheaded families without mothers were in families

with incomes below 150 percent of the Federal

poverty level. Adolescents living in two-parent

families are at the lowest risk of being poor or

near-poor; in 1988, about 15 percent of the adolescents living with both parents were in families with

incomes below 150 percent of the poverty level.

Family composition affects not only the risk of

being poor or near-poor but the dynamics of poverty.

Available research on the dynamics of income and

poverty indicates that the presence of two parents in

a family offers children substantial (though not

absolute) protection from sustained poverty (154).

Poverty among two-parent families fluctuates widely

from year to year and is highly dependent on wages

and other income (including Aid to Families With

Dependent Children (AFDC)) (154). In contrast,

poverty among female-headed families without

fathers reflects the vulnerability of having only one

parent, usually a mother who is a low-wage earner,

as the sole source of economic support (154).

Female adolescents who bear children out of wedlock are at particularly great risk of living in

poverty. 9

Data from the March 1989 Current Population

Survey indicate that certain groups of racial and

ethnic minority adolescents are far more likely than

white, non-Hispanic adolescents to be living in

families with incomes at or near the Federal poverty

level. As shown in figure 18-4, about half of

Hispanic adolescents, half of black, non-Hispanic

adolescents, half of American Indian and Alaska

Native adolescents, and one-third of Asian adolescents in the United States lived in poor or

near-poor families in 1988 (106). That same year,

less than one-fifth of white, non-Hispanic adolescents lived in poor or near-poor families.

Data from the March 1989 Current Population

Survey indicate that some parts of the country have

a higher percentage of adolescents living in poor or

near-poor families than others. The South10 has a

higher percentage of adolescents who live in poor or

near-poor families than the West11 or North12: 31.7

percent of adolescents living in the South, 26.4

percent of adolescents living in the West, and 22.9

8w&.n ~olexcnts WC ~fi~, even if they ~e fiving wi~their pWCUtS, @~US~y considemdto be a separate ftiy for purposes of h~t

Population Survey.

9As ~wW~ ~ Ch, 10, C*R_y and Parenting: Prevention and Services, “ in Vol. II, about 65 percent of the approximately 500,000 births to

U.S. adolescents in 1988 were out-of-wedlock births (240).

IOrhe sou~~cludes ~~a~~~, De~ware, ~ori~, ~orgia, Kentucky, huis~ ?v@land, Mississippi, North ~0~, okkihOm& SOUth

CaroliruL lkmessee, ‘IkMs, Virgin@ and West Virginia (107).

1 l~e West ~~ludes -,~zor~, c~o~% Colorado, Idaho, ~w~, Mon~ New Mexico, Orego~ Neva~ Ub@ Wtish@tO~ and

Wyoming (107).

lz~e Nom includes COUUeCtiCU~ Illinois, lndi~ lowq Kansas, Maine, Massachusetts, Michigw Minnesot& MSOuri, NW ~pti, New

Jersey, New York, North Dakota, Nebrw@ Ohio, Pennsylvania Rhode Island, South Dako@ Vermont, and Wisconsin (107).
Chapter I8--Issues in the Delivery of Services to Selected Groups of Adolescents ● III-163

Figure 18-3-Family Incomes as a Percent of the Federal Poverty Level

by U.S. Adolescents’ Living Arrangements, 1988a

Incomes of families in which adolescents Incomes of families in which adolescents

are living with both parents are living with their father only

\

.

Income 300% of

poverty and above

(54.1%)

Incomes of families in which adolescents

are living with their mother only

Income less than

150% of poverty

(57.0%)

and above

Income 150-299% (15.4%)

of poverty

(27.6%)

Income 300% of

poverty and above

(40.4%)

Incomes of families in which adolescents

are not living with parents or

are married and living with

their parent(s)

e 300% of

Income 150-299% poverty and above

of poverty (18.8%)

(23.6%)

NOTE: Figures may not add to 100 percent because of rounding error.

aFamily in~me is express~ in relation to the F~eral poverty level. In 198B, the Federal poverty level WaS $9,431 for a family of three.

SOURCE: Office of Technology Assessment, 1991, based on R. Kronick, Adjunct Professor, University of California, San Diego, CA, calculations based on

U.S. Department of Commerce, Bureau of the Census, March 1989 Current Population Survey public use files, 1990.

percent of adolescents living in the North live in account variations in the cost of living across regions

poor or near-poor families (107).13 It is important to or across residential areas (i.e., urban, suburban,

note that these comparisons are based on the official rural) within regions. Differences in the cost of

definition of poverty, which does not take into living in different areas can be quite substantial.

lsDa~ from ~dwestem Stites ~e not reported as a sep~te goup ~a~ of fie low nu~s of adolescents sarnpkd from Midwestern States; data

from these States me reported as pm of other regions to increase the reliability of tbe data (107).
///-164 . Adolescent Health--Volume III: Crosscutting issues in the Delivery of Health and Related Services

Figure 18-4-Family Incomes as a Percent of the Federal Poverty Level by U.S. Adolescents’ Race/Ethnicity, 1988a

White, non-Hispanic Asian

Inco

o

Income less than

150% of poverty

(17.3%) Income 151-299%

of poverty

(25.0%)

e less than

of poverty

32.0%)

Income 300% of

poverty and above

(52.4%)

Hispanic

Income less t

150% of pove

(49.0%)

Income 300% of

Income 151-29 overty and above

of poverty (19.5%)

(31.5%)

Black, non-Hispanic

Income 300% of

I overty and above

(21.0%)

American Indian

and Alaska Native b

Income less than A

150% of poverty

(51.0%) A

I

/’ Income 300% of

- w

. /“ poverty and above

(17.0%) Income 151-299%

of poverty

-

b

(31.0%)

aFamil~ in@me is expre=~ in re{ation to the F~eral poverty level. In 1988, the Federal poverty level W= $9,431 fOr a family of three.

bBecauseof thesmallnumberof Amerfcafl lndiansandAlaska Natives sampled forthe Current Population Survey and various limitations of thesurveydesign,

the estimates for this group may be unreliable. The proportion with incomes less than 150 percent of poverty could be between 41 to 61 percent (108).

However, the high rate of poverty amonfl American Indians and Alaska Natives found through the Current Population Survey is consistent with estimates

from other sources (204).

SOURCE: Office of Technology Assessment, 1991, based on R. Kronick, Adjunct Professor, University of California, San Diego, CA, calculations based on

U.S. Department of Commer% Bureau of the Census, March 1989 Current Population Survey publk use files, 1990.
Chapter 18-issues in the Delivery of Services to Selected Groups of Adolescents . III-165

Thus, the impact of living in a family whose income

falls below the Federal poverty level may differ

depending on where one lives.

Health Status of Poor Adolescents

Limitations of Data and Research on

the Health of Poor Adolescents

Existing data on the health status of poor adolescents and research on the health effects of poverty

have a number of significant limitations. As discussed elsewhere in this report, there is no regular

monitoring of U.S. adolescents’ health, and information on the health status of U.S. adolescents is often

not available.14 National data on the health status of

U.S. adolescents by income level are practically

nonexistent.

Data on births, deaths, various indicators of health

status, and the utilization of health resources are

collected on an ongoing basis by the National Center

for Health Statistics in the U.S. Department of

Health and Human Services (DHHS). Much of the

data collected by the National Center for Health

Statistics is not analyzed in terms of income level.15

Thus, for example, the major Federal report on

health indicators in the United States—Health,

United States—tabulates mortality and most morbidity statistics by age, sex, and race but not by

income or other factors indicative of socioeconomic

status (156,238a).

One of the few national surveys sponsored by the

National Center for Health Statistics that does

collect morbidity data by family income is the

National Health Interview Survey. The National

Health Interview Survey uses personal household

interviews to obtain information from a sample of

the civilian noninstitutionalized population on personal and demographic characteristics and various

health topics (238a). This survey has a number of

limitations. As a household survey, it does not

include individuals who are homeless or in institutions. For individuals under age 17, information is

collected from a proxy respondent, typically a parent

or guardian.

The prevailing stereotype of poverty is as an inner

city phenomenon, and much of the research on poor

people has focused on poor people living in urban

areas. Thus, it has often overlooked poor people in

rural or suburban areas. In fact, a substantial

percentage of poor families with children live in

rural areas (30 percent in 1987) or suburban areas (28

percent in 1987) (13). Urban areas tend to have high

concentrations of racial and ethnic minority poor

people. Thus, much research on the poor has focused

disproportionately on people from racial and ethnic

minorities. There have been few attempts by researchers to examine poverty’s unique impact on

adolescents’ physical or mental health status, apart

from the effects of such factors as family structure,

race and ethnicity, and place of residence.

Another problem is that many researchers rely on

impressionistic criteria, such as the apparent socioeconomic characteristics of neighborhoods, for determining adolescents’ socioeconomic status instead

of using multiple criteria including family income

levels (146). Adolescents themselves often do not

know enough about the details of their parents’

employment to permit accurate assessment of their

family’s economic status.

Finally, it should be noted that much of the

research on adolescents living in poverty has focused on the “failures” (e.g., individuals who drop

out of school, individuals who exhibit emotional or

behavioral problems, individuals who remain dependent on welfare) rather than the successes. These

“failures,” however, are not representative of all

poor adolescents.

16 While the deficit model can

ldDa~ on adolescent health are not collectd in any single place, and for many important problems (e.g., nonfatal accidents, sex@Y ~“tted

diseases, mental health problems, delinquency), there are no reliable sources of national data. The problems with available information on adolescent

health are summmizd in app. c, ‘ ‘Issues Related to the Lack of Information About Adolescmt Health and Health and Related Services, ’ in Vol. I.

Sources and limitations of mtional data sources on .speciflc aspects of adolescents’ health are discussed in each chapter in Vol. II.

15~e Natio~ Health ~“ tion Survey conducted from 1966 to 1970 used a variety of direct physical examinations and clinical and laborato~

tests, to obtain information on the measures, including health status of a representative national sample of U.S. adolescents ages 12 to 17. This survey

did obtain information on family income, but data from that survey are now over 20 years old. The National Health and Nutrition Examination Survey

(NHANES) was initiated as a successor to the National Health Examination Survey in 1971. NHANES III, currently underway, will include questions

related to income, but the sample of 3,200 adolescents ages 12 to 19 (56) may be too small to allow m “ eamgful comparisons by income level.

16-Y c~l~en who ~w up b we~are.dependent familim, for example, do not become welfare-dependent themselves m ad~m. One s~dy found

that 42 percent of black females and 27 percent of white fernales growing up in highly welfare-dependent families--i.e., defined as families who relied

on welfare for at least 25 percent of average total family income in the years between the time the child was between the ages of 10 and 17-did not

receive any welfare between the ages of 24 and 30 (196). Only 19 percent of black daughters and 26 percent of white daughters in highly

welfare-dependent families in this 1984 analysis became highly welfare-dependent themselves (l%).
III-166 . Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Box 18-A-Research on Resilient Children and Adolescents

It is well established that some children from impoverished homes or neighborhoods, dysfunctional families,

or other adverse cimumstances grow up to become mentally and socially healthy adults. Such individuals have

sometimes been called “resilient” or “invulnerable” (59,126,238).

Although there has been little longitudinal research tracking children and adolescents from disadvantaged

homes and neighborhoods and comparing their long-term outcomes with outcomes among individuals from

nondisadvantaged homes, the research that has been conducted generally suggests that two importantvariables for

helping children overcome adverse circumstances are having access to supportive individuals and networks and having

personal characteristics that enable one to draw upon this support (e.g., social competence,greater intelligence).

A 30-year longitudinal study of children born on the Hawaiian island of Kauai in 1955 identified 30 percent

of the children as high risk because they had experienced four more selected risk factors-e.g., experiencing

moderate to severe perinatal stress, growing up in chronic poverty, having parents with no more than an eighth grade

education, and having family environments characterized by discord, divorce, or parental alcoholism or mental

illness (268). Many of these high-risk children subsequently experienced problems such as behavioral or learning

problems, delinquency, mental health problems, or teenage pregnancy. By the time they were assessed at age 18,

however, one-third had grown into competent young adults. By the time the cohort was assessed at age 30, additional

numbers of children who had experienced problems during their teens were better off than they had been at age 18.

The study identified a number of factors that seemed to protect these children from the potentially negative effects

of their environments. Protective factors included the following:

● constitutional Characteristics of the children themselves (e.g., a teperament that elicits positive responses

from others),

. environmental factors (e.g., having fewer siblings),

● having the opportunity to establish a close relationship with at least one caring adult (not necessarily a

parent), and

● the availability of social support outside of the immediate family.

Another longitudinaI study followed 456 economically disadvantaged boys (all white) from adolescence

until age 47 (59). From this sample, 75 individuals were identified as high-risk because they had experienced at least

10 negative family characteristics--ranging from a lack of parental supervision, to having an alcoholic father, or

having high numbers of social agency contacts. Preliminary data indicate that boys who were rated as most

competent as adults tended also to have been rated as competent as boys and were less likely to have exhibited

emotional problems as boys.

Another study involved interviews of 68 rural black adolescents who had been identified by their teachers as

being academically and socially successful indicated that the adolescents had supportive family relationships,

extensive social networks outside of the family, active participation in school and church activities, a strong future

orientation, and identification with positive role models (117). This was a cross-sectional study rather than a

longitudinal one and did not fallow the adolescents over time. The study also did not provide information on less

successful adolescents. Thus, it is not really possible to determine the variables that actually led to the adolescents’

success.

Hopeful findings about resilient children and adolescents should not be taken to suggest that “extreme poverty

ultimately presents no problems to the next generation or that benign neglect is an appropriate solution to desperate

social problems” (126). Instead they should be taken to suggest that need for additional research to improve the

knowledge of the factors that make a long-tarn difference in the lives of children and adolescents growing up in

poverty or other adverse Circumstances. The findings from such research could be used to design societal

interventions that enable such children and adolescents to live healthier and longer lives (126).

provide critical information about needs and the Research on so-called “resilient” children and

etiology of problems, the pronounced lack of infor- adolescents is summarized in box 18-A. This

mation about the variables associated with positive research generally suggests that having access to

outcomes limits the identification of pathways to supportive individuals and networks and having the

health and the maintenance and support of health- ability to draw upon this support (social competence,

enhancing characteristics. greater intelligence) are factors that help children
Chapter 18—issues in the Delivery of Services to Selected Groups of Adolescents . III-167

Table 18-1—Reported Health Status of U.S. Adolescents Ages 10 to 18, by Family Income, 19886

Number of

persons at Reported health status (percent distribution)

family

Family income and age income levels Excellent Very good Good Fair Poorb

Under $10,000

All ages (10 to 18) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,676,000

10 to 14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,807,000

15 to 18 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,869,000

$10,000 to $19,999

All ages (10 to 18) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,880,000

10 to 14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,633,000

15 to 18 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,247,000

$20,000 to $34,999

All ages (10 to 18) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,491,000

1Oto 14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,213,000

15 to 18 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,278,000

$35,000 or more

All ages (10 to 18) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10,576,000

1O to 14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,665,000

15 to 18 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,911,000

35.3%

35.8

34.8

42.9%

44.5

41.0

53.1%

55.1

50.5

63.0%

64.4

61.3

25.6%

24.4

26.7

27.8%

29.0

26.4

27.4%

26.6

28.5

23.7%

22.7

24.8

31.9840

33.7

30.2

24.8%

23.4

26.5

17.0940

16.1

18.2

12.3%

11.8

12.9

6.3%

5.1

7.3

3.9%

2.4

5.6

2.3%.

2.2

2.4

0.9%

0.9

0.9

— “

— *

● —

—*

●

☛

—*

—*

—*

●

☛

☛

~hedataprasentad in this table are from thetdational Health interview Survey, acontinuing nationwide sample surveyofthe civilian noninstitutionalized

population inwhichpersonal household interviewsareused tocollect dataondemographic eharacteristies, illness,injunes, utilization ofhealth resources,

and other health topics. This survey uses proxy interviews (generalty with a parent) for all persons under age 18.

bEntnes ma~~ with an ~terisk did not meet the requisite standard fOr reliability.

SOURCE: U.S. Department of Health and Human SeMces, Public Health Service, Centers for Disease Control, National Center for Health Statistics,

unpublished data from the 1988 National Health Interview Survey, Hyattsville, MD, 1989.

overcome adverse circumstances. Further research

to identify the components of resiliency among

adolescents from disadvantaged backgrounds could

be helpful in developing effective interventions.

Health Status of Adolescents

by Family Income Level

As noted above, the National Health Interview

Survey is one of the few sources of national data on

U.S. adolescents’ health status by family income

level. The National Health Interview Survey is a

survey of a sample of the civilian noninstitutionalized population and thus does not include adolescents who are homeless or in institutions (e.g.,

correctional institutions for juvenile offenders, homes

for dependent and neglected children, homes and

schools for the mentally or physically handicapped,

or homes for unwed mothers). As discussed elsewhere in this report, homeless adolescents are at

high risk of experiencing a variety of physical and

mental health problems and typically lack access to

a regular source of health care.17 Adolescents in

juvenile justice facilities are also at particular risk.18

In the 1983 and 1985 National Health Interview

Surveys, U.S. adolescents ages 10 to 18 from poor

families were significantly less likely to be reported

to be in excellent health than were adolescents from

nonpoor families (37.5 percent of poor v. 55.9

percent of nonpoor) (157). Adolescents from poor

families were also considerably more likely to be

reported to be in fair or poor health than were

adolescents from nonpoor families (7.3 percent of

poor v. 2.3 percent of nonpoor) (157).

The 1988 National Health Interview Survey had

similar findings. As shown in table 18-1, adolescents

in families with incomes under $10,000 were far less

likely than adolescents in higher income families to

be reported to be in excellent health. Adolescents in

families with incomes under $10,000 were also far

more likely than other adolescents to be reported to

be in fair health (238).

The 1988 National Health Interview Survey

further found that adolescents in the lowest income

families experienced more restricted-activity days

due to acute and chronic conditions than did

adolescents in higher income families. As shown in

17s& Ch. 1A, ‘ ‘Hopelessness: Prevention and Services, ’ ti VO1. ~.

ISSM ch. 13, * ‘Del@uency: Prevention and Services, ’ iII VO1. ~.
111-168. Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Table 18-2—Reported Restricted-Activity Days Among U.S. Adolescents

Ages 10 to 18, by Family Income, 1988a

Reported restricted-activity days per person

All Bed- School- or

Family income and age restricted-activity daysb disability daysc work-loss daysd

Under $10,000

All ages (10 to 18) . . . . . . . . . . . . . . . . .

10 to 14 years.. . . . . . . . . . . . . . . . . . . .

15 to 18 years . . . . . . . . . . . . . . . . . . . . .

$10,000) to $19,999

All ages (10 to 18) . . . . . . . . . . . . . . . . .

10 to 14 years . . . . . . . . . . . . . . . . . . . . .

15 to 18 years . . . . . . . . . . . . . . . . . . . . .

$20,000 to $34,999

All ages (10 to 18) . . . . . . . . . . . . . . . . .

10 to 14 years . . . . . . . . . . . . . . . . . . . . .

15 to 18 years . . . . . . . . . . . . . . . . . . . . .

$35,000 or mom

All ages (10 to 18) . . . . . . . . . . . . . . . . .

10 to 14 years . . . . . . . . . . . . . . . . . . . . .

15 to 18 years . . . . . . . . . . . . . . . . . . . . .

11,8

11.4

12.3

9.1

8.1

10.4

8.4

8.6

8.2

8.0

7.5

8.6

5.8

5.7

5.8

4.2

3.8

4.7

4.0

3.9

4.2

3.9

3.8

4.0

6.7

6.9

6.5

5.0

4.5

5.7

4.8

4.5

5.3

4.1

4.2

4.1

~he data presented in this table are from the Nationai Health Interview Survey, a continuing nationwide sample survey

of the avilian noninstitutionaiized population in which personal household interviews are used to collect data on

demographic characteristics, illnesses, injuries, utilization of health resources, and other health topics. This survey

uses proxy interviovvs (generally with a parent) for all persons under age 18.

bR=~t~-@tiv~ dap are unduplieated ~unts of bed-disability, work-loss, and school-ioss daYs, as weli as other

days during which a person cuts down on his or her usual activities.

CA ~~-=bil~~ayis a day on whi~ a person stays in bed for more than hatf of the daylight hours (or normai waking

hours) because of a speeified iliness or injury.

dA S~wPIoSS day IS a rjay on Wflictl a child did not attend school for at least haif the normal school day beCaUSe Of

a specific iilness olr injury. A work-loss day is a day on which a person did not work at his or her job for at least half of

the normal workday because of a specific illness or injury.

SOURCE: U.S. Department of Health and Human Serviees, Public Health Service, Centers for Disease Control,

National Center for Heaith Statistics, unwbiished data from the 1988 National Health Interview Survev,.

Hyattsville, MD, 1989.

table 18-2, adolescents in families with incomes

under $10,000 were reported to experience an

average of 11.8 restricted-activity days per person in

1988 (238). This average included 6.7 school-loss

days per person. Adolescents in families with

incomes of $10,000 or more were reported to

experience fewer restricted-activity and school-loss

days than adolescents in the poorest families.

Overall, the 1988 National Health Interview

Survey found that 9.8 percent of adolescents in

families with incomes under $10,000 and 5.1 percent

of adolescents in families with incomes of $35,000

or more were reported to experience activity limitations as a result of chronic: conditions (238). The

1983 and 1984 National Health Interview Surveys

found that adolescents in poor families were significantly more likely to suffer from chronic disabling

conditions-e. g., mental disorders, diseases of the

respiratory system, and diseases of the musculoskeletal system and connective tissue-than were nonpoor adolescents (8.8 percent of poor v. 6.0 percent

of nonpoor) (157).19

Some researchers have found that adolescents

living in poverty are at increased risk of attending

schools which are characterized by “poorly prepared teachers, inadequate educational facilities,

ineffective administrators, and low teacher expectations” (71).20 Some poor adolescents may have to

drop out of school because of family economic

problems (71). Others may drop out because of

academic difficulties, disciplinary problems, or pregnancy (272). Adolescents who drop out of school or

otherwise become educationally disadvantaged are

likely to be unprepared to fill available jobs (119).

lgc~o~c physic~ he~th problems among adolescents are discussed i.u ch. 6, “Chronic Physical Illnesses: Prevention and Services,” in Vol. II,

~or a discussion of how school environments affect adolescents, see ch. 4, “Schools and Discretionary Time,” in Vol. II.
Chapter I8--lssues in the Delivery of Services to Selected Groups of Adolescents ● 111-169

Poor urban neighborhoods are frequently typified

by high rates of crime, decaying and crumbling

buildings, open drug sales, and lack of employment

and educational opportunities (124, 130, 142). Living

in a poor inner-city area increases the likelihood that

an individual will be a victim of crime. For crimes

of violence, the victimization rate for adolescents in

inner cities is higher than that for residents of urban

and suburban areas (71).

Living in poverty, especially in urban areas, is

associated with an increased likelihood of early

sexual activity and teenage pregnancy (68, 141).21

The causal relationships between poverty and increased levels of teenage pregnancy are not well

understood. There is some evidence that adolescents

from socioeconomically disadvantaged families tend

to initiate sexual activity at an earlier age than

adolescents from nondisadvantaged families (149a).

There is also some evidence that adolescents from

poor families may be less likely than adolescents

from other families to use some form of contraception at first intercourse (84) or to continue using

contraception (52). Poor adolescents who become

pregnant are less likely to have an abortion and less

likely to give their child up for adoption than

adolescents from less disadvantaged backgrounds

(149a).

There is little information available about the

relationships between social class and income differences and the use of alcohol, illegal drugs, or

tobacco.22 There is some evidence from One longitudinal study, however, that amount of available

spending money and family income are positively

related to substance use, presumably because adolescents with more economic resources are more

able to purchase alcohol or drugs. However, another

study found that working class adolescents were

more likely to use hard drugs, but this difference by

family income was found for only 1 year of the

longitudinal survey (51). Yet another study found

that lower income adolescents are more likely to

smoke cigarettes than adolescents from families

with higher incomes (55).

A number of researchers have found no relation

between social class and self-reported delinquency

(e.g., 81,269), but others have found that poorer

adolescents are more likely than those of higher

incomes to commit serious crimes .23

Access to Health Services by Poor Adolescents

Patterns of Health Care Utilization

by Poor Adolescents

Although data on the patterns of health care

utilization among poor adolescents in this country

are scarce, these patterns appear to differ from the

patterns among nonpoor adolescents (157). The

1983 and 1984 National Health Interview Surveys

found that even though adolescents in the lowest

income families are reported to be in poorer health

than other adolescents, they are somewhat more

likely than nonpoor adolescents to wait 2 or more

years between physician contacts (157). On average,

poor adolescents waited 2 years between physician

visits and nonpoor adolescents waited 1.8 years

(157). Furthermore, poor adolescents whose activities are limited by chronic health problems are

reported to have significantly fewer physician visits

(5.3 visits per person per year) than nonpoor

adolescents whose activities are similarly limited

(7.3 physician visits per person per year) (157).

Interestingly, the 1988 National Health Interview

Survey found that adolescents ages 10 to 18 in

families with incomes under $10,000 had more

hospital stays reported than adolescents in families

with higher incomes. As shown in table 18-3, even

when hospital stays for deliveries are excluded, poor

adolescents in families with incomes under $10,000

had more hospital stays than other adolescents. This

finding suggests that when poor adolescents do

finally seek care, their health problems may be more

severe, but alternative explanations are possible

(238).

Barriers to Access for Poor Adolescents

Lack of money is a major barrier to access to

health services for poor adolescents. For some

adolescents, including poor ones, the effect of lack

of money on having access to services is attenuated

by health insurance. As discussed elsewhere in this

report, however, significant numbers of U.S. adoleszlFor a gene~ discussion of pregnancy among adolescents, s= ch. 10, “Pregnancy and Parenting: Prevention and Services,” in Vol. II.

22For ~ ~en~~ &Xu~slon of the u~ of ~coho~ Neg~ drugs, ~d tob~co ~o~ tiolescents, s~ ch. 12, “Alcoho~ ~bilcCO, and Drug Abuse:

Prevention and Services, ” in Vol. II.

22Da~ on de~quency and studies e

xaminkg the relationships between family income and delinquency are discussed in ch. 13, “Delinquency:

Prevention and Semices, ” in Vol. II.
III-170 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Table 18-3-Reported Number of Hospital Discharges

Among U.S. Adolescents Ages 10 to 18,

by Family Income, 1988’

Reported number of hospital

discharges per 100 personsb

All causes Excluding deliveries

All

10

15

All

10

15

All

10

15

All

10

15

Under $10,000

ages (10 to 18) . . . . . . . 6.9 4.7

to 14 years . . . . . . . . . . . —* —*

to 18 years . . . . . . . . . . . 10.6 6.3

$10,000 to $19,999

ages (10 to 18) . . . . . . . 6.1 4.2

to 14 years . . . . . . . . . . . —* —*

to 18 years . . . . . . . . . . . 10.7 6.5

$20,000 to $34,999

ages (10 to 18) . . . . . . . 4.0 3.6

to 14 years . . . . . . . . . . . 3.6 3.5

to 18 years . . . . . . . . . . . 4.5 3.8

$35,000 or more

ages (10 to 18) . . . . . . . 3.4 3.2

to 14 years . . . . . . . . . . . 1.7 1.7

to 18 years . . . . . . . . . . . 5.3 5.0

abata are from the National Health Interview Survey, a nationwide smple

survey of the civilian noninstitutionalized population In Mid personal

househokt interviews are used to collect data on demographic characteristics, illnesses, injuries, utilization of health resoureas, and other health

topics. The National Health Interview Surveydefines a hospital discharge

as any continuous stay of a night or more in a hospital as an inpatient. The

discharges shown in this table are discharges from short-stay hospitals

(i.e., hospitals or hospital departments in which the type of service

provided is general; maternity; eye, ear, nose, and throat; ehikfren’s; or

osteopathic).

bEntnes mark~ with an asterisk did not meet the requisite SWdWCf for

reliability.

SOURCE: U.S. Department of Health and Human Serviees, Public Health

Services, Centers for Disease Control, National Center for

Health Statistics, unpublished data from the 1988 National

Health Interview Survey, t-lyi~ttsville, MD, 1989.

cents are without private or public health insurance,

and adolescents in poor or near-poor families are

much more likely to lack health insurance than

others. 24 In 1988, about one-third of the 5.3 million

U.S. adolescents living in poor families--or about

1.7 million adolescents--did not have health insurance coverage (107). That year, an additional

932,000 adolescents in near-poor families were also

without coverage (107).

As discussed elsewhere in this report, adolescents

who have health insurance coverage, whether private or public, do not always have access to the

services they need. 25 Private health insurers often

place restrictions on the services most likely to be

needed by adolescents (e.g., mental health care,

substance abuse treatment, maternity care and related services, preventive services, services provided by nonphysician providers, and dental care).

Even if appropriate benefits are available, adolescents who are concerned about confidentiality may

be reluctant to seek care from providers if their

private health plan requires parents to submit a claim

for reimbursement (as most do). The services offered

to eligible adolescents by Medicaid vary widely by

State.

Distance from service sites and lack of access to

transportation-either because good public transportation is unavailable or because available transportation is costly—are also potentially important

barriers to seeking care for people who are economically disadvantaged. In addition, certain types of

services, such as mental health services, may be less

available in poor areas (34). Although data specific

to adolescents are generally lacking, it seems

reasonable to assume that these concerns are also

important barriers to service for poor adolescents.

Services and Interventions To Increase Access to

Health Services Among Poor Adolescents

Various approaches have been developed to

address the health-related needs of adolescents

living in poverty. Apart from Medicaid and other

Federal programs for low-income people discussed

in the next section of this chapter, there have been

some attempts to make health and related services

more accessible to adolescents living in poverty by

providing affordable, comprehensive services in

community-based settings.26

As discussed elsewhere in this report, a national

demonstration project funded for 4 years beginning

in 1982 by the Robert Wood Johnson Foundation

enabled 20 teaching hospitals to work in concert

with 54 community-based agencies to implement

programs of community-based, comprehensive services for young people in inner-city communities

XFor ~ ~ms~ion of tie nm~r of poor and other adolescents ~thout h~~ insurance, see ch. 16, “Financial Access to Health Services, ’ in this

volume,

zs~ ~= t. Utibmtion of services by adolescents ti~h~th insurance coverage are discussed inch. 16, ‘‘Financial Access to Health Services, ’

in this volume.

26~ditio~ fio-tion on effo~ t. delivm ~~rehensiveh~~ ~d re~t~ s~ic~ to tiolm~nts is presented ch. 15, “Major Issues Pertain@

to the Delivexy of I%mary and Cornprehensive Health Services to Adolescents, ” in this volume.
Chapter I8 Issues in the Delivery of Services to Selected Groups of Adolescents .111-171

believed to be at high risk for serious socioeconomic

and medical problems (49,1 16,187).27

In the frost 2 years of the comprehensive clinics’

operation, about two-thirds (64 percent) of the

young people who visited the clinics were ages 15 to

19; the clinics were also used by young people ages

20 to 24 (21 percent of patients) and ages 10 to 14 (15

percent of patients) (49). Researchers found that

adolescents attending the Robert Wood Johnsonfunded comprehensive clinics that were specially

geared toward adolescents were more likely to

disclose behavioral and lifestyle problems to their

clinical providers than adolescents attending comparison sites; consequently, larger proportions of

adolescents attending the comprehensive clinics

received care for such problems (49). Despite their

better identification and treatment capabilities for

adolescents, however, the comprehensive clinics

were not able to effect greater improvements in

selected health problems (including persistent depressive symptoms, unmet contraceptive needs, and

heavy alcohol or drug use) than the comparison sites

(49). The researchers were also disappointed in the

ability of the comprehensive clinics to reach adolescent male clients, as adolescent males in inner cities

are at especially high risk of problem behaviors.

Earls and colleagues suggest three reasons for the

failure of the Robert Wood Johnson-funded projects

failed to demonstrate differences in health outcomes: 1 ) the followup period of 1 year may have

been too brief; 2) lack of adolescent-specific skills

among primary care providers (and lack of time for

funded providers to develop specialized skills); and

3) it may be difficult for medical clinics alone to

make a difference in difficulties that are deeply

embedded in the economic and social contexts from

which some adolescents come (49).

Recently, the Robert Wood Johnson Foundation

began finding a longer-term project that placed

adolescent clinics in school settings in medically

underserved areas. This project is still underway,

and the health outcomes for adolescents attending

the school-linked clinics have not been evaluated.

Several nongovernmental programs have sought

to provide poor inner-city adolescents with alternatives to poor urban street life and to enhance their life

options.

●

●

●

The privately funded Kansas City Youthnet

program uses extensive outreach to recruit

young people in poor urban areas to participate

in programs of athletics, dance, theater, and art

instead of joining drug gangs (89). In its first

year, the Kansas City Youthnet program contacted some 3,000 adolescents ages 13 to 16.

A program sponsored by the Youth Services

Unit of the Bayview-Hunter’s Point Foundation provides daily counseling to 12- to 22-yearolds living in poverty in the San Francisco area

and experiencing difficulty in school or with

the juvenile justice system as a result of

involvement with drugs (16). This program

provides a range of additional services, including recreation, mutual support groups, and

opportunities to perform court-required community service or restitution activities.

The University of Illinois at Chicago sponsored

a workshop on medical careers for inner-city

teens designed to encourage students to ignore

negative messages, and pursue positive options

(181). Students were introduced to black medical students who had grown up in poverty,

given tours of the medical school, and provided

with advice about how to prepare for college.

Unfortunately, none of these programs for poor

inner-city adolescents has been systematically evaluated.

Major Federal Programs Pertaining to

Poor Adolescents

In 1989, OTA held a workshop on the Federal role

in adolescent health and conducted a survey of

numerous Federal agencies thought to be involved in

adolescent health. As discussed in the next chapter

of this Report, many Federal agencies have programs that are relevant to U.S. adolescents, but it is

almost impossible to get a firm sense of the impact

of Federal programs on adolescents’ lives .28 Few

Federal agencies were able to break out amounts

budgeted specifically for adolescents, and OTA

found both overlap and fragmentation in the overall

Federal approach to adolescent health issues. The

zTThe ev~Wtion Of the RObeII Wood Johnson Foundation program for high-risk young people and its support of SLHCS is described iII more detail

inch. 15, “Major Issues Pemining to the Delivery of Primary and Comprehensive Health Services to Adolescents,” in this volume.

~The fidings of~e OTA Wey of F~e~ agencies thought to be involved in adolescent health is described in ch. 19, ‘The Role of Federal Agmcies

in Adolescent Health+’ in this volume.
///-172 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Federal agencies surveyed by OTA were not asked

to disaggregate program information as it applied to

adolescents of differing socioeconomic levels. Their

general inability to provide adolescent-specific information, however, makes it doubtful that they

would have been able to provide adolescent-specific

information by income level.

Various programs of DHHS and other Federal

agencies that are intended to help low-income

persons are described below to provide a rough sense

of the Federal approach to the issues affecting poor

29 Unfortunately , the and near-poor adolescents.

description or programs below provides little sense

of the actual impact of Federal programs on the lives

of individual adolescents living in poor and nearpoor families. One way to get a sense of that would

be to conduct an interview survey of poor adolescents in which their use of federally funded programs could be assessed in relation to their needs.

ACTION

ACTION administers several Federal domestic

volunteer service programs that provide human

services to disadvantaged, poor, and elderly Americans. ACTION’s Office of Domestic Operations

sponsors a number of efforts that affect adolescents.

In fiscal year 1988, there were 469,000 ACTION

volunteers, and ACTION had a budget of about $163

million (l). With this budget, ACTION supported

the Retired Senior Volunteer Program ($30.6 million), the Foster Grandparent Program ($57.4 million), the Senior Companion Program ($23.1 million), Volunteers in Service to America, the Student

Community Service Program, Citizen Participation

Program and the Program Demonstration and Development Division (l). Although ACTION’s budget is

not broken down in a format that separated expenditures, the agency estimates that its fiscal year 1990

budget request for adolescents was about $16

million (5).

The Retired Senior Volunteer Program provides

opportunities for retired persons age 60 and over to

serve as volunteers in schools, museums, libraries,

hospices, and a range of other public and private

nonprofit organizations (1). In 1988, there were

about 750 projects involving about 400,000 volunteers. Information on the number of adolescents

served by these projects is not available. However,

some of the projects emphasize substance abuse

prevention and intergenerational assistance.

The Foster Grandparent Program provides direct

benefits (e.g., stipend, transportation, meal assistance, annual physical examination) to low-income

individuals ages 60 and over who work 20 hours a

week with children and adolescents who have

special needs (l). In fiscal year 1988, the Foster

Grandparent Program sponsored 252 projects (l).

That year, the program served about 70,000 young

people, including about 25,500 ages 6 through 12

and 15,400 ages 13 through 20 (2). Typically, the

youth served by the program are at risk of drug or

alcohol use, are in the delinquent detention system,

are pregnant or parenting, or are mentally, physically, or emotionally disabled (l).

The VISTA program tries to help low-income

people become self-sufficient by supporting projects

sponsored by local public and private nonprofit

organizations (l). In fiscal year 1988, there were 612

VISTA projects and 5,048 VISTA volunteers (l).

That year, 244 VISTA projects focused on youth. As

of August 31, 1989, 15 VISTA projects involving 66

volunteers were focusing on juvenile health, including the prevention of adolescent pregnancy, substance abuse, suicide, and violence (5).

The Student Community Service Program, a

program begun in 1987, funds projects that enable

high school and college student to work as volunteers to help eliminate poverty-related problems. As

of October 1, 1989, ACTION was funding 121

Student Community Service Projects (3,4). For

fiscal year 1990, the estimated budget for the

Student Community Service Program was $893,000

(24). In 1988, an estimated 28,000 students provided

more than 850,000 hours of community service in

various settings, such as Head Start programs,

juvenile diversion programs, shelters, and soup

kitchens (l).

ACTION’s Program Demonstration and Development Division was created, in part, to award

demonstration grants to organizations that have the

potential to generate volunteer activity within a

community and have the ability to serve as a model

for other organizations. In fiscal year 1988, the

Division awarded $2.6 million in demonstration and

other grants for 79 projects (1). Thirteen grants

29wY, if ~t mos~ F~e~ h~~-re~t~ programs for adolese.ents are probably directed to or have an emphasis on low-income adolescents. This

approach is consistent with the Federal emphasis on providing a “safety net” for those who are the most disadvantaged in this country (e.g., 180),
Chapter 18-issues in the Delivery of Services to Selected Groups of Adolescents ● III-173

supported projects using volunteers to establish

illicit drug use prevention networks either statewide

or in low-income communities. Three grants supported efforts to alleviate problems faced by at-risk

youth (e.g., youth in foster care). One supported a

network to place low-income youth with volunteer

mentors.

The role of ACTION, and other Federal and local

agencies, in promoting youth service opportunities

for adolescents should be expanded by passage of

the National and Community Service Act of 1990

(Public Law 101-610). The legislation emphasized

opportunities for disadvantaged children, adolescents, and young adults,

U.S. Department of Health and Human Services

Each of the following four major components of

DHHS has programs relevant to low-income populations:

● the Family Support Administration (FSA),

. the Health Care Financing Administration (HCFA),

● the Office of Human Development Services

(OHDS), and

. the Public Health Service (PHS).30

Family Support Administration (FSA)-FSA

in DHHS administers various programs intended to

strengthen the American family, especially lowincome families (213). According to FSA, the major

thrust of its efforts is to prevent chronic welfare

dependency through the provision of support services (212).

FSA’s Office of Family Assistance administers

the Aid to Families With Dependent Children

(AFDC) program and the Job Opportunities and

Basic Skills Training (JOBS) program. AFDC,

which is funded jointly by the Federal and State

governments, is the largest cash assistance program

serving needy families with children (215). Under

Title IV-A of the Social Security Act, AFDC funds

are made available to States to maintain and

strengthen family life by providing financial assistance and care to needy dependent children in their

homes or the homes of caretakers relatives. AFDC

has a twofold statutory mission: 1) to assist families

with dependent children meet an immediate financial need; and 2) to help parents in these families

become self-sufficient (213). AFDC programs are

administered by the States, and States have wide

latitude in deciding how their AFDC programs are to

be organized and administered, who is eligible for

aid, and how much aid eligible persons receive

(215). In fiscal year 1987, 33 percent (2.5 million

children) of the child recipients were ages 10

through 18 (215). Another 121,000 adolescents (85

percent of whom where females) received AFDC

benefits as heads of household (215).

Under the Family Support Act of 1988 (Public

Law 100-485), States can begin to replace their

AFDC programs with a comprehensive education,

job training, and work experience program known as

the JOBS program (213). The JOBS program is

designed to provide AFDC families 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 mothers with children over age 3 with

child care services and out-of-school youth ages 16

and over in AFDC homes are expected to participate

(212). All States were required to have a JOBS

program by October 1, 1990 (213). As discussed

elsewhere in this Report, the JOBS program, if

well-implemented, could have a substantial impact

on adolescent parents.31

FSA’s Office of Child Support Enforcement

supports State efforts to enforce support obligations

owed by absent parents to their children (213).

Under the Child Support Enforcement Program,

established in 1975 as part D of title IV of the Social

Security Act, States and territories provide direct

services to individuals and families to enable them

to collect child support from absent parents (214).

FSA’s Office of Child Support Enforcement helps

States to develop, manage, and operate their programs, and the Federal Government shoulders the

preponderant share of administrative costs of the

program ($745 million (70 percent of the total) in

fiscal year 1987 [214]). An estimated 8.8 million

mothers rearing children alone could potentially

benefit from these services, but the number of

precognition of existing Federal fragmentation in attempts to assist poor families, the DHHS recently announced areorganizationof several DHHS

programs for children and families (225). The reorg anization was not complete as this Report went to press. The programs intended to be affected included

the Family Support A&mm“ ‘stratiom the Office of Human Development Services, and the maternal and child health block grants program in the Bureau

of Maternat and Child Health (HRSA) (225). Medicaid and programs outside DHHS would not be affected by the reorganization.

SISee ch. 10, “~e~cy and Parenting: Prevention and Services, ’ in VO1. n.
111-174 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

adolescents potentially affected is unknown. In

fiscal year 1987, $3.9 billion in child support was

collected and $278.5 million was returned to AFDC

families, the net amount returned to families with

adolescent children is not available. Another $2.5

billion was collected on behalf of non-AFDC

families (214), but the net amount returned to

families with adolescents is not available.

FSA’s Office of Community Services administers

several programs intended to assist poor people,

including the community services block grant.

Though the community services block grant, FSA

provides annual Federal funding to States, territories, Indian tribes, and tribal organizations to help

them provide a wide range of services and activities

to local communities to assist low-income persons

(213). Community service block grant funds are

primarily used to meet employment, education,

housing, income management, energy, health, and

emergency needs of the poor (213). What portion of

block funds goes to meet the needs of poor and

near-poor adolescents is not known.

FSA’s Office of Community Services also administers discretionary community service grants, lowincome home energy assistance grants, and emergency community services for the homeless grants.

Discretionary community service grants are made

directly to public and private nonprofit organizations for a wide range of activities, including

economic development, rural housing, rural community facilities, assistance to migrants and seasonal

farm workers, community food and nutrition, projects that involve innovative approaches to deal with

particularly critical needs or problems of the poor,

and recreational activities for low-income youth

(213). The low-income energy assistance program

provides Federal grants to States, territories, Indian

tribes and tribal organizations that wish to assist

low-income households in meeting the costs of

home energy. The emergency community services

homeless grant provides annual funds to States,

territories, and federally recognized Indian tribes to

provide comprehensive services (emergency food

and shelter, employment and educational training,

medical care, counseling, case management, and

related services) to homeless individuals and families.32 In part because these programs almost all

involve grants to States and/or other entities (e.g.,

Indian tribes), the amounts expended specifically for

adolescents are generally not available from the

Federal Government.33

Health Care Financing Administration (HCFA)-

HCFA in DHHS administers Medicaid, a Federal/

State program established in 1965 under Title XIX

of the Social Security Act to increase access to

health services for poor people (218).

In 1988, there were about 23 million Medicaid

recipients, including about 10 million dependent

children under age 21, and total benefit payments

were $51.6 billion ($29 billion Federal and $22.6

billion State moneys) (219). An estimated 4.58

million U.S. adolescents ages 10 to 18 had Medicaid

coverage at some point in time during fiscal year

1988; and Federal and State Medicaid expenditures

for these adolescents totaled approximately $3.322

billion (220). In 1988, HCFA estimated that adolescents made up 17.1 percent of Medicaid enrollment

and accounted for 6.9 percent of national Medicaid

expenditures (220).34

Title XIX of the Social Security Act requires that,

in order to receive Federal matching funds, States

offer a specified minimum benefit package in their

Medicaid program. In addition to offering hospital

inpatient and outpatient services, physician services,

skilled nursing home care for adults, laboratory and

X-ray services, nurse midwife services, family

planning services, rural health clinic services, and

transportation services, State Medicaid programs

must provide early and periodic screening, diagnosis, and treatment services for eligible individuals

under age 21 (218). Under Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

program, eligible children must be screened and

treated for vision, hearing, and dental problems;

their growth and development must be checked; and

they must be immunized against infectious diseases

(218,219). The funding of abortions under Medicaid

is prohibited.

szFede~ programs for homeless adolescents are addressed in ch. 14, “Homelessness: Frevemtion and Services,” in Vol. II.

3SM addition to being involved in the= legiSktiVely Illii.ndil@d pm~ tic efforts, FSA oversaw a panel on teen pregnancy prevention. Materials

developed during the initiative, which took place during the Reagan administration were transferred to the CMce of Adolescent Pregnancy in the Fublic

Health Sefice.

~For ~m discussion S- ch. 16, “Financial Access to Health Services,’ and app. C, “HCFA’S Method for Estimating National Medicaid

Enrollment and Expenditures for Adolescents Ages 10 Through 18,” in this volume.
Chapter 18--Issues in the Delivery of Services to Selected Groups of Adolescents .111- 175

Although the Medicaid program is funded by the

State and Federal Governments, it is administered by

the States. States have broad discretion in determining, within Federal guidelines, which groups their

Medicaid programs will cover and the financial

criteria for Medicaid eligibility. States are required,

however, to provide Medicaid coverage for most

recipients of Federal and/or State income maintenance assistance programs, including recipients of

AFDC, recipients of adoption assistance and foster

care under Title IV-E of the Social Security Act.

States are also required to cover children ages 1

through 6 and pregnant women who meet the State’s

AFDC financial requirements, and to cover pregnant

women (and infants to age 2) if their income is at or

below the Federal poverty level.

Enrollment in Medicaid appears to have a strong

effect on the utilization of health care by poor

adolescents, increasing their level of utilization to

levels similar to those of nonpoor adolescents (157).

As discussed elsewhere in this report, however,

many adolescents living in poverty are not covered

by Medicaid.35 In 1988, fewer than half of U.S.

adolescents living in families with incomes below

the Federal poverty level were covered by Medicaid

(107). Even among adolescents in the poorest

families, those with incomes under half the poverty

level, only half are covered by Medicaid.

Furthermore, even for adolescents who are eligible, Medicaid does not ensure access to health

services. One problem is that coverage of some

services (e.g., dental services, mental health services) is limited (203). Another problem for poor

adolescents who are eligible for Medicaid is low

levels of physicians’ participation in the Medicaid

program (200,276). Physician participation in Medicaid is particularly low among two specialties of

importance to adolescents, gynecologists and psychiatrists (200). Other potential barriers to the

utilization of services include adolescents’ concerns

about confidentiality.36

Office of Human Development Services (ODDS)---

OHDS within DHHS oversees various social and

economic development programs for poor children

and youth, families, Native Americans, persons

living in rural areas, disabled people and elderly

people (226). Like FSA, this agency sees as its major

mission the promotion of self-sufficiency among the

people it serves (223). In fiscal year 1988, appropriations for OHDS programs were $5.2 billion (226).

The largest appropriation was for social services

block grants ($2.7 billion), followed by appropriations for the Administration for Children, Youth,

and Families ($1.5 billion), family social services

($811 million), the Administration on Developmental Disabilities ($92.9 million), and the Administration for Native Americans ($29.7 million). Comprehensive counts of OHDS services specifically for

adolescents-thus, including low-income adolescents-cannot be readily provided. It is likely,

however, that many OHDS services provided to

adolescents are provided to low-income adolescents.

The social services block grant program, authorized under Title XX of the Social Security Act as

amended by the Omnibus Budget Reconciliation

Act of 1981 (OBRA-81, Public Law 97-35), provides Federal assistance to States for social services

directed at five goals: 1) achieving or maintaining

economic self-support; 2) achieving or maintaining

self-sufficiency; 3) preventing or remedying neglect, abuse, or exploitation of children or adults; 5)

preventing or reducing inappropriate institutional

care by providing for community-based care, homebased care or other forms of low-intensity, lower

cost care; and 5) securing referral for institutional

care, where appropriate (222). States and other

jurisdictions that are eligible to receive social

services block grant funds are given wide discretion

in determining what services will be provided, who

will be eligible for services, and how the funds will

be distributed within the State (222). OBRA-81

eliminated Federal mandates regarding priority recipients and eliminated provisions relating to the

targeting of services not all services to low-income

individuals or families. There is little information on

the use of Title XX funds by States. According to

OHDS, however, 22 States used fiscal year 1988

social services block grant funds to provide indigent

children and adults with supportive health services

to identify health needs and services available to

help people remain in their own homes; secure

admission to medical institutions; assess the appropriateness of institutional placements; and ensure

35s= & 16, ‘‘F~c~ ACCMS to Health Semices, ’ ‘ in thiS vOlme.

MSee ch. 17, ‘ ‘Consent ~d Confldentiahty in Adolescent Health cue Decisio~“ g,” in this volume.
III-176 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

the continuity of treatment (223). The number of

adolescents affected is unknown.

OHDS’ Administration for Children, Youth, and

Families administers a number of programs relevant

to children and adolescents (226). The Administration’s Head Start Bureau funds the Head Start

program for low-income preschool children. The

Administration’s Family and Youth Services Bureau administers the Runaway and Homeless Youth

Act, which seeks to address the crisis needs of

runaway and homeless youth and their families.37 In

fiscal year 1988, about 340,000 young people were

served by the 327 federally funded runaway centers

across the country (226). Funding for the centers was

about $22 million (226).

The Administration’s Children’s Bureau administers provisions of the Child Abuse Prevention and

Treatment Act and has within it the National Center

on Child Abuse and Neglect (226). The Children’s

Bureau provides Federal support for child welfare

services (including funds for Title IV-E foster care

maintenance and adoption subsidies for children

who are hard to place) and provides Independent

Living Formula Grants to States that assist adolescents in foster care make transitions into the world

of work (223). How many poor adolescents are

affected is unknown.

OHDS’ Administration on Developmental Disabilities administers the Developmental Disabilities

Act and supports programs for developmentally

disabled persons of all ages. How many poor

adolescents are affected is unknown.

OHDS has several special initiatives for adolescents using discretionary funds. It maybe that many

of these programs focus on adolescents who are

already low-income or who, by reason of their own

behaviors or life circumstances, are at risk of

eventually becoming dependent on public assistance. In 1986, OHDS and other agencies in DHHS

funded the Youth Self-Sufficiency initiative (Youth

2000) in concert with the U.S. Department of Labor

and others (e.g., the Business Roundtable). A

public-private partnership was formed to discuss the

needs of at-risk youth and to ensure their economic

and social self-efficiency, and several grants were

made to attempt to meet the multiple needs of youth

in a comprehensive manner.

Public Health Service (PHS)---PHS supports a

wide variety of efforts to improve the physical and

mental health of Americans. At least two PHS

agencies administer programs that are specifically

intended to help poor people:

● the Health Resources and Services Administration (HRSA), and

. the Office of the Assistant Secretary of Health

(OASH).

The Health Resources and Services Administration (HRSA)--HRSA oversees a number of programs of general health services and resources issues

relating to access, equity, quality, and cost of care.

HRSA’s Bureau of Health Care Delivery and

Assistance supports States and communities in their

efforts to plan, organize, and deliver health services

to medically underserved populations and to special

populations at risk (e.g., undeserved pregnant

women and children, homeless people). The Bureau’s Division of Primary Care supports the provision of primary health care services to low-income

persons by providing Federal funds for community

and migrant health centers (about $426 million in

fiscal year 1988) (422). The Bureau’s Division of

Special Populations Program Development provides

Federal grants to organizations to provide health

care for the homeless programs ($60 million in fiscal

year 1988), comprehensive perinatal care programs

for low-income pregnant women and children ($20

million in fiscal year 1988), and other services (242).

Specific funding for adolescent health initiatives is

not available. On the basis of the average number of

adolescent visits to community health centers (CHCs)

and migrant health centers, however, the Bureau of

Health Care Delivery and Assistance estimates that

it spent about $33 million on medical care for

adolescents in 1988 (242).

CHCs provide primary health care services (including primary medical care and ancillary services

such as laboratory test and X-ray services, plus

preventive dental services and family planning

services) to medically underserved, disadvantaged

populations (241).38 CHCs are located in areas of the

37s= Ch. 14, “Homel~sness: Prevention and Services, ‘‘ in Vol. II for discussion of runaway and homeless youth centers funded under this act.

380BRA.81 (~blic Law 96-35) established a primary care block grant pro= and States were given the option to receive block mtWfOr

CHCS or to administer CHCS under section 330 of the Public Health Service Act.
Chapter 18-issues in the Delivery of Services to Selected Groups of Adolescents .111-177

country where there are financial and/or geographic

barriers to primary care for a substantial part of the

population; they are staffed by personnel on assignment from the National Health Service Corps. About

6 million individuals receive services at CHCs

annually (24 1). Migrant health centers provide

comprehensive primary health care to migrant and

seasonal farmworkers. The centers are located in

over 300 rural areas in 35 States and Puerto Rico and

serve about 450,000 migrant and seasonal farmworkers (about 15 percent of the migrant and

seasonal farmworker population) annually (242). In

1989, according to the Bureau of Health Care

Delivery and Assistance, 814,000 adolescents received medical care in community and migrant

health centers; of these adolescents, 117,000 females ages 10 to 14 received family planning

services (242). At least 121,000 adolescents received dental care in these centers in 1989 (242).

HRSA’s Bureau of Maternal and Child Health

(formerly the Office of Maternal and Child Health

(227a)) administers the maternal and child health

block grant programs authorized by Title V of the

Social Security Act. It awards maternal and child

health block grants to States “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. In

fiscal year 1988, the appropriation for the maternal

and child health services block grant program was

$526 million (240a). Eighty-five percent of this

appropriation ($444.3 million) was allocated to State

health agencies to assist them in promoting, improving, and delivering maternal and child health services for children with special health needs, and 15

percent ($82.3 million) was set aside for the Bureau

of Maternal and Child Health to award on a

competitive basis to support special projects of

regional and national significance (SPRANS) which

contribute to the health of mothers, infants, and

children and children with special needs (240a). The

amount specific to poor adolescents is not known.

Office of the Assistant Secretary of Health (OASH)---

OASH’s Office of Population Affairs carries out

Public Health Service Act Title X and Title XX

programs related to adolescent pregnancy, family

planning, and population research. The Office of

Population Affairs provides Title X funds to public

or private nonprofit organizations operating family

planning projects for low-income individuals and

encouraging family participation when possible.39

Approximately one-third of all Title X money is

specific to adolescents. As of 1989, organizations

receiving Title X funds were prohibited from using

the money to provide counseling and referral for

abortion services except in medical emergencies

(54 FR 35440-35441). In a 5-4 decision on May 23,

1991, the U.S. Supreme Court upheld this regulation, despite the concern of some dissenting judges

that the regulation ‘‘raises serious First Amendment

[free speech] concerns.”40

The Office of Population Affairs also distributes

Public Health Service Act Title XX funds for

adolescent family life demonstration projects. An

average of 60 demonstration grants and seven

research grants are funded under Title XX each year.

Projects funded under Title XX attempt to establish

innovative, comprehensive, and integrated health

care services for pregnant and parenting adolescents

under age 17. Abstinence from premarital sexual

intercourse and adoption as an alternative to abortion are encouraged. Title XX money cannot be used

to provide abortion, abortion counseling, or abortion

referrals, and adolescents must obtain parental

consent before participating in any Title XX program. Title XX programs are not limited to lowincome individuals, but Congress has suggested that

service areas with a high proportion of low-income

families should receive priority when grant applications are considered (Public Health Service Act,

Title XX, Sec. 2005).

U.S. Department of Agriculture

The U.S. Department of Agriculture administers

a wide range of programs related to farms, nutrition,

food, hunger, rural development and the environment. Several programs to make food assistance

available to low-income people are administered by

sWor tier d~ussion of servlc~ pmvid~ to pregnant and parenting adolescents under Titles X and XX of the Public Health Sewice AW wx ch.

10, “Pregnancy and Parenting: Prevention and Services,” in Vol. II.

@Justice O’Comor, m cited in The New York Times, “Excerpts From Court Ruling Curbing Family Planning Clinics, ” May 24, 1991, p. A19. in

essence, the Federal regulation upheld by the Court bars employees of federally fmced family planning clinics from all discussion of abortion with

their patients; requires them to inform any wornan who inquires about abortion that “the project does not consider abortion an appropriate method of

family planning’ and requires a referral to prenatal care (L. Greenhouse, ‘‘Five Justices Uphold U.S. Rule Curbing Abortion Advice,’ The New York

Times, p. A19, May 24, 1991).
III-178 . Adolescent Health-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

the Department’s Food and Nutrition Service within

the Office of the Assistant Secretary, Food and

Consumer Services. Such programs include the

Food Stamp Program, the National School Lunch

and Breakfast Programs., and the Special Supplemental Food Program for Women, Infants, and

Children.

The Food Stamp Program provides low-income

individuals and families with children with noncash

transfers that can be used only for food. For those

participating, the program has been associated with

significant improvements in dietary intake (197).

According to the U.S. Department of Agriculture’s

1977-78 Nationwide Food Consumption Survey,

however, 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

(197). Adolescents ages 1.5 to 17 makeup 34 percent

of the participants in the Food Stamp Program (206).

But all eligible adolescents may not benefit; in 1979,

less than 60 percent of all poor households participated in the Food Stamp Program (195). Some

observers have suggested improving nutrition for

low-income youth by increasing food stamp benefit

levels or making sure that people who are eligible

receive them (71).

The School Breakfast and School Lunch Programs provide meals for low-income school children

free or at a reduced price depending on family

incomes. An estimated 24 percent of participants in

the School Breakfast Program and 43 percent of

participants in the School Lunch Program are in

grades 7 through 12 (206). Evaluations of these meal

programs have shown that they have a positive effect

on the overall caloric intake of participants (195),

although they may have other shortcomings.41 Some

observers have suggested extending the programs to

all schools in low-income areas (71).

The Special Supplemental Food Program for

Women, Infants, and Children is intended to improve the health of low-income pregnant, breastfeeding, and postpartum women, infants and children up

to their fifth birthday (206). Federal funds are used

to purchase food packages to supplement participants’ diets and to provide nutrition education.

Females under age 18 make up an estimated 2.8

percent of participants in this program.

Finally, it should be noted that the Department of

Agriculture’s Extension Service has been developing an agenda to better serve ‘‘youth at risk’ due to

poverty, lack of family support, or negative peer

pressure (205).

U.S. Department of Labor

The U.S. Department of Labor has responsibility

for fostering U.S. workers’ welfare, improving

working conditions, and promoting opportunities for

employment. The Department Employment and

Training Administration has responsibilities related

to job training and supports employment and training programs for economically disadvantaged youth

Titles II-A and II-B and Title IV.

Titles II-A and II-B of the 1982 Job Training

Partnership Act authorize block grants to States.

Under Title II-A, training services are offered

throughout the year to economically disadvantaged

adults and youth. In program year 1989, 40 percent

($715,1 million) of the Tide II-A budget was

earmarked for adolescents. Title II-B establishes a

summer employment program for low-income youth.

Funding for Title II-B was $709.4 million for

summer 1990 (258).

Title IV of the Job Training Partnership Act

authorizes the Job Corps and various other federally

administered programs. The Job Corps provides

employment and training in primarily residential

centers for disadvantaged adolescents and young

adults ages 16 to 21 (259). Health care is also

provided by Job Corps. In 1989, the U.S. Department of Labor provided $741.8 million for the

centers, and there were 100,000 participants in the

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.

Racial and Ethnic Minority Adolescents:

Issues in the Delivery of Health and

Related Services

The U.S. population is increasingly coming to be

made up of blacks, Hispanics, Asians, and other

racial and ethnic minorities. By the year 2000, an

estimated 29 to 31 percent of the new entrants into

the U.S. workforce will be from racial and ethnic

dlsee ch. 7, ‘‘Nu~tion ~d Fi~~s Problems: Prevention ~d Services. ’ k VO1. u.
Chapter I8--Issues in the Delivery of Services to Selected Groups of Adolescents . III-179

minority groups, a figure twice that of only a few

years ago (66,67). Overall, 26 percent of the

workforce-and 26 percent of the overall U.S.

population-in 2000 is expected to be from racial

and ethnic minority groups and the proportions of

blacks, Hispanics, and other minorities (i.e., Asians)

are expected to climb steadily throughout the 21st

century (67) (see figure 18-5).

What are the implications of these demographic

trends for U.S. health policymakers? Currently,

about 30 percent of American adolescents ages 10

through 18 are members of racial and ethnic

minorities (21 1). By the year 2010, as many as 38

percent of Americans under the age of 18 will belong

to minority groups. This trend is promising in that it

will increase the cultural diversity of the United

States. But, as noted earlier in this chapter, about half

of black, Hispanic, American Indian and Alaska

Native, and one-third of Asian adolescents live in

poor or near-poor families (see figure 18-3). At least

in part because these adolescents live in poverty, and

for other reasons which are not entirely clear, black,

Hispanic, and American Indian adolescents are at

increased risk of experiencing a range of healthrelated problems, including physical health problems, psychosocial problems, criminal victimization, and teen pregnancy. If the percentage of racial

and ethnic minority adolescents increases and the

social economic status of racial and ethnic minority

groups does not improve, U.S. adolescents’ need for

publicly financed health care will continue to

grow.

4 2

Even if the socioeconomic status of racial and

ethnic minority groups does improve, there may be

a need for ‘‘culturally competent’ health services

for racial and ethnic minority adolescents. The need

for culturally sensitive and locally appropriate

health services has recently become an increasingly

common topic of discussion (e.g., 44,86,185). Questions that have arisen include the following: Are

there alternatives to mainstream health care in the

United States that are used within particular cultures? Do cultural factors affect some populations’

willingness to use certain types of services (e.g.,

mental health services)? Are there certain cultural

norms, strengths, or traditions (e.g., strong, traditional families or church involvement) that “protect’ individuals in certain groups from health

risks? Are there genetic, cultural, or historic factors

Figure 18-5-Projected Changes in the Racial and

Ethnic Makeup of the U.S. Population,

All Ages, 1982 to 2080

Percent of the total population, projected

80 . +

]

+ 4

+..

-+ I

*

60 1

-+. -. *

40 1

o !

1982 1985 1990 1995 2000 2010 2020 2030 2050 2080

* White, non-Hispanic 3 Hispanic

Black . Other races

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Commerce, 8ureau of Census, Projections of the

HispanbPopulation: 1983 to 2080, Current Population Reports,

Population Estimates and Projections, Series P-25, No. 995

(Washington, DC: U.S. Government Printing Office, 1986).

that put individuals at risk for health problems? Does

the mainstream health care system have certain

characteristics that make it less accessible to or less

effective for certain population groups? What culturespecific innovations in service delivery have been

found to be effective in addressing the health needs

of certain groups?

Data on the utilization of health services by racial

and ethnic minority adolescents are limited, but

existing data suggest that racial and ethnic minority

adolescents confront not only economic barriers but

also cultural barriers to access. Minority providers

and providers trained in cultural awareness are few.

Some of the cultural traditions and institutions of

different racial and ethnic minority groups----strong

family and community ties, for example-may turn

out to be resources on which programs that provide

health and health-related services can capitalize to

provide effective services.

The focus of the discussion that follows is on the

delivery of health and related services to five

categories of racial and ethnic minority adolescents

in which Congress expressed particular interest:

. black adolescents,

. Hispanic adolescents,

. Asian adolescents.

dmTA knOWS of no adolescent population projections based on socioeconomic s~ms.
III-180. Adolescent Health—Volume III; Crosscutting Issues in the Delivery of Health and Related Services

● American Indian and Alaska Native adolescents, and

. Native Hawaiian adolescents.43

The health and other effects of belonging to a

racial or ethnic minority group have not been fully

investigated. It is important to note, however, that

racial and ethnic minorities and American Indians

have been the target of much racism and discrimination in this country (71,185,191). Although civil

rights legislation in the 1960s legally removed racial

barriers in access to voting and public accommodations, discrimination in many aspects of American

life remains (58). Blacks, the largest minority group

in the United States, were defined as subordinate and

inferior to whites by a racial caste system introduced

by slavery (71,72). Asians were legally prohibited

from immigrating to the United States by the

Chinese Exclusion Act of 1882 and the Oriental

Exclusion Act in 1924 that banned all immigration

to the United States from Asia. The internment of

Japanese families during World War II targeted

Japanese Americans for separation from the larger

society (148). Throughout the Nation’s history,

Federal Government policies undermined American

Indian cultures (199). Native languages were prohibited from being taught in schools, religious ceremonies and traditional practices were discouraged, and

populations were relocated. The impact of the loss of

culture faced by many Indians has been cited as a

chief contributor to many of the health and social

problems confronting the American Indian population today.

Recent immigrants to this country may have

problems related to their immigration experience.

The immigration experience sometimes exposes

individuals to special risks that may cause or

exacerbate health and mental health problems. Many

immigrants from Southeast Asia, for example, left

Vietnam, Laos, and Cambodia under extremely

adverse and dangerous circumstances; the experience of having been physically and sexually assaulted by sea pirates is not uncommon among

Photo credit: Capitol Hill Arts Workshop, Washington, DC

Adolescence is a crucial period for identity formation,

and an individual’s racial or ethnic minority status

takes on a new importance during adolescence.

adolescent refugees escaping from these war-tom

countries (20,62). Many adolescent refugees from

Central America left to escape from the horrors of

war and economic privation and separated from their

families (260). These recent immigrants may have

language and other difficulties adjusting to American culture.

Adolescence is a crucial period for identity

formation (185). As pointed out by Spencer and

43~e ~~butionof ~aceor ~~cil~ is somet~es ra~er arbi~. For ex~ple, many ‘ ‘blacks’ have white ancestors, Hisptic peOple can have White

or black ancestry, and American Indm.ns may also have black or white ancestors. Use of these limited categories obscures the diversity found witbin

minority groups (266). lkrrninology may also change over time. For example, some black Americans are coming to prefer the designation

“African-Arnencan’ over ‘black. ’ The term ‘African-American’ could, for example, be used to distinguish some individuals who are U.S. citizens

from some recent immigrants from Africa and the Caribbean. Because the term ‘black’ is still used by the Federal Government to collect and calculate

Populatio% healt@ and other statistics, and because potential distinctions among ‘‘African-Amezicans’ and other “blacks” is as yet not clear, the term

“black” has also been used in this Report. Finally, it is impo:tant to note that, in terms of Federal health policy, American Indians have a somewhat

different relationship with the Fedeml Government than do other racial or ethnic minorities. IrI large pr@ Indian tribes function as “domestic dependent

nations, ’ ‘ and the U.S. Supreme Court has ruled that special programs for the benefit of Indians are not racial in nature but based on a unique political

relationship between Indian tribes and the Federal Government (Morron v. A4ancan, 417 U.S. 535 [1974]; see 199).
Chapter 18—issues in the Delivery of Services to Selected Groups of Adolescents .111- 181

Dornbusch in their review entitled “Challenges in

Studying Minority Youth,’ an individual’s racial or

ethnic minority status takes on a new importance

during adolescence (185):

The adolescent’s awareness of minority status is

qualitatively different from that of the child. Very

young children often think of their race. . .as mutable, something that may change as they grow. . .

In contrast to young children, adolescents have the

ability to interpret cultural knowledge, to reflect on

the past, and to speculate about the future. With

cognitive maturity, minority adolescents are keenly

aware of the evaluations of their group made by the

majority culture. . .

The minority adolescent’s awareness of. . .[the

majority culture’s] negative appraisals [of the minority group], of conflicting values, and of restricted

occupational opportunities can affect life choices

and the strategies selected for negotiating a life course.

It is particularly important to recognize that racial

and ethnic minority adolescents may be faced with

“negotiat[ing] a balance between two value systems: that of their own group and that of the

majority’ (185). Some racial and ethnic minority

adolescents may perceive that adhering to the values

of the ‘‘mainstream culture’ is essential to achieving success in that culture but may regard such

adherence as forcing them to reject their own ethnic

identity (185). Members of minority groups who

reject their own culture for that of the ‘‘mainstream

culture’ are sometimes characterized pejoratively

by other members of their minority group (e.g.,

blacks who “act white” may be called “Oreos”;

American Indians who “act white” may be called

“Apples’ Asians who ‘‘act white’ may be called

‘‘Bananas’ Hispanics who “act white” may be

called “Coconuts’ ‘). Some minority adolescents

may be faced with conflicting role models; others

(e.g., some young black males in the inner city), with

a lack of role models (185). Some minority females

come to devalue their own appearance (185).

According to Spencer and Dornbusch, “Even

when they have a positive personal identity. . . ,

minority adolescents may develop ambivalent or

negative attitudes towards their own group’ (185).

Of the strategies for dealing with cultural conflict

(alienation, separation, assimilation, and biculturalism), the ability to develop “bicultural competence’ appears to offer some advantages (185).

Biculturally competent individuals would have the

Figure 18-6-Race/Ethnicity of U.S. Adolescents

Ages 10 to 18, 1987

Total population ages 10 to 18 - 31 million

White, non-Hispanic /“

(22.01 million) ~’

71%

i

‘,, is panic

ion)

“ \

“’..—--- ..’””

SOURCE: Office of Technology Assessment, 1991, based on R. Kronick,

Adjunct Professor, University of California, San Diego, CA,

calculations based on U.S. Department of Commerce, Bureau

of the Census, March 1988 Current Population Survey public

use files, 1989.

norms of both majority and minority groups available to them; the standard to be used would depend

on the situation (185). A requirement to develop a

bicultural identity suggests that minority individuals

bear an extra load during the critical developmental

period of adolescence.

There is some evidence that racial and ethnic

minority adolescents today see themselves and their

opportunities differently from white adolescents. In

a survey of adolescents in grades 7 through 12 in

Minnesota, minority adolescents reported worrying

more than white adolescents about their future job

prospects and their current economic condition; they

were also significantly more likely to report being

worried about being treated unfairly because of their

race (176).

Overview of the Number of Racial and

Ethnic Minority Adolescents

As noted above, according to data from the U.S.

Department of Commerce, Bureau of the Census,

adolescents who are not ‘‘white, non-Hispanic’

made up about 30 percent of the country’s31 million

adolescents in ages 10 through 18 in 1987. As shown

in figure 18-6, non-Hispanic black adolescents made

up 15 percent of the population of 10- to 18-yearolds; Hispanic adolescents (both black and white)

made up about 10 percent of the adolescent population; and other adolescents (including Asians) made

up 4 percent of the adolescent population (107).

The percentage of U.S. adolescents who are not

‘ ‘white, non-Hispanic ‘‘ is growing and in a growing

number of cities, localities, schools, and regions of
III-182 . Adolescent Health–-Volme Ill: Crosscutting Issues in the Delivery of Health and Related Services

Figure 18-7—Projected Changes in the Racial and

Ethnic Makeup of the U.S. Population Under Age 18,

1982 to 2080

Percent of the total population, projected

80 ~-— —

‘–1

4 0 4

I

k

.~---J4-4 e

~~+-+- +- &’> – -—-+? —+—

() - –– , – — ————— ~.— T– ——, -— -. ——T

1982 1985 1990 1995 2000 2010 2020 20302050

‘

- White, non-Hispani c ~ Hispanic

‘

--- Blac k ~ Other races

SOURCE: U.S. Department of Commerce, Bureau of the Census, Projections of the H@anid Population: 1983 to 2080, Current Population Reports, Population EAtimates and Projections, Series

P-25, No. 995 (Washington, DC: U.S. Government Printing

Office, January 1986).

the country, those who are not “white, nonHispanic’ are numerically dominant. By the year

2010, as many as 38 percent of Americans under the

age of 18 will belong to minority groups (see figure

18-7). By the year 2000, Hispanics are expected to

be the largest minority group as a result of their high

rates of fertility and immigration (73,267,208).

Health Status of Racial and Ethnic

Minority Adolescents

Limitations of Data and Research on the Health of

Racial and Ethnic Minority Adolescents

Data and research on the health status and health

care utilization patterns of racial and ethnic minority

adolescents have several limitations. Data on births

and deaths in the United States are collected from the

States by the National Center for Health Statistics.

The National Center for Health Statistics publishes

death rates for 72 causes by race (white, black, all

other) by 5-year age groups (including 10 to 14 and

15 to 19), but data on deaths for adolescents in many

ethnic groups is not readily available. Historically,

national health and health services utilization surveys sponsored by the National Center for Health

Statistics, such as the National Ambulatory Medical

Care Survey and the National. Health Interview

Survey, have provided little reliable data on the

health status or health care utilization patterns of

adolescents from racial and ethnic minority groups.

Data on certain subgroups of minorities, such as

refugee adolescents, the largest portion of whom

come from Southeast Asia, are nearly nonexistent

(20,118,216). Even when race or ethnicity are

considered as variables in research, culture, which is

sometimes but not always related to race or ethnicity,44 is rarely considered as a variable (44,131).

Information about specific health concerns of

racial and ethnic minority adolescents is greatly

limited by a paucity of reliable, population-based

data (21,175). Much of the information available

about cultural beliefs and practices of different racial

and ethnic minority groups is based on data gathered

on adult populations. Little is actually known about

the beliefs and practices of adolescents in particular.

Especially in the case of recent immigrant families,

the beliefs of adolescent members may differ substantially from the beliefs of their parents and

grandparents.

Until recently, research on the health-related

beliefs and practices of black adolescents has

generally been conducted on black adolescents

living in urban settings, usually in poverty (e.g.,

24a,30,31,63,173). It is questionable whether the

findings from such research are applicable to the

many black adolescents who do not live in central

cities and/or are not poor.

45 According to a recent

review by Spencer and Dornbusch, the social

science research base on American minority adolescents has broadened somewhat to include some

suburban and rural black adolescents, wellfunctioning minority adolescents from blue-collar

families, and economically advantaged racial and

ethnic minority adolescents (185). Overall, however, the available research base on racial and ethnic

minority adolescents is thin.

A particularly critical limitation of much available current research is that the effects on health

status and health care utilization of factors related to

race or ethnicity are frequently confounded with

~Acumjing to Cross et al., cUltUre “implies the integrated pattern of human behavior that includes thoughts, communications, actions, customs,

beliefs, values, and institutions of a racial, ethnic, religious, or social group” (44).

As~le 57 ~ment of bhck over~l live in wntr~ cities, 18 percent live in nonmetmpolitan areas, and another 25 percent live ti metmpditan ZUW,

but outside of central cities (209). And while about half of black adolescents lived in families with incomes below or near the Federal poverty level, nearly

one-quarter Live in incomes that exceeded 300 percent of the poverty level (107).
Chapter 18--Issues in the Delivery of Services to Selected Groups of Adolescents . III-183

effects related to socioeconomic status or other

sociodemographic factors (64). When interpreting

the results of most small-scale research studies, it is

difficult to differentiate between the effects of race

and ethnicity and the effects of socioeconomic status

(131,175,185).

In addition, biases and prejudices of the mainstream culture are sometimes reflected when studying racial and ethnic minority adolescents. For

example, theories of adolescent development (e.g.,

Erikson’s theories [53,54]) are based on white

adolescents, and so may ignore cultural differences

between these and black or other minority adolescents and not provide an appropriate framework for

understanding the development of minority adolescents (160, 191). Additional evidence suggests that

there may be a tendency for some minority youth

with problems to be referred to different service

systems than whites. For example, black adolescents

with behavioral problems may be more likely to be

referred to the juvenile justice system, while white

adolescents with behavioral problems may be more

likely to be referred to the mental health system

(17,44,46).

Another important limitation of existing research

is that most studies with ethnic and racial minorities

have been conducted using a problem-focused

approach that examines minority groups’ disproportionate risk of experiencing various problems, frequently using nonrepresentative samples such as

clinical populations or adolescents in institutional

settings (21,1 17,13 1,185). While the deficit model

may be useful for identifying critical areas of need

among minorities, it does little to explain the means

by which many of these adolescents achieve positive

outcomes.

Despite the adversities they confront, many adolescents from poor or otherwise disadvantaged

backgrounds have significant cultural and personal

strengths that protect them from experiencing some

problems or that could potentially attenuate their

effects. As noted above, much of the research that

does exist on adolescents living in poverty and on

racial and ethnic minority adolescents has focused

on the “failures’ rather than the successes. These

failures, however, are not entirely representative. In

order to design services that can capitalize on

individual and cultural strengths, it would be helpful

to have more information about the factors associated with positive outcomes.

Health Problems Experienced by Racial and

Ethnic Minority Adolescents

Information on some of the specific types of

problems that have been reported for black adolescents, Hispanic adolescents, Asian adolescents,

American Indian and Alaska Native adolescents,

and Native Hawaii adolescents is presented below.

Despite the severe limitations in available information, there is evidence that adolescents from these

racial and ethnic minority groups are at increased

risk of experiencing some health problems. The

reasons are not entirely clear. Whether there are

genetic or cultural factors that contribute to the

health problems experienced by racial and ethnic

minorities has not been fully investigated.

In some cases, racial or ethnic minority adolescents are at reduced risk of experiencing health

problems. For reasons that are unclear, for example,

black adolescents appear to have lower rates of

alcohol and illicit drug use than white adolescents

(21,149,228). Black adolescents are also less likely

to die from automobile crashes than white adolescents, at least in part because poor black adolescents

and those living in inner cities tend to have less

access to cars.46 Suicide rates for black adolescents,

although increasing, are also lower than those for

white adolescents (75,232).47 Asian-American adolescents tend to defer involvement in sexual activity

and to have lower rates of pregnancy than white

adolescents (189).48

Black Adolescents—As shown in figures 18-8

and 18-9, black adolescents in this country have

considerably higher death rates than white adolescents (238 b). Among all U.S. adolescents, adolescent males ages 15 to 19 have the highest death rates.

In 1987, the death rate for all adolescent males ages

15 to 19 was 119.6 deaths per 100,000 population;

the death rate for black adolescent males in this age

group was 144.2 deaths per 100,000 (see figure

18-9). While young white males die primarily from

accidents, young black males die primarily from

homicide (71). In addition, black males are much

aSee ch. 5, ‘ ‘Accidental Injuries: Prevention and Services, ’ in Vol. II for further discussion.

47 See ch. 11, ‘‘Mental Health Problems: Prevention and Services,‘‘ in Vol. II for further discussion.

~See Ch, 10, ‘‘~e~cy ~d Parenting: Prevention and Services, ’ in VO1. ~ for fIUther discussion.
///-184 . Adolescent Health-–Volume ill: Crosscutting Issues in the Delivery of Health and Related Services

Figure I8-8--Death Rates for All Causes for

U.S. Adolescents Ages 10 to 14, by Race and Sex, 1987

Deaths/100,000 population

o 40 80 120 160

E

—. .—

All races: Both sexes 26.9

Male ~- >34.8 1

Figure 18-9-Death Rates for All Causes for

U.S. Adolescents Ages 15 to 19, by Race and Sex, 1987

Deaths/100,000 population

o 40 80 120 160

All races: Both sexes

Male 119.6 11 Female 18.7 Female 48.2

White: Both sexes ~ 25.5 White: Both sexes 83.2

Male -32.8 I

Female 17.9

Black: Both sexes L:~4.6 -----i

Other: Both sexes ‘2::R:A’

Male ] 43.3

Female

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Services, Public Heaith Service,

Centers for Disease Control, National Center for Health Statistics, unpublished 1987 mortality data, Hyattsville, MD, 1990.

more likely to be victims of police brutality or killed

in confrontations with police than whites (166).

Black adolescent males are disproportionally at risk

for being victims of crime; they are nearly six times

more likely to die from homicide than white

adolescent males (235). The risk of death from

homicide for black males increases if they reside in

high-risk neighborhoods, if they use drugs, if they

engage in criminal behavior, and if they live in the

North Central region. These disparities diminish

considerably, however, when socioeconomic status

is held constant (46).49

The second leading cause of death among young

black males is accidents. The proportion of accidental injury deaths due to nonvehicular accidents (e.g.,

fires, drownings) is higher among black adolescents

than among white adolescents (71). Suicide rates

among black adolescents have traditionally been

much lower than suicide rates among white adolescents, in spite of blacks’ “obvious exposure to

greater external stresses of discrimination, poverty,

and marginal minority status in American society’

(71). What sociocultural factors account for this

phenomenon are not known, although it has been

suggested that protective factors may have been

provided by five institutions (family, church, fraternal and social organizations, community schools,

Male 116.3

Female

Black: Both sexes

Male 144.2

Female 49

Other: Both sexes 90.6

SOURCE: Office of Technology Assessment 1991, based on U.S. Department of Heaith and Human Services, Public Health Service,

Canters for Disease Control, Nationai Center for Health Statistics, unpublished 1987 mortality data, Hyattsville, MD, 1990.

and extended kin and social support networks)

which characterized the traditionally segregated

black community (71).

Mortality rates are only one indicator of adolescents’ health status. As noted elsewhere in this

report, a broad definition of adolescent health could

include aspects of traditional definitions of health

(i.e., the presence or absence of physical disease or

disability); adolescent problem behaviors (e.g., delinquency, drug use, sexual activity); positive components of health (e.g., social competence); health

and well-being from the perspective of adolescents

themselves; and social influences on health (e.g.,

families, schools, communities, policies) .50 But, as

noted earlier, reliable population-based information

about black adolescents’ health status is lacking.

Overall, a number of analyses have shown that black

adolescents--especially poor black adolescents living in central cities--appear to be at higher risk than

white adolescents for many health problems (33,71,

149).

As discussed elsewhere in this report, arrest rates

for serious offenses, particularly serious violent

offenses, are much higher for black adolescents than

for white adolescents, and black adolescents are

disproportionately represented in juvenile justice

d~or tier disassion of ho~cide rates ~ong black adolescents, see ch. 13, “Delir@ency: Prevention ~d ScrviCCS,” in VO1. D.

50SM ~x A in Vol. I, ‘ ‘ Sunfrnmy and ~liCy oj)tiOIIS, ”
Chapter 18-issues in the Delivery of Services to Selected Groups of Adolescents .111-185

facilities (253,257).51 In 1987, the arrest rate for

serious violent offenses was about six times higher

for black adolescents than for white adolescents

(253), One explanation for the racial disparity in

arrest rates is that crime rates are strongly associated

with low socioeconomic levels and urban location,

and both of these factors impinge more profoundly

on black youth, Statistics comparing racial groups

do not typically control for such demographic

factors. A second explanation for the racial disparity

is that blacks adolescents are more likely to be

arrested than whites engaged in the same behavior

(90). When self-reports of offenses are examined,

racial disparities are much smaller than those

typically reported in arrest statistics (51,105). A

third explanation for the racial disparity in arrest and

incarceration rates is that antisocial behavior in

white adolescents is more likely to be interpreted as

an indicator of emotional disturbance and treated as

such, whereas black adolescents are more typically

referred to the juvenile justice system rather than the

mental health system (19,46).

There are significant differences between black

and white adolescents in sexual activity, pregnancy,

abortion, and childbearing rates. Black adolescents,

many of whom are from socioeconomically disadvantaged families, tend to initiate sexual activity at

an earlier age, are less likely to use contraceptives,

are more likely to experience out-of-wedlock births,

and are less likely to have an abortion. Researchers

disagree on the relative importance of socioeconomic status and other factors in accounting for

these racial differences.

52 IN any event, it has been

estimated that 40 percent of all black females

become mothers before the age of 20; nearly 90

percent of those births are to single mothers (1 11,140).

As discussed elsewhere in this report, black

adolescent females are at particularly high risk of

experiencing iron-deficiency anemia (60) and obesity .53

As noted elsewhere in this report, adolescents

who engage in sexual intercourse are at risk of

infection with human immunodeficiency virus (HIV)

or other sexually transmitted diseases (STD).

Through August 1990, black adolescents accounted

for 36 percent of the 568 AIDS cases among U.S.

adolescents ages 13 to 19 (236a) .54

Hispanic Adolescents--In general, data on the

health of Hispanic adolescents are limited (260). The

Hispanic Health and Nutrition Examination Survey

(HANES), a special population survey conducted in

1982-84 by the National Center for Health Statistics

in DHHS, found that Mexican-American adolescents may experience higher rates of obesity, increasing their risk of eventually developing Type II

(adult-onset) diabetes (138,260).

Higher arrest rates for drunkenness have been

found for some Hispanic adolescents in comparison

with white adolescents, and inhalant abuse is a

significant problem for Mexican-American adolescents, especially those living in inner cities (163,169).

High school dropout rates among Hispanic adolescents are high; as many as 45 percent of MexicanAmerican adolescents drop out in some areas

(37,82). In 1989,33 percent of Hispanics ages 16 to

24 were high school dropouts (21la).55

There are few data on mental disorders among

Hispanic adolescents (175). Nonetheless, there is

some evidence that Mexican-American adolescents

(but not other Hispanics) report higher levels of

depression than whites or blacks (175,260).

In 1980, the overall birth rate for Hispanic

adolescents (all races) was about double the rate for

non-Hispanic white adolescents and about fourfifths the rate for non-Hispanic black adolescents

(192). Through August 1990, Hispanic adolescents

(all races) accounted for 18 percent of the 568 AIDS

cases among U.S. adolescents ages 13 to 19 (236a).56

Asian Adolescents--Information concerning the

health status of Asian and Asian-American adolescents is quite limited. Asians and Asian-Americans

tend to have diets that are high in sodium, possibly

increasing their eventual risk of heart disease

(35,41). In addition, because Asians may have

SISee ch. 13, ‘‘Del@uenq: Prevention and Semices, ’ fi VO1. ~.

Szsee ch 10, * ‘pre~cy md parenting: Prevention and Sewices, ’ in Vol. ~ fOr fUrther discussion.

S3See ch. 7, ‘ ‘Nutrition and Fitness Problems: Prevention and Services, ” in Vol. II.

‘See ch. 9, “AIDS and Other Sexually Transmitted Diseases: Prevention and Services, ” in Vol. II for further discussion.

SsFor ~ tier di~ussion of dropout mtes, see ch. 4, ‘ ‘Schools ad Di~retio~ Time,” k VO1. ~.

Scsee ch 9, ‘ ‘-s and Other Sexually Transrnitted Diseases: Prevention and Services, ” in Vol. II for further discussion.

292-872 0 - 91 - 7 QL 3
///-186 . Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

difficulty maintaining traditional dietary patterns

that include sources of calcium not readily available

in the United States, their low use of dairy products

results in low calcium intake (99,190).

As noted earlier, a systematic national epidemiologic study of mental health problem U.S. adolescents has not been conducted. Asian adolescent

refugees have been found to suffer from depressive

disorders and a delayed onset of chronic posttraumatic stress disorder syndrome (20). One study

indicated that a third of Vietnamese teenage refugees

in foster care had experienced clinical depression

during their first 18 months in the United States (20).

A study of adolescent and young adult Vietnamese

refugees in the Philippine Refugee Processing Center prior to their resettlement in the United States

indicates that adolescents (ages not specified) who

had been in the resettlement camp longer than 3

years scored higher on a depression measure and a

psychological symptom checklist than those without

camp experience (94).

Asian refugees are also at particularly high risk of

experiencing problems such as tuberculosis (122).

Health examinations of 80 Indochinese (Cambodian, Vietnamese, or Laotian) adolescent refugees

ages 11 to 19 indicated that half had positive tests for

tuberculosis, 38 percent had incomplete immunizations, a third tested positive for parasites, and 14

percent tested positive for hepatitis B (62).

American Indian and Alaska Native Adolescents--

A 1986 OTA report entitled Indian Health Care

found that in almost every Indian Health Service

area and on almost every health indicator, the health

of American Indians is poorer than that of the U.S.

population in general (199).

Studies have found that, although rates vary

across tribes, American Indian and Alaska Native

adolescents are at increased risk of experiencing

mental health problems such as low self-esteem,

alienation, depression; they also have high rates of

suicide, alcohol and substance abuse, and running

away from home (109,1 12,128,136,202). American

Indian adolescents are at high risk of having been

physically or sexually abused (202).

Because of the high rates of alcoholism among

American Indians, Indian adolescents are at increased risk of having been born with fetal alcohol

syndrome (202) High rates of childhood otitis media

(ear infections) lead to higher rates of hearing

impairment (136,202). Developmental disabilities,

such as mental retardation and learning disabilities,

occur at higher rates in American Indian and Alaska

Native children than in white children (159,172,202).

Mortality due to accidental injuries among American Indian adolescents is high. As discussed elsewhere in this report, American Indian adolescents

experience death from accidental injury at nearly

twice the rate of black or white adolescents (22).57

One explanation for this is that Indian adolescents

have high rates of “ drinking and driving (45). In

addition, because many of them live in rural areas,

Indians are less likely to have speedy access to

trauma centers. Road and vehicle conditions have

also been mentioned as factors contributing to

serious injuries among Indians of all ages.

Nutritious traditional dietary patterns of American Indian communities have generally been lost

with increasing contact with non-Indians (22).

American Indian adolescents are more likely than

non-Indian adolescents to be overweight and to

eventually experience and die from adult-onset

diabetes (22).

The prevalence of untreated dental disease among

American Indian adolescents is high (22). In 1983-

84, the Indian Health Service of DHHS conducted a

service-wide study of children and found that

overall, American Indian children have twice the

amount of dental caries as the national average

(248). It also found that by the end of adolescence,

two out of five young American Indian patients have

destructive periodontal disease with bone loss.

In 1986, almost a quarter of the births to American

Indians were to females younger than age 20; the

adolescent fertility rate appears to be rising, although there is substantial variation across tribes

(22).

Native Hawaiian Adolescents--There are more

than 200,000 persons of Hawaiian ancestry, or

Native Hawaiians, residing in the State of Hawaii,

and they comprise nearly 20 percent of the State’s

s7See ch. 5, “Accidental Injuries: Prevention and Services,” in Vol. II.
Chapter I8--Issues in the Delivery of Services to Selected Groups of Adolescents . III-187

population (139).58 The Native Hawaiian population

is young and growing, and the Native Hawaiian

adolescent population in Hawaii is among the largest

ethnic grouping. In 1986, 22 percent of the Native

Hawaiian population (an estimated 44,000 individuals) were between the ages of 10 and 18, and 24

percent were ages 9 or younger (139). While there

are clusters of predominantly Native Hawaiian

communities in Hawaii, the Native Hawaiian population of Hawaii is distributed throughout the islands

of Hawaii (139). Native Hawaiians are more likely

than other ethnic groups in Hawaii to be poor and are

also more likely to receive public assistance (139).

A number of health and related problems particularly affecting Native Hawaiians have been identified by various surveys by the State of Hawaii

Department of Health, although adolescent-specific

data are scarce (139). Native Hawaiian students

persistently perform below statewide averages on

standardized achievement tests, and their performance relative to other ethnic groups worsens in the

higher grades (75a). Compared to all other State

students, a much lower percentage of Native Hawaiian students receive some college education (40

percent versus only 20 percent) (166a). Hearing

impairments among Native Hawaiian children, most

likely from untreated middle ear infections, have

been recognized as a major problem and a probable

contributor to poor school performance (139). State

of Hawaii Health Department surveys find that other

impairments can also be found at relatively high

rates among Native Hawaiian children and adolescents ages 5 to 17 (vision, back and spine, upperextremity/hip), with only Caucasians in Hawaii

having higher rates overall and for most categories

(139). Native Hawaiians have the highest rate of

obesity among ethnic groups in Hawaii, putting

them at higher risk of developing Type II diabetes

(251).

Native Hawaiian adolescents are more likely than

adolescents in other ethnic groups in Hawaii to give

birth: in 1987, 5.9 percent of total Native Hawaiian

births were to mothers 17 or younger, compared to

2.1 percent for all other ethnic groups combined

(77).

Hawaii has examined its adolescent population in

relation to delinquent acts and found a disproportionate incidence of arrests among Native Hawaiians

who account for 35 percent of all arrests among

individuals under age 18 (139).

On the positive side, Native Hawaiian children are

more likely than non-Native Hawaiian children to

live in family households (139). Among those

family systems that build on strong Hawaiian

traditions, common characteristics include multiple

parenting within an ‘ohana (extended family), early

indulgence followed by a shift at 2 to 3 years of age

to a primarily peer-directed socialization experience, socialization toward a group- and familyoriented values system, and learning experiences

that emphasize modeling and mutual participation

rather than verbal interaction. Some of the typically

Hawaiian values (e.g., cooperation over aggressive

individualism) are diametrically opposed to Western

cultural characteristics for success in many areas

(e.g., education, business) (139). Further, it may be

important to note that Hawaiian concepts of health

differ from Western’ or mainstream U.S. concepts

(139). Hawaiian cultural concepts of health are more

holistic than Western concepts and include physical

and spiritual states (76). There is no word, for

example, for ‘‘mental’ health or illness (76). This

broader conceptualization has had an impact on the

delivery of some prevention interventions to Native

Hawaiian adolescents (139). However, extensive

intermarriage with other ethnic groups has produced

a wide variety of beliefs, childrearing patterns, and

other practices among Native Hawaiians.

Access to Health Services by Racial and

Ethnic Minority Adolescents

Patterns of Health Care Utilization by

Racial and Ethnic Minority Adolescents

Information on the utilization of mainstream

health services by racial and ethnic minority adoles58 B=aux of ~~ d~u~r of Native Ha~~ians liv~g elsewhere in he unit~ states, ad ~ause ~OSt d infomtion about Native Hawaiian

health status and specialized health services is horn sources in the State of Hawaii (139), this discussion of Native Hawaiian adolescents is lirnitcd to

such adolescents living in the State of Hawaii. According to data from the U.S. Census, 69 percent of all Native Hawaiians living in the U.S. live in Hawaii

(1 39). For purposes of this chapter, in Federal statutes, and for most analyses by the U.S. Department of Commerce, Bureau of the Census, and the Hawaii

State Department of Health Health Sumeilkmce Program, a Native Hawaiian is a person of either partial or sole Hawaiian ancestry ( 139). However, less

than 5 percent of the Native Hawaiians are pure Hawaiians, and probably two-thirds would identi@ themselves as primarily Native Hawaiians, rather

than primarily some other ethnic group (139).
III-188 . Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

cents is quite limited. Even for adult populations,

data on the utilization of health services are quite

limited, as national surveys have generally not

sampled enough individuals from ethnic or racial

minority groups to provide meaningful data. As

noted earlier, racial and ethnic minority persons

disproportionately live in poverty, and many of them

experience financial barriers to the utilization of

health care. In addition, some of them experience

geographic or other nonfinancial (e.g., cultural)

barriers to the utilization of services.

Information from a variety of sources, while

extremely limited, suggests that the utilization of

mainstream health-related services tends to be lower

among black and Hispanic adolescents than among

white, non-Hispanic adolescents. Black children and

adolescents, for example, may be less likely than

whites to receive preventive care or appropriate

medical services (239). A study of Job Corps

participants ages 16 to 22, all of whom were low

income, found that blacks were more likely than

whites or Mexican Americans to have incomplete

immunizations (57 percent of blacks v. 42 percent of

Mexican Americans and 51 percent of whites) (61),

The National Health Interview Surveys for the years

1985 through 1987 found that blacks under 18 years

of age were far less likely than whites of that age to

have had a physician contact (239). More disturbing,

this was particularly true if they were in fair or poor

(as opposed to good to excellent) health (239).59

These surveys also found that the only large

black-white differences in rate of annual physician

contacts was for individuals under 18. Blacks under

age 18 had about 2.8 physician contracts per person

per year, while whites under age 18 had 4.5

physician contacts per person per year (239).

Nearly one-fourth of the Mexican-American adolescents ages 12 to 17 who were surveyed in the

Hispanic HANES in 1982--84 reported having no

regular source of health care; one-fifth reported that

they had not seen a physician within the past 5 years,

and about one-third reported that they had not had a

preventive care visit within 5 years (138). Some

evidence suggests that less acculturated Mexican

Americans are less likely than more acculturated

Mexican Americans to use outpatient care for

physical or mental health problems. These differences persist even when socioeconomic status is

controlled for (267).

Although the population surveyed was not adolescent, it is interesting that one national survey by

Louis Harris and Associates found that blacks and

Hispanics were less likely to report being completely satisfied with the most recent medical visit

on five out of seven measures: travel time, time with

physician, information received, quality, and the

overall medical visit (11).W Similarly, black and

Hispanic adults reported more “special access

problems” (e.g., in obtaining health insurance and

obtainin g and financing care for serious illness and

emergencies) than did whites (1 1). The research

group that analyzed the survey results suggested that

racial and ethnic minorities were experiencing

particular difficulties and barriers in obtaining

needed health care services, despite the considerable

improvements in access they experienced as the

result of policy and program changes in the 1960s

and 1970s (1 1).

Adults from some minority groups use informal

helping networks (e.g. families, folk healers) to

address health problems, although the extent to

which racial and ethnic minority adolescents use

these networks is not generally known (17). Asian

adults with emotional difficulties, for example, often

turn to their families for help and turn to outside

agencies as a last resort (188). Alternatives to

mainstream health services used by Asian-American

adults for health problems include herbal medicines,

acupuncture, and diet and exercise regimens (189).

Whether Asian-American adolescents use these

strategies is unknown. Native Hawaiians in general

appear to make widespread use of informal sources

of care, although the actual level of use of these

sources of care by Native Hawaiian adolescents is

not known (139).61

For the most part, it appears that racial and ethnic

minority adolescents who do obtain health and

health-related services obtain them through the

s~te ch,il~en under age 18 in fair or poor health had an average of 15.5 physician contacts per yew, compared to 6.5 physician contacts per y~

for black children in fair or poor health (239). Sumey data were not given separately for 10 to 18-year-olds; thus, it is not clear whether differences existed

between younger children and adolescents.

WLevels of satisfaction were similar for otllce waiting time and out-of-pocket cost (1 1).

bl~le the Sbte of fiw~l is diligent about collecting health status data on an ethnic basis, the issue of health and related services specflczd~y for

Native Hawaiians is a relatively recent policy issue and there have been few quantitative analyses of services to Native Hawaiians (139).
Chapter 18--Issues In the Delivery of Services to Selected Groups of Adolescents . 11/-189

mainstream service system (44). The use of alternative health systems among Mexican-American adolescents is apparently limited; only 2 percent of

Mexican-American adolescents surveyed in the

Hispanic HANES reported using a folk healer in the

past year (138).

Services and interventions that address linguistic,

geographic, economic, and cultural barriers (44,98,167)

to the utilization of services are likely to improve

racial and ethnic minority adolescents’ access. It is

likely that it is quite important for services to be in

the neighborhoods where minorities reside, be

provided in the language spoken by the adolescent

and his or her family, be financially affordable, and

be responsive to the cultural background of the

adolescent (44).

Services and Interventions To Increase Access

to Health Services Among Racial and Ethnic

Minority Adolescents

As noted earlier, a disappropriate number of racial

and ethnic minority adolescents are poor or nearpoor, and they confront many the same financial and

other barriers to access other poor adolescents do.

For these adolescents, the expansion of health

insurance coverage or the establishment of schoollinked or community-based health centers may

effectively improve access to services.62 A question

that arises, however, is whether racial and ethnic

minority adolescents have special needs for services

that cannot be effectively met in the “mainstream”

system. More research on this topic would be useful.

There is an increasing consensus, however, that

services for racial and ethnic minority individuals,

including children and adolescents, would be improved if they were ‘‘culturally competent. ’

Culturally competent services for adolescents

may be difficult to design, because there is little

systematic information about how racial and ethnic

minority adolescents experience adolescence. There

is beginning to be some systematic analysis of what

a culturally competent system of care is, but the

knowledge base has not yet been applied systematically to the design of training programs for health

care and other service providers. Overall, there is

little systematic description of how services have

been developed or adapted to meet the specific needs

of racial and ethnic minority adolescents, and even

e

Photo credit: Office of Technology Assessment

Services that address linguistic, geographic, economic,

and cultural barriers to utilization are likely to improve racial

and ethnic minority adolescents’ access to needed

services. The Latin American Youth Center provides a

broad range of services, as well as a place to

“hang out,” for young people in a Washington, DC,

neighborhood populated by large numbers of immigrants

from Central America.

less scientific evaluation of the effectiveness of

available services. Currently, however, minority

providers and providers trained to be sensitive to the

sociocultural aspects of providing health care are

few (6,17,44).

Developing Culturally Competent Systems of

Care—The concept of a “culturally competent

system of care’ has been suggested as a model for

working effectively in cross-cultural situations (44,

202). Several characteristics are said to be necessary

for a system to be considered culturally competent

~2F~ra discussion Of sch~l-ilrlk~ halt. h centers and other innovation in the delivery of hedthand related semices to adolescents, sw Ch. 15, “Major

Issues Pertaining to the Delivery of Primary and Comprehensive Services to Adolescents, ’ in this volume,
III-190 . Adolescent Health-Volume III: Crosscutting Issues in the Delivery of Health and Related Services

(44). The system must value diversity at all levels,

have a sense of its own culture, be aware of the

dynamics involved when cultures interact, have

institutionalized cultural knowledge, and have developed adaptations to diversity. A culturally competent system of care recognizes and values cultural

diversity, and works effectively with the natural

support and helping networks within minority communities. Effective providers must be sensitive to

cultural differences within as well as across racial

and ethnic groups.

There is some evidence that, when given the

choice, black adults prefer to be seen by a black

provider (6). Black or other racial and ethnic

minority adolescents may similarly prefer to have

access to minority providers, although information

on this topic is scarce. Currently, there are few

minority providers in the health professions. Between 1980 and 1987, only 11 percent of doctoral

degrees in health education earned were awarded to

minorities; half of them went to blacks (6). In 1987,

blacks made up only 5.2 percent of medical school

graduates (181). A recent report by a DHHS task

force recommended the recruitment and training of

more minority doctors (227) and a new law passed

in the 101st Congress (Public Law 101-527) will

provide additional scholarships and loans to minority students.

According to some observers, however, not all

minority providers can be assured to be culturally

competent. Some racial and ethnic minority doctors

trained in major medical schools have the same

attitudes and values as their white peers (71), and

changes in the health care field have made individual

practice in low-income areas, less attractive. Further,

while members of broad racial and ethnic minority

groups (e.g., Asians, Hispanics) may have some

things in common with other members of that group,

the cultural differences of subgroups may prove

more important. An Asian health care provider of

Japanese heritage, for example, will not necessarily

be competent to deal with a Hmong adolescent from

Southeast Asia. Perhaps the most well-recognized

need is for the cross-cultural training among white

health professionals, who are often ignorant of the

dynamics and interpretations of the behavior of

racial and ethnic minority adolescents (8,123).

Considerations in Developing Services for Racial and Ethnic Minority Adolescents-Many

studies have found that blacks, Asian Americans,

Hispanics, American Indians, and Native Hawaiians

strongly value the family (23,63,72,80,92,1 13,118,

135,169,186,265,270). Thus, services that include

the family may very well be most effective. For

Asian-American adolescents, services that gain

family involvement, use supportive family networks, and promote family decisionmaking are

believed likely to be more effective, although there

have been no tests of this model (1 18,277). Attempts

to involve parents may pose practical difficulties for

single-parent households, however, and some adolescents report that they prefer that parental involvement bean option rather than a requirement (47,201).

For black adolescents, particularly those in singleparent households, family involvement may include

using a total kinship network composed of persons

related by blood, marriage, friendship, neighboring

residence, or work association (96). When providing

services to Hispanic adolescents and their families,

it may be important to respect the traditional family

age and sex hierarchies of power ( 169), although this

too may pose problems for the adolescent clients.

Although churches have been identified as important community resources, especially for black

adolescents, some observers believe that churches

may not be appropriate or willing sources of health

information, particularly regarding issues related to

sexuality or drug use (47). When willing, they may

not have the necessary staff, funds, or technical

expertise (161).

Level of acculturation is another important variable to consider when developing interventions and

services for adolescents (e.g., 88,169). Normal

conflict between adolescents and older generations

in the family may be exacerbated by culture conflicts, when more ‘‘acculturated’ adolescents do not

wish to follow traditional practices (1 18,189). For

example, there can be conflict between an HispanicAmerican adolescent girl and her traditional grandmother when the adolescent wishes to experience

the same freedom to go on unchaperoned dates as her

peers. Three primary sources of intergenerational

conflict for Southeast Asian refugee adolescents

have been identified: conflicts concerning pressure

for the adolescents to date and marry within their

ethnic group; conflicts concerning career choices,

with adolescents experiencing pressure to pursue

professional careers; and conflicts caused by role

reversal, for example when an adolescent assumes

greater familial responsibilities because he or she
Chapter 18--Issues in the Delivery of Services to Selected Groups of Adolescents .111-191

has the language proficiency to interact more

effectively in the outside world (1 18).

Effectiveness of Programs Targeting Racial

and Ethnic Minority Adolescents-Information

on programs geared to the delivery of health and

related services to racial and ethnic minority adolescents is severely limited. Several models of programs designed to serve racial and ethnic minority

adolescents have emerged, but few of these have

been evaluated. Thus, it is difficult to draw conclusions about which are the best models for delivering

services to ethnic and racial minority adolescents.

Much of the information about the effectiveness of

such models is anecdotal information based on the

experiences of providers rather than scientific evidence.

Some programs aim to increase the self-esteem of

minority adolescents by providing ethnic role models or mentors. One such program is Project IMAGE,

a church-based program in Chicago that pairs young

black males ages 8 to 18 with volunteer black men

in an effort to provide a positive force for the youth

and to link them with special services and programs

(168). Another program, the Las Madrinas (Godmothers) program administered by Hacer, Inc., in

New York City, pairs low-income Hispanic girls at

risk of dropping out of school with young Hispanic

professional women who act as volunteer mentors

(83). The goal of this program is to promote

leadership among the girls and encourage them to

stay in school. Activities include workshops, referrals to services, and field trips to cultural, educational, and recreational sites.

One program that has been evaluated used short

stories about well-known Puerto Rican men and

women who had overcome adversity (heroes) to

emphasize the importance of cultural identity and

foster the development of self-esteem and coping

skills among Puerto Rican adolescents having trouble

in school (42,43). An evaluation of this program

indicated that Puerto Rican adolescents who participated in the program experienced increased ethnic

identity and reduced anxiety compared with similar

adolescents randomly assigned to a control group.

Interestingly, the intervention had somewhat negative effects on ethnic identity and self-esteem for

adolescents in families headed by two biological

parents, as opposed to mother-headed single-parent

households (43).

Another approach to the promotion of health and

well-being among racial and ethnic minority adolescents is to instill a sense of cultural awareness by

involving adolescents in culturally traditional ceremonies. The use of interventions incorporating

Afrocentric rites of passage for adolescents is an

example of this approach (44). Programs incorporating Afrocentric rites of passage are intended to

support the transition of black adolescents into

responsible adult roles (50). Many traditional American Indian health practices are gradually being

incorporated by tribes and ‘‘Western’ mental health

providers into contemporary approaches to mental

health treatment for Indian adolescents. These include the ‘‘four circles, ’ sweat lodge, and “talking

circle, ’ which are treatment strategies based on

traditional healing practices (112,202).

Information about the effectiveness of mentoring

and modeling programs for racial and ethnic minority adolescents is generally lacking. However, Project EPIC (Education and Prevention in Communities) at Wayne State University in Michigan is

developing an evaluation to assess the effectiveness

of rites of passage programs in reducing substance

abuse among adolescents (264).

Hawaii currently offers a wide range of services

for adolescents (194,262). Although culturally appropriate services targeted specifically to Native

Hawaiian adolescents are few and have not been

evaluated for effectiveness, the number of services

for Native Hawaiian adolescents is increasing (139).

The Native Hawaiian Health Care Act of 1988

(Public Law 100-579) will lead to the eventual

establishment of Native Hawaiian health systems

throughout the State that will provide health promotion, disease prevention, and primary care services

(139). The implementation of this act provides a

critical opportunity to target services for Native

Hawaiian adolescents.

Major Federal Programs Pertaining to

Racial and Ethnic Minority Adolescents

The Federal programs to help low-income persons

discussed earlier in this chapter tend to serve many

minority persons because of the disproportionate

number of minorities who live in poverty. The

discussion here focuses on Federal programs that are

concerned specifically with serving racial and ethnic

minority populations.
///-192 . Adolescent Health-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Many of the programs are within DHHS, but the

U.S. Department of Education, the U.S. Department

of Agriculture, and the U.S. Department of Justice

also have some programs. In addition to the programs discussed here, there are isolated examples of

federally funded grants that focus on meeting the

health needs of minority adolescents. There are also

programs that focus on other needs of minority

adolescents, such as education or job training.

U.S. Department of Health and Human Services

Three of the four major components of DHHS

mentioned earlier-the Family Support Administration, and the Office of Human Development Services, and the Public Health Service-have programs

that focus specifically on racial and ethnic minority

populations. The Health Care Financing Administration does not focus specifically on these populations.

Family Support Administration (FSA)--FSA’s

Office of Refugee Resettlement provides Federal

funds to States for refugee and entrant assistance

programs (213). Refugee and entrant assistance

programs were established in 1980 in order to assist

refugees and Cuban and Haitian entrants in becoming employed, self-sufficient, and assimilated into

U.S. society as soon as possible after their arrival

(213). Federal funds are provided to help offset

necessary costs, although most funds are used to

provide grants to States for refugee assistance and

services by way of cash assistance, medical assistance, State administrative costs, social services, and

targeted assistance. The amount of assistance provided specifically to adolescent refugees or their

families is not available.

One program of the Office of Refugee Resettlement that has a substantial impact on adolescents is

in the Unaccompanied Minor Refugee Program

which provides support for unaccompanied refugee

minors (216). The U.S. Catholic Conference and

Lutheran Immigration and Refugee Service help the

Office of Refugee Resettlement place unaccompanied refugee minors in licensed child welfare

programs (e.g., foster care, group care, independent

living, residential care), and costs incurred on their

behalf are reimbursed by the Office of Refugee

Resettlement until a month after the minor’s 18th

birthday.63 Since 1979, more than 8,500 unaccompanied minor refugees have entered this program.

Nearly half of these minors who enter the program

continue to be under its jurisdiction through their

adolescence. There are now about 3,000 unaccompanied refugee minors in care.

Another program of the Office of Refugee Resettlement is the Transition Program for Refugee

Children. This program provides funds for the

special educational needs of refugee children and

adolescents, including bilingual education, remedial

programs, school counseling and guidance services,

and instruction to improve English language skills.

Support is also provided for training for parents, and

in-service training to educational personnel (216).

Under the Immigration Reform and Control Act

of 1986 (Public Law 99-603), the Office of Refugee

Resettlement provides Federal grants to States for

the purpose of helping State and local governments

defray expenses incurred in providing public assistance, public health assistance, and educational

assistance to eligible legalized aliens. These grants

are called ‘‘legalization assistance impact grants. ”

States may use the grants for educational services for

legalized alien children and adolescents who have

been in the United States for less than 3 years and

who reside in school districts with large concentrations of eligible legalized aliens (217). Although

$898.5 million was available to States under this

grant program in fiscal year 1989, and adolescents

were eligible for services, the amount of such

assistance specific to adolescent immigrants is not

available from the Federal Governrnent.

Office of Human Development Services (OHDS)--

OHDS oversees a number of programs related to

racial and ethnic minority populations.

OHDS’ Administration for Children, Youth, and

Families makes funds available through its Family

and Youth Services Bureau for programs to prevent

substance abuse among runaway and homeless

Native American adolescents. Projects are expected

to incorporate Indian tribal values and languages,

and develop a positive cultural and family identity

(54 FR 15092-15106).

OHDS’ Administration for Native Americans

provides training and technical assistance to assist

public and private Native American organizations in

developing, conducting, and administering projects

to carry out locally determined social and economic

sss~tes may permit support to extend for longer periods (216).
Chapter 18--lssues in the Delivery of Services to Selected Groups of Adolescents . //1-193

development strategies (223). In recent years, the

Administration for Native Americans has targeted

the problem of drug and alcohol abuse prevention. In

fiscal year 1989, OHDS used its coordinated Discretionary Funds program to allocate about $250,000 to

a total of five projects in this area. Not all of the

projects were adolescent-specific.

OHDS used its Coordinated Discretionary Funds

Program for fiscal year 1989 to make funds available

for prevention and treatment of alcohol abuse among

minority youth using culturally sensitive interventions; for the prevention and treatment of alcohol

abuse among Native American adolescents using

runaway and homeless youth centers; and for

innovative community approaches to entrepreneurial

activity with Native American adolescents (53 FR

33686-33722).

Through interagency agreements with the Indian

Health Service and the Bureau of Indian Affairs, the

Administration for Native Americans has also funded

health promotion activities, including alcohol and

drug abuse prevention education. In 1989, the

Administration for Native Americans transferred

$70,000 to the Bureau of Indian Affairs for a health

education program expected to involve 27,000

students attending Bureau of Indian Affairs schools

(223). In the past, OHDS has used its discretionary

funds to fund projects to increase minority access to

runaway and homeless youth center services; prevent child abuse among minorities; reunite American Indian families with children separated because

of parental substance abuse; and prevent substance

abuse among Native American adolescents. OHDS

has also funded programs to increase the participation of historically black colleges and universities

and Native American organizations in OHDS funding opportunities (221).

OHDS also provides funds to increase the number

of minorities entering the field of social work to do

work in the area of child welfare. Funds are provided

for traineeships and in-service training to historically black colleges and universities and to colleges

controlled by Indian tribes or serving Indian reservations.

Public Health Service (PHS)—PHS has a number of agencies with programs that address the health

needs of racial and ethnic minority adolescents:

. the Alcohol, Drug Abuse, and Mental Health

Administration (ADAMHA);

. the Health Resources and Services Administration (HRSA);

. the Indian Health Service (IHS); and

● the Office of Minority Health.

Alcohol, Drug Abuse, and Mental Health Adminis -

tration (ADAMHA)--ADAMHA consists of three

agencies concerned with mental health and with

substance abuse:

. the National Institute on Drug Abuse,

. the National Institute of Mental Health, and

● the Office of Substance Abuse Prevention.64

ADAMHA’s National Institute on Drug Abuse

has several initiatives related to substance abuse

among minority adolescents. Most of the projects

focus on epidemiology and risk factors; fewer focus

on prevention or specific treatment approaches.65

Projects include several studies examining the

effects of drug use on school dropout rates in

minority communities, a study examining the etiology of substance abuse among high-risk black

adolescents, and a study of cultural factors affecting

vulnerabilities to substance abuse among Hispanic

adolescents (229,230).

The National Institute on Drug Abuse also conducts the National Household Survey on Drug

Abuse, aperiodic national prevalence survey of drug

use. The survey oversamples person ages 12 to 34,

blacks, and Hispanics, but still has a very small

sample of nonwhite adolescents.

The National Institute on Drug Abuse has Special

Populations Research and Training Programs that

work to enhance research and training opportunities

for minority researchers. Technical assistance is

provided to potential researchers to develop their

grant writing and research skills (230).

ADAMHA’s National Institute of Mental Health

administers the Child and Adolescent Service Sys64Bmic activitieOf ~AMHA agencies focusing on alcohol and drug abuse are described in ch. 12, ‘‘Alcohol, Tobacco, and Drug Abuse: Prevention

and Semices, ‘‘ in Vol. II. Activities of the National Institute of Mental HealttL the ADAMHA agency focusing on mental heal@ are described in ch.

11, “Mental Health Problems: Prevention and Services, ” in Vol. II. Basic ADAMHA activities in the context of the entire Federal role in adolescent

health are described in ch. 19, “The Role of Federal Agencies in Adolescent Healt&” in this volume.

6sMost Fede~ drug abuse prwe.rltic)rl activities relevant to minority adolescents take place in the Office of Substance Abuse neventiOU (w below).
III-194 . Adolescent Health—Volume III: Crosscutting Issues in the Delivery of Health and Related Services

tern Program (CASSP), a. small grant program

established in 1984 to develop new initiatives to

improve the delivery of mental health services to

severely emotionally disturbed children and adolescents (23 1). CASSP is aimed at improving coordination among the child welfare, juvenile justice,

mental health, and special education systems (71). It

provides technical assistance and acts as a clearinghouse for research information to CASSP grantees,

and provides funding for grants to States.66 As of

June 1989, CASSP had been funded in 42 States

(231). Fiscal year 1989 funding for CASSP was $9.8

million.

A major goal of CASSP is to ensure that services

to severely emotionally disturbed children and

adolescents from racial and ethnic minorities are

sensitive to cultural differences. In 1986, CASSP

sponsored a workshop on the development of mental

health programs for minority children and adolescents and their families. Following that workshop,

CASSP project directors were instructed to develop

at least one major goal related to improving services

for cultural and ethnic minority children and adolescents in their States; each State receiving a CASSP

grant is required to develop a minority objective.

State efforts include such activities as developing

training programs in cultural issues for service

providers, establishing task forces to explore the

difficulties that minority children and adolescents

have in gaining access to existing mental health

services and to advise in the implementation of

minority objectives, and making outreach efforts to

involve minorities in CASSP activities (231). Technical assistance is available through CASSP to help

develop and implement minority objectives (e.g., 44).

The National Institute of Mental Health funds six

centers that do research and provide treatment

targeted to the needs of particular ethnic groups

(84a). It recently awarded $1.4 million for a new

Research Center on the Psychobiology of Ethnicity

that will investigate, among other things, ethnic

differences in how people respond to drugs for

mental disorders, ‘‘culture-bound syndromes, ’ and

how different groups conceptualize psychiatric disorders (84a). How much of a focus will be on

adolescents is unknown.

ADAMHA’s Office of Substance Abuse Prevention was created in 1986 to provide national

leadership for alcohol and drug abuse prevention

(234). The Office of Substance Abuse Prevention

has a demonstration grant program with a strong

focus on minority and multicultural adolescents. Of

the 130 demonstration grants awarded in 1987 (most

of which target adolescents), 56 percent are targeted

at minority groups. Of these, 24 programs focus on

blacks, 15 on Hispanics, 12 on American Indians and

Alaska Natives, 6 on Asian Americans and Pacific

Islanders, and 16 on multiethnic minority groups.

Most of the remaining grants are for multiethnic

projects that include whites. Many of the projects

incorporate strategies to enhance their cultural

competence, such as involving respected community members in the program, recruiting minority

staff at all levels, encouraging the use of traditional

cultural activities (e.g., celebrating cultural festivals

or teaching traditional languages), and using culturally appropriate media and messages in drug and

alcohol education efforts.

Health Resources and Services Administration

(HRSA)-As noted earlier, HRSA’s Bureau o f

Maternal and Child Health (formerly the 0ffice of

Maternal and Child Health) administers the maternal

and child health block grant programs authorized by

Title V of the Social Security Act. In administering

this program, the Bureau seeks to remove cultural,

communication, and systems barriers to health

services for medically underserved women, infants,

and children, many of whom belong to minority

groups (91). The Bureau has established a

Workgroup on Culturally Distinct Populations to

provide advice on the best use of grant money to

improve health care for minorities.

As noted earlier, the Bureau of Maternal and

Child Health sets aside 15 percent of Federal

maternal and child health block grant funds to

support special projects of regional and national

significance (SPRANS) which contribute to the

health of mothers and children with special needs. A

number of the projects that have been funded focus

on improving the provision of health services to

minority and poor adolescents (91). Examples include a project to reduce teenage pregnancy among

black adolescent girls, a project to prevent injuries

among American Indian adolescents, and a project

to promote the health of American Samoan adolescents (91,15 1,244).

fisee ch. 11, “Men~ Health Problems: Prevention and Services, “ in Vol. II for further discussion of CASSP.
Chapter 18--Issues in the Delivery of Services to Selected Groups of Adolescents . ///-195

HRSA’s Bureau of Health Professions and Bureau of Health Care Delivery and Assistance support a variety of personnel training programs. The

Division of Disadvantaged Assistance in the Bureau

of Health Professions administers a Health Careers

Opportunity Program, which provides assistance to

health profession training programs that serve minorities and other disadvantaged persons to facilitate

the recruitment and retention of minorities in health

professions; about 13,000 students take part in

programs of the Health Careers Opportunity Program annually (240a). The program also provides

direct financial assistance to disadvantaged students.

In fiscal year 1988, HRSA began providing

awards through its “Excellence in Minority Health

Education Program” to historically black colleges

and universities to strengthen their capacity to train

minority students in health professions (240a).

Personnel from the National Health Service Corps,

who staff community and regional health centers,

receive orientation about linguistic and cultural

aspects of health care (240a).

Indian Health Service (IHS)---The IHS provides

health services to American Indians and Alaska

Natives (199,202). IHS clinical facilities have generally been placed on or near reservations (199). About

half of American Indian adolescents reside on

reservations and are eligible for health care services

through the IHS (202).

The IHS finds three regional adolescent treatment

centers for substance abuse rehabilitation through its

Alcohol and Substance Abuse Programs Branch

(249). The IHS also provides partial funding for teen

centers in or near four Albuquerque area schools,

and health services at Bureau of Indian Affairs

boarding schools (22). In addition, the IHS has made

youth a priority for its prevention programs, planning to specifically emphasize teen pregnancy,

alcohol and drug abuse, mental health, violence, and

suicide.

Unfortunately, however, numerous factors make

the provision of health services to Indian adolescents

inadequate, even for reservation-based Indian adolescents. In recent years, overall IHS funding has just

kept pace with inflation with no real increases (48).

Most IHS funds are used to provide acute care to

Indians of all ages; except for some funding for

substance abuse services, teen pregnancy services

and participation in several multifunded adolescent

health centers in Albuquerque, New Mexico (45),

there is no targeted treatment funding for adolescents. Little money is available for prevention

services (48). Although the IHS has a Maternal and

Child Health Program, it is merely advisory and has

no budget of its own to implement programs.

Similarly, although the IHS policy recognizes that

adolescents have special needs in health care, and

youth are a priority, adolescent clinics have not been

established as part of the usual IHS health care

delivery system, and there are no adolescent medicine specialists in the IHS (22).

Confidentiality is often important to adolescents

considering the use of health care services67 (201).

Various aspects of IHS delivery may result in a lack

of privacy for American Indian and Alaska Native

adolescents, and the lack of privacy may reduce such

adolescents’ willingness to seek appropriate health

care (22). For example, especially in small communities, the IHS is a major employer of members of

local tribes. Research on this or other nonfinancial

factors affecting access to care for American Indian

adolescents is nearly nonexistent.

Office of Minority Health—The Office of Minority Health was created within the DHHS Office of

the Assistant Secretary of Health in 1985 to address

the problems and implement the recommendations

of the Secretary’s Task Force on Black and Minority

Health (164). These recommendations included

stimulating the development of innovative programs

to improve the health status of minority populations

and advocating a national strategy to address the

health needs of minorities (164,227).

The Office of Minority Health has developed a

research center to investigate minority health problems (164). The Office of Minority Health has also

provided funding for a number of demonstration

grants for the development of community health

coalitions to reduce risk factors among minority

populations (252). Funded projects include programs designed to reduce teenage pregnancy; reduce

the risk of alcohol and other drug problems among

high-risk, urban Latino youth; and provide AIDS

education to American Indian high school students

and adults using Native healing principles and

67 See ch. 17, ‘ ‘Consent md Cofildentitity in Adolescent Health Care Decisionmaking, ” in thk volme.
111-196. Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

techniques. Additional HIV education and prevention programs directed at black and Hispanic adolescents and adults have also been funded (25,252) as

has a special initiative on minority males (54 FR

22312).

Although the overall goal of the Office of

Minority Health is to improve the health status of

blacks, Hispanics, Asian-Americans, Pacific Islanders, and Native Americans, the U.S. General Accounting Office recently reported that the office

‘‘does not have specific goals or objectives for each

of these groups, nor does it have short- and

long-term strategic plans for its objectives” (194a).

Later in 1990, the potential role of the Office of

Minority Health was expanded when the U.S.

Congress statutorily established such an Office, to

be headed by a Deputy Assistant Secretary for

Minority Health (Public Law 101-527, the “Disadvantaged Minority Health Improvement Act of

1990,’ Section 2). Public Law 101-527 also authorized an increase in funding for the Office of Minority

Health, to $25 million per year for fiscal years 1991

through 1993. The potential role of the Office in

improving the health of minority adolescents is as

yet unknown.

U.S. Department of Agriculture

The U.S. Department of Agriculture’s Food and

Nutrition Services administers a food distribution

program for low-income Indians living on or near

reservations (206). Participating agencies receive

monthly distributions of food from local warehouses. How many Indian adolescents benefit from

this program is not known.

U.S. Department of Education

Funding by the U.S. Department of Education of

programs focusing on minority adolescent health is

limited, but examples of such programs do exist.

One is a Drug-Free Schools and Communities

Program for Hawaiian Natives to develop a culturally appropriate curriculum for 3,000 Native Hawaiian students. Another is a Drug-Free Schools and

Communities Program for alcohol and drug education and prevention among Indian children who live

on reservations and attend schools operated or

funded by the Bureau of Indian Affairs.

U.S. Department of Justice

The Office of Juvenile Justice and Delinquency

Prevention (OJJDP) in the U.S. Department of

Justice focuses on problems related to delinquency

among adolescents in general rather than among any

particular group of minority adolescents.68 Nevertheless, OJJDP does on occasion make efforts to

address special issues related to adolescents from

minority groups.

For example, OJJDP is funding several research

projects on Minorities in the Juvenile Justice System

in an effort to determine the extent to which

processing decisions are influenced by the racial or

ethnic background of the adolescent offender (257).

OJJDP has also provided funding for Proyecto

Esperanza. The goal of this project, implemented by

the National Coalition of Hispanic Health and

Human Services Organizations,69 is to assess family

strengthening and crisis intervention programs and

to design model programs to prevent child abuse and

reduce the incidence of running away within Hispanic families (1 10,257). OJJDP has also asked the

National Coalition of Hispanic Health and Human

Services Organizations to provide technical support

to the National Court Appointed Special Advocates

Association and the National Council of Juvenile

and Family Court Judges to improve the quality of

their services to Hispanic children and adolescents

at risk of out-of-home placement.

Rural Adolescents: Issues in the

Delivery of Health and Related Services

Data from an analysis by McManus indicate that

about one-third of all U.S. adolescents ages 10 to 18

live in rural (nonmetropolitan) communities (132).

About half of these adolescents live in the South;

another one-quarter live in the Midwest (132).

Special Health Issues for Rural Adolescents

Limitations of Data and Research on the

Health of Rural Adolescents

It is difficult to determine the health status of rural

adolescents for several reasons, only some of them

specific to rural areas. First, as discussed throughout

613sW Ch. 13, “De~quency: Prevention and SeXVICeS, “ in Vol. II and ch. 19, “The Role of Federal Agencies in Adolescent Health, ” in this volume

for further discussion.

% National Coalition of Hispanic Health and Human Services Organizations is a nonprofit national Hispanic organization focused on imprvving

the health and psychosocial well-being of the Hispanic population (153).
Chapter 18—issues in the Delivery of Services to Selected Groups of Adolescents . ///-197

this report, there have been few large-scale epidemiologic studies of adolescents. Second, limitations in

access to the health care services system for adolescents in general, and for rural adolescents in

particular (see below), make clinical samples less

than valid as indicators of health status. For example, families of adolescents with complex health

problems sometimes may move to metropolitan

areas solely because of a lack of specialized services

in rural areas. Similarly, when adolescents are

treated in metropolitan medical centers, they may

not be reflected in clinical prevalence studies as

‘‘rural’ cases, even though they continue to reside

in rural communities. Finally, synthesis of the

literature on rural-urban differences is hampered by

diverse definitions of rural and by failure to account

for confounding variables and the heterogeneity of

rural communities.

Sufficient data do exist, however, to leave two

broad impressions. First, the idyllic image of rural

life that may still persist is quite discrepant from

reality. Second, although it is a mistake to ignore or

underestimate the health risks experienced by rural

adolescents, it also seems true that rural adolescents

generally are similar to their urban peers in the

health problems they experience. Given the extent of

health problems among adolescents on average,

these impressions are not contradictory. Additional

descriptive research designed to separate rural,

regional, social class, and ethnic factors and analyses to determine the effects of particular dimensions

of rural life on adolescent health would be useful in

assessing the true level of health problems among

rural adolescents. It would also be useful to have

more information on the extent to which rural health

facilities meet the needs of rural adolescents.

Health Problems Experienced by Rural Adolescents

As noted earlier, the most comprehensive national

health data collected on a continuing basis are

National Health Interview Survey data by the

National Center for Health Statistics. 70 According to

National Health Interview Survey data, the incidence of both acute and chronic conditions in

children and adolescents is generally similar in

metropolitan and nonmetropolitan areas (132,133).

About 75 percent of both metropolitan and nonmetropolitan adolescents report (or, more likely, have

reported for them) that their health is excellent or

very good (132).

In terms of the prevalence of problems, the most

sizable urban-rural differences that show up in

available data from a variety of sources reviewed for

OTA by Melton and Oberlander are differences in

rates of accidental injuries and delinquency (137).

Rural adolescents have higher rates of accidental

injuries and lower rates of delinquency (137). The

prevalence of other problems may not be different

for rural and urban adolescents, but the risk factors

for the problems may be different.

The American Academy of Pediatrics has identified rural injuries as a major public health problem

with unregulated use of farm machinery by adolescents being a prime culprit (10). Using national

databases of the National Center for Health Statistics

and the Consumer Product Safety Commission,

Rivara reported substantial risks for adolescent

males in farm families, with farm injuries taking

22.4 per 100,000 lives among 10- to 14-year-old

males, 30.9 per 100,000 lives among 15- to 19-yearold males, and accounting for 4,397 emergency

room visits among 10- to 19-year-old males in a

single year (174). Fatalities resulted most commonly

from machinery-related injuries (especially involving tractors), drownings, and firearm accidents

(144,174). In addition to severe trauma, farm adolescents are vulnerable to more subtle injuries related to

the use of farm machinery, such as noise-induced

hearing loss (28). It should also be noted that rural

adolescents have been found to engage in behaviors

that put them at high risk for automobile and other

types of accidents (263).71

Data from the National Crime Survey, conducted

periodically by the U.S. Department of Justice,

shows less victimization by adolescents (and other

7(IA~ dl~cu~~~ ~~ve, Natio~ H~~ Interview su~ey have several &tations with resptXt tO tXdUa@ he health Status of adolescen~. One issue

is that parents, rather than the adolescents themselves, typically report on their children’s health status and health care utilization.

71ne Universiv of~mesob swey of 7ti tiou@ 12th ~aders in Minnesota found, for example: that only 35 percent of w~ adoles~nts s~ey~

use their seat belt all or most of the time; that 64 percent of rural adolescent males never used a seat belc that nearly one out of four rural adolescents

surveyed (and three times more males than females) never wear a helmet when riding a motorcycle; that fewer than half the rural adolescents suxveyed

say they would nor drink and drive; that only 43 percent said they would not ride with a driver who used alcohol or drugs; that about 20 percent sometimes

ride with a driver who’s been using alcohol or drugs; that rurat adolescents start drinking earlier and drink more often and drink in greater quantity than

urban adolescents (263).
III-198 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

age groups) in rural than in urban areas.72 For the

most part, however, rural crime and delinquency do

not appear to differ in their origins or quality from

offending in urban communities (1 15).

Data on mental health problems among rural

adolescents are scarce (155). The few epidemiologic

studies of adolescents that have included rural-urban

comparisons have shown somewhat more risk in

urban communities (e.g., 179). However, the surveys and studies tend to vary on so many dimensions

(e.g., ethnicity, social class other than size of

community that the research gives little understanding as to any protective factors that may be

associated with rural communities per se. There are,

however, characteristics of’ rural life, both longstanding and contemporary, that may affect the

mental health and coping ability of rural adolescents

differently from adolescents living in metropolitan

areas. On the negative side, there is substantial

evidence that farm youth have been at greater risk of

stress in recent years, in part as a result of the farm

crisis of the early 1980s (see 57). Researchers have

documented a substantial increase in guilt, alienation, aggressiveness, depression, helplessness, and

poor school performance in. rural adolescents (18,

70,155,261). One study of 4,300 15-to 19-year-olds

in three communities in rural Minnesota, conducted

in the early 1980s at the peak of the farm crisis,

found that 3 percent reported having attempted

suicide in the past month (70). The University of

Minnesota Adolescent Health Survey found that

about 10 percent of rural females and 7 percent of

rural males reported having attempted suicide at one

point, and about 3 percent of students had both

attempted suicide and were seriously considering

taking their own lives at the time of the survey (263).

Rural adolescents who live on farms worried about

killing themselves at two times the rate of other

adolescents (263). Thirty percent of Minnesota

respondents had experienced the suicide of a fellow

student or adult in the school, and 14 percent had

experienced the loss in the previous school year

(263).

In addition to change related to the recent farm

crisis, perennial instability in many rural communities has resulted from constant migration away from

such communities and, during the 1970s, reverse

migration, as the dominant rural industries in

particular regions have “boomed” and “busted”

(29,162). More generally, simply because the range

of institutions and social situations is relatively

narrow in small communities, change within rural

communities is likely to have a greater impact than

comparable change in larger communities (271).

Conversely, the relatively low complexity of life

and slow diffusion of innovations in rural communities may also contribute to a lack of excitement about

the future (137). As evidence, those who stay behind

are more likely to be high school dropouts (19.5 v.

16.0 percent73), twice as likely to be married during

adolescence (3.4 percent among nonmetropolitan

adolescents), and less likely to have at least some

college education (35.0 v. 44.5 percent74) (132).

However, there are many positive aspects to life

in rural communities. In general, rural communities

are viewed as desirable places to live, in large part

because of the greater sense of neighborliness that

can arise from ‘‘undermanning (14),75 and a lower

rate of crime than in more densely populated

communities (104,27 1). Many of the pressures

experienced by adolescents in rural communities are

similar to those experienced by adolescents in urban

and suburban communities (e.g., 178).76

Access to Health Services by Rural Adolescents

Adolescents in rural areas face special barriers to

access to health services, in terms of availability,

affordability, and approachability. Perhaps reflecting this differential accessibility and affordability,

rural adolescents, especially those who are from

poor families, do use health services somewhat less

~see Ch. 13, “~lirquency: Prewmtion and Services, ” in Vol. II for a discussion of delinquency.

Ts~ese @Q refer to heads of ho~hold.

Tq~se ~~ refer to heads of hou~hold.

75’ ‘Unde~ ‘‘ results when there are more socially necessary roles to be fdled than there are people to fill them (14). This phenomenon can have

positive health consequences, because il. is positively associated with a greater press for personal involvemen~ and thus more personal control, which

in turn have been shown to be related to positive physical and mental status (165). Such general features of rurat life as ‘‘undermanning’ do not always

apply to rural adolescents, however. For example, as small rural schools are consolidated into larger institutions, students may become alienated and

show behavior problems and psychosomatic disorders (15,69).

76~ ~eu review for OW, w~ch was limit~ by scant inforrnatio~ Melton and Oberlander found no CletU whll-d differenc= in subs~ce u*

or in sexual behavior or attitudes (137). There were, however, more studies, and more variations in resuks, on the topic of substance use. Studies of

maltreatment were not able to be analyzed in terms of rural-urban differences.
Chapter 18----Issues in the Delivery of Services to Selected Groups of Adolescents ● ///-199

frequently than their urban peers. Nonmetropolitan

adolescents have been found to report 2.7 physician

visits per year, compared with 3.2 visits annually

among metropolitan adolescents (132). On the other

hand, the proportion of nonmetropolitan adolescents

who report having been hospitalized in the previous

year is somewhat higher than among metropolitan

adolescents (5.4 percent v. 3.9 percent) (132). It is

unclear whether this discrepancy results from differences in accessibility of outpatient care, severity of

health needs, or some other factor.

The availability of professionally staffed mental

and physical health services is often limited in rural

communities (137,204). Surveys of rural mental

health professionals have shown that professionals

who choose to work in rural areas tend to be people

who received their graduate training in a rural locale.

There is a need, then, for more clinical training

programs in rural areas. Only 20 percent of physicians, few of them specialists, practice in rural areas;

similarly, mental health professionals are concentrated in urban areas. One consequence of the lack of

providers is that adolescents in rural areas are

especially likely to receive their health care from

hospital clinics, and are relatively unlikely to have

any consistent source of care. Furthermore, even

when services are available, transportation problems

may make them inaccessible and, therefore, functionally unavailable to adolescents in rural areas.

Adolescents in rural areas also face economic

barriers to care, as Medicaid benefits tend to be more

limited in rural States, and many rural families are

poor (204). In 1984, 19.3 percent of adolescents in

nonmetropolitan areas lived in poverty, compared

with 15.5 percent in metropolitan areas (132), but the

difference in median family income between metropolitan and nonmetropolitan areas is more striking

($30,045 V. $21,956 in 1985 [158]). In addition,

disadvantaged rural families are less likely to be

eligible for public assistance programs, as poor

parents in rural communities are commonly employed for at least part of the year.

Even when help is available, it may not be sought

due to the strong sense of individual responsibility

characteristic of many rural people. A study of

welfare programs (including AFDC, food stamps,

and Medicaid) throughout Wisconsin showed perceptions of stigma to be much greater in rural

communities (170).77 Perhaps as a result, welfare

exits in rural communities were substantially more

frequent and faster—an outcome that is positive in

most respects, but that may signal a willingness to

give up needed health services when they are

perceived as a sign of personal weakness. In a survey

that was conducted among adolescents, the University of Minnesota found that, overall, 25 percent of

rural adolescents tried to solve their problems on

their own rather than seek help from parents,

doctors, friends, clergy, or school people; adolescents living on farms were less likely than other rural

adolescents to seek help for problems, even though,

as noted above, they were more likely to be troubled

(263). 78 However, the survey was not able to

determine whether the adolescents who did not seek

help were extremely self-reliant, undesirous of help,

or unable to go and get help (263).

Although the population of rural America is

predominately white, some regions contain substantial numbers of racial and ethnic minorities. For

example, the majority of Native Americans live in

rural communities, large numbers of blacks live in

the rural South, and many Hispanics live in the rural

Southwest. Much of the disproportionate poverty of

rural America is accounted for by such communities.

Consequently, it is important to consider cultural

differences when planning and delivering health

services to adolescents in rural areas. In addition, it

seems important to consider whether rural adolescents live on a farm, because farm youth appear to

have different health risks (e.g., serious injury),

attitudes toward help seeking, and access to health

care, than nonfarm youth.

Major Federal Programs Pertaining to

Rural Adolescents

Despite the number of programs that can indirectly affect rural adolescents, it is striking how few

Federal programs directly address the health and

related needs of rural adolescents (137). Of most

relevance to rural adolescents are the Office of Rural

Health Policy in the Health Resources and Services

m~s s~dy was not adolescent-spedc.

78A awoup, ~ey d. not seekcon~ception~o~tion from anyone (25 percent), they are less likely tO get health fio~tion or c~~ ~~out P~n~

consent (71 percent), and they do not seek out other family members as resources as readily as other young people (22 percent) (263).
/1/-200 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Administration (HRSA) of DHHS79; the Office of

Rural Mental Health Research in the Alcohol, Drug

Abuse, and Mental Health Administration of DHHS80;

and the Extension Service in the U.S. Department of

Agriculture, which funds 4-H programs.81 In addition, the National Center for Nursing Research at the

National Institutes of Health is funding a $500,000

grant to identify psychological and environmental

health-compromising behaviors in early adolescents

in a rural area (79). The community health center

program administered by HRSA’s Bureau of Health

Care Delivery and Assistance provides grants to

about 600 public and nonprofit entities to provide

primary health care to medically underserved populations, and about 60 percent of the grantees are

located in rural areas of the country (241) (see

discussion in section on Federal programs for poor

adolescents above; also see 137), and a number of

recent congressional initiatives dealing with training

of rural health professionals and reduction of ruralurban disparities in health care reimbursement

policies (204) also have the potential to positively

affect the delivery of health services to adolescents

in rural areas, albeit indirectly.

As a general matter, the Secretary of DHHS

responded to a recommendation of the National

Advisory Committee on Rural Health that a national

adolescent health demonstration program be established in five rural community sites, by saying that

he had decided to make adolescent health an area of

emphasis throughout DHHS for budget year 1992

(247).

Conclusions and Policy Implications

Certain groups of adolescents-adolescents living in poverty, racial and ethnic minority adolescents, and adolescents living in rural areas—

experience health problems at disproportionate rates

and face barriers to health care because of lack of

financial resources, limited local availability of

resources, or other factors.

Poor Adolescents

In 1987, nearly one-third of U.S. adolescents lived

in families with incomes that did not exceed 150

percent of the Federal poverty level. One of the

primary determinants or whether an adolescent was

living in poverty was living arrangement. Adolescents who were living with both parents or with their

father were far less likely to be living in poor

families than were adolescents living with their

mother only or adolescents living on their own.

The effects of growing up poor are complex and

not well understood (154). It is well known that

children growing up in poverty confront more risk

factors and benefit from fewer protective and

supportive factors than their more advantaged peers.

Among the risk factors that many (though not all)

poor children confront are a highly stressed and

disorganized family environment, dilapidated housing, substandard schools, and often, especially in

inner cities, dangerous, blighted neighborhoods

where crime and violence seem to have become the

norm (71 ). Access to health care for poor adolescents

appears to be limited, based on utilization data and

known barriers to access (e.g., low physician participation in Medicaid, problems with transportation,

lack of services in poor areas). The rates of many

health and related problems (e.g., days of restricted

activity due to acute and chronic conditions, overall

self-reported fair or poor health, school dropout,

adolescent pregnancy, cigarette smoking, involvement in serious forms of delinquency, victimization)

are higher among poor than nonpoor adolescents.

Research on the predictors of resiliency among

adolescents from disadvantaged backgrounds (e.g.,

impoverished homes or dysfunctional families) is

receiving increasing attention from researchers,

although it has received little Federal support. Past

research on this topic suggests that having access to

supportive individuals and networks, and the ability

to draw upon existing networks (e.g., through

greater social competence and intelligence), are

important factors in helping adolescents overcome

T9’HRsA*s ~ce of Rti H~th pt)licy WaS eqiiblished in 1987 and as of August 1989 had seven professionals (246). Its role in rural adolescent

health has been limited. The Work Group on Health Services of the National Advisory Committee on Rural Health Mice has targeted teenage health

as a focus because of concern about adolescent suicide, pregnancy, and lack of access for health and mental health services.

-e Office of Rural Mental Health Research was established in the National Institute of Mental Health in 1990 to coordinate and adrmms “ “ terrelevant

research and demonstration studies (204). This office will administer a newly advertised research effort that will include grants to rural mental herdth

research centers (233).

sl~e US. Dep~ent of Agric~ture’s Extension Service is diSCUSSCd mOre fly in ch. 19, “The Role of Federal Agencies in Adolescent HealtiL”

in this volume.
Chapter 18—issues in the Delivery of Services to Selected Groups of Adolescents .111-201

adverse circumstances. For many adolescents these

factors may be amenable to intervention.

Racial and Ethnic Minority Adolescents

Currently, about half of black, Hispanic, and

American Indian adolescents, and one-third of

Asian-American adolescents, live in poor or nearpoor families. The disproportionate occurrence of

health problems that is found among adolescents in

these racial, ethnic, and tribal groups is attributable

at least in part to their low socioeconomic status and

the lack of access to health care that is associated

with being poor. A long history of discrimination

against people of color may contribute to stress in

racial and ethnic minorities (e.g., 100,176).

Among the pressing prevention and service needs

for racial and ethnic minority adolescents include

preventive mental health and mental health outreach

programs for Hispanic, Asian, and American Indian

and Alaska Native adolescents; dental care and

fluoridation for American Indian and Alaska Native,

and Hispanic adolescents; dental care for lowincome black adolescents; victimization and violence prevention for black adolescents in poor

neighborhoods; pregnancy prevention services for

black and Hispanic adolescents; HIV prevention and

treatment services for black and Hispanic adolescents. In general, however, these problems are not

restricted to these groups, and the sources of the

problems are not related to race per se (e.g.,

genetically based), but to complex interactions

among economic, neighborhood, and societal factors.

There is an increasing consensus that services for

racial and ethnic minority adolescents would be

improved if they were ‘‘culturally competent.

Culturally competent services for adolescents may

be difficult to design, though, because there is little

systematic information about how racial and ethnic

minority and poor adolescents experience adolescence. There is beginning to be some systematic

analysis of what a culturally competent system of

care is, but the knowledge base has not yet been

applied systematically to the design of training

programs for health care and other service providers.

Overall, there is little systematic description of how

services have been developed or adapted to meet the

specific needs of racial and minority adolescents,

and less scientific evaluation of the effectiveness of

available services. There are, however, very few

health care providers who are racial or ethnic

minorities. The number who are racial and ethnic

minorities and trained to work specifically with

adolescents is not known.

As health care providers and policymakers consider the impact of racial or ethnic minority status on

individual adolescents and the impact of coming into

adolescence on individuals from specific racial or

ethnic minority groups, they should take numerous

factors into account. Such factors include:

●

●

●

demographic factors (e.g., the size of the

adolescents’ minority group; its relative distribution in the wider society and the adolescent’s

immediate community; and its geographic location, whether urban or rural);

historical factors (e.g., whether the group at

large immigrated voluntarily or was forced to

relocate to the United States; the history of

discrirnination against the group); and

contemporary ‘sociocultural’ factors (e.g., the

beliefs, values, social perceptions, and behaviors of the minority group at large; available

social institutions, such as the role of a church

or religion).

Health care providers and policymakers should

also recognize that the adolescent’s basic challenge

of forming an identity may be made more difficult

for those racial and ethnic minority adolescents who

are faced with the challenge of straddling two (or

more) cultures.

Rural Adolescents

With the exception of the higher rate of accidental

injuries (due in part to farm injuries) and lower rate

of delinquency for adolescents living in rural areas,

there are few known sizable rural-urban differences

in adolescent health. Although research on adolescents living in rural areas is limited, this suggests

that rural adolescents are at least as likely to

experience many of the same health problems

experienced by adolescents in metropolitan areas.

However, additional descriptive research designed

to separate rural, regional, social class, and ethnic

factors is needed, in addition to analyses to determine the possibly differential effects of particular

dimensions of rural life (e.g., living on a farm v. in

a town) on adolescent health and well-being.

Rural adolescents’ access to health services is

limited by shortages of professionally staffed mental
111-202. Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

and physical health services, transportation problems, and less access to Medicaid in rural States

(204). Thus, adolescents in rural areas are especially

likely to receive their health care from hospital

clinics, and are relatively unlikely to have any

consistent source of care (137). Some research

suggests that adolescents who live on farms are

particularly unlikely to have access to sources of

health care (263). Innovations in efforts to provide

more comprehensive and integrated services will

have to be adapted to the specific needs of rural

adolescents, and specific limitations in health care

resources (e.g., the relative scarcity of health care

professionals).

Summary

As is documented throughout this Report, U.S.

adolescents face a number of health problems that

could very well be ameliorated by access to health

and related services.82 Thus, the conventional wisdom that adolescents as a group are so healthy they

do not require health services is not justified. It is

disturbing, then, to note that many adolescents face

barriers to access to health services. Some of the

barriers are common to individuals in other age

groups (e.g., lack of health insurance, inadequate

coverage), but some of them are unique to, or

particularly affect, adolescents (e.g., lack of independent income, requirements for parental consent,

lack of information about the need for and availability of health services). This chapter pulls together

evidence that some groups of adolescents—

adolescents in poor families, racial and ethnic

minority adolescents, and rural adolescents—are

particularly at risk for selected health problems and

for problems in access. Rather than stereotyping

adolescents by one factor or another, however, it is

important to note that the health issues and barriers

to service faced by any adolescent depend on a

variety of interrelated factors. Adolescents who are

poor, minority, and living in a rural area will face

somewhat different issues than those who are poor,

minority and living in an impoverished inner-city

area. The families of black adolescents may subscribe to health-related beliefs and behaviors that

differ from those of poor white rural adolescents, of

recently arrived immigrants from Cambodia, or of

Native Hawaiians.

Unfortunately, a lack of research attention to

issues affecting many of the adolescents discussed in

this chapter typically makes it difficult to design a

detailed and specific public policy response to these

adolescents’ health and related needs. Thus, an

enhanced commitment to research on the health

needs and developmental experiences of poor, racial

and ethnic minority adolescents, and adolescents in

rural areas, and the relationships among these

specific background factors, should be a top priority

for appropriate public policy intervention. Unfortunately, the development of an integrated and comprehensive research base may be impeded by the

fragmented Federal approach to adolescent health

issues.83

As an adequate research base is developed,

however, much of the information provided in this

chapter and elsewhere in this Report can be used to

help improve the health of those adolescents particularly at risk. Examples of changes that could be made

at the Federal level and elsewhere include the

following:

●

●

●

●

●

Expand support for training of racial and ethnic

minority, rural, and low-income health care

providers with an interest in adolescent health

care;

support training in cultural competence for

health care providers who work with racial and

ethnic minority adolescents, incorporating evaluations of the effects of such changes;

Support the expansion of data collection efforts

to oversimple racial and ethnic minority adolescents and to include information on socioeconomic status;

Collect data on the availability and accessibility of health services for racial and ethnic

minorities, rural, and poor adolescents, with

such research to include adolescents’ perceptions of accessibility and availability;

Support efforts to improve environments in

poor areas (including hard-hit farm-belt communities, Indian reservations, and inner cities),

focusing on family support, improving school

environments, improving substandard housing,

increasing access to nutritional food, increasing

access to recreational and fitness facilities and

g=or a smmmary, see Vol. I, ‘‘Summary and Policy Options’ of this Report.

83s= ch. 19, ‘ ‘me F~e~ Role in Adolescent HealtlL’ in this volume, ~d VO1. I, ‘‘SUIWIUWY and Policy Options. ’
Chapter 18--Issues in the Delivery of Services to Selected Groups of Adolescents . lil-203

activities, and, where needed, increasing access

to appropriate adult role models.84

In addition, the major policy options suggested as

a result of OTA’s analysis are designed to help

improve in particular the lives of those adolescents

85 Finally, OTA at greatest risk of health problems.

finds that any policy changes should be undertaken

with attention to a guiding principle of providing a

prolonged sympathetic and supportive environment

for all adolescents, of whatever socioeconomic

status, race, ethnicity, or residence. Such a change in

policy orientation is essential to help adolescents

face a crucial turning point in their lives, and maybe

essential to the well-being of the Nation as well.86

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///-204 . Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

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214.

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Chapter I8--Issues in the Delivery of Services to Selected Groups of Adolescents ● 111-209

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242.

243.

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Chapter 19

THE ROLE OF FEDERAL AGENCIES

IN ADOLESCENT HEALTH
Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Federal Agencies’ Definitions of the Adolescent Population ......, . . . . . . . . . ...**,... . . . . . . 213

Federal Programs and Expenditures for Adolescents . . . . . . . . . . . . . . . . . ● ...*.... . . . . . . . . . . . . . 224

U.S. Department of Health and Human Services: Programs and Expenditures for Adolescents . . . . 225

Family Support Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Health Care Financing Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Office of Human Development Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

Public Health Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

Agencies Other Than DHHS: programs and Expenditures for Adolescents . . . . . . . . . . . . . . . . . 244

ACTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

U.S. Consumer Product Safety Commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

U.S. Department of Agriculture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

U.S. Department of Defense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

U.S. Department of Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

U.S. Department of Justice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250

U.S. Department of Labor ..*. ... ... ... .. . $ * * . * . . . * * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .251

U.S. Department of Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

Coordination at the Federal Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256

Chapter 19 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

Box

Box Page

19-A. History of the Children’s Bureau . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

Figures

Figure Page

19-1. Estimated Adolescent-Specific Expenditures by U.S. Executive Branch Agencies

Responding to OTA’s 1989 Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226

19-2. U.S. Department of Health and Human Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228

, 19-3. U.S. Department of Health and Human Services, Office of Human

Development Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

19-4 U.S. Department of Health and Human Services, Public Health Service,

Alcohol, Drug Abuse, and Mental Health Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

19-5. U.S. Department of Health and Human Services, Public Health Service,

Centers for Disease Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

19-6. U.S. Department of Health and Human Services, Public Health Service,

Health Resources and Services Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

19-7. U.S. Department of Health and Human Services, Public Health Service,

National Institutes of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238

19-8. U.S. Department of Health and Human Services, Public Health Service,

Office of the Assistant Secretary for Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

19-9. U.S. Department of Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248

19-10. U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention . . . . . 251

Tab/es

Table Page

19-1. Primary Functions of U.S. Executive Branch Agencies With a Role in Adolescent Health . . . . 214

19-2. How Adolescence Is Defined by Different Federal Agencies and Their Components . . . . . 219

19-3. Components of the Expenditures on Adolescent Health by the U.S. Department of

Health and Human Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

19-4. Adolescent Research Priority Areas of the Components of the National Institutes

of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

19-5. Expenditures on Adolescent Health by Federal Agencies Other Than the

. . . . . . . . . . . . . . . .

U.S. Department of Health and Human Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

19-6. Congressional Committees With a Role in Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . 259
Chapter 19

THE ROLE OF FEDERAL AGENCIES IN ADOLESCENT HEALTH

Introduction

The Federal Government has both direct and

indirect involvement in providing services, developing policies, designing and implementing programs,

and conducting research aimed at improving the

health of adolescents. Some Federal efforts target

adolescents specifically, and other Federal efforts

are aimed at a more general population that includes

adolescents. Because of the way funds are allocated,

it is difficult to ascertain the extent to which the

Federal Government supports activities designed to

improve the health of adolescents.

As part of its adolescent health project, OTA

surveyed Federal agencies that it identified as

possibly having a role in adolescent health. The

survey included agencies of the U.S. Department of

Health and Human Services (DHHS) and of the U.S.

Departments of Agriculture, Commerce, Defense,

Education, Interior, Justice, Labor, and Transportation, and several independent Federal agencies such

as ACTION (see table 19-1). Agencies were asked

about the following:

●

●

●

●

●

●

●

T he

their definition of adolescence;

current agency research priority areas;

overall agency budgets for fiscal years 1979

through 1990;

level of funding for adolescent initiatives for

fiscal years 1979 through 1990;

research activities and demonstration projects

related to adolescents;

participation in intra-agency and interagency

coordination activities related to adolescents;

and

data collection activities related to adolescents.

findings of OTA’s survey clearly indicate that

the Federal Government funds numerous activities

aimed at improving the health of adolescents. This

chapter analyzes the information sent to OTA in

response to its survey questionnaire regarding Federal agencies’ adolescent health initiatives. Unless

otherwise indicated, the information in this chapter

is from Federal agency responses to this questionnaire. Other sources of information are used to

provide context to the discussion.

The Federal agencies that were sent OTA survey

questionnaire were also invited to send representatives to OTA for a l-day discussion on the Federal

role in adolescent health. OTA’s workshop for

Federal agencies was held in October 1989, and the

discussions are summarized and incorporated into

the conclusions of this chapter.

Federal Agencies’ Definitions of the

Adolescent Population

The Federal agencies responding to OTA’s survey

define adolescence inconsistently (see table 19-2).

Definitions of adolescence or the ages it encompasses vary not only from one Federal department to

another but also within departments and even within

agencies.

The variation in definitions of adolescence is

particularly evident within the Public Health Service

of DHHS. Within the National Institutes of Health,

for example, the National Institute of Child Health

and Human Development defines adolescence as

including, but not being restricted to, ages 12 and 19.

Other institutes within the National Institutes of

Health define adolescence very broadly. The National Institute of Neurological Disorders and

Stroke, for example, defines adolescence as the

period between late childhood and early adulthood.

Within the Centers for Disease Control, the

definition of adolescence also varies. It is ages 10 to

19 in the Division of Adolescent and School

Immunization and ages 10 to 18 in the National

AIDS Information and Education Program. Further,

within the Health Resources and Services Administration’s Bureau of Health Care Delivery and Assistance, definitions of adolescence vary by program:

●

●

☛

●

A

community/migrant health centers programs,

ages 10 to 19;

homeless programs, ages 15 to 19;

perinatal programs, under age 15 and ages 15 to

19; and

substance abuse programs, ages 13 to 19.

significant number of Federal agencies and

programs do not define any particular age grouping

as adolescence. These include the Family Support

Administration of DHHS, the Bureau of the Census

-111 -213 -
Table 19-1-Primary Functions of U.S. Executive Branch Agencies With a Role in Adolescent Healtha

Agency Primary function(s)

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHHS) .

1. Family Support Administration (FSA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

A. Office of Family Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

B. Office of Child Support Enforcement . . . . . . . . . . . . . . . . . . . . . . . . .

C. Office of Community Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Health Care Financing Administration (HCFA). . . . . . . . . . . . . . . . . . . .

3. Office of Human Development Services (OHDS) . . . . . . . . . . . . . . . . . .

A. Administration for Native Americans.. . . . . . . . . . . . . . . . . . . . . . . .

B. Administration on Development Disabilities . . . . . . . . . . . . . . . . . . .

C. Administration for Children, Youth, and Families. . . . . . . . . . . . . .

4. Public Health Service (PHS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

A. Alcohol, Drug Abuse, and Mental Health Administration . . . . . . .

● National Institute on Alcohol Abuse and Alcoholism . . . . . . . . .

● National Institute on Drug Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . .

● National Institute of Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . .

● Office for Substance Abuse Prevention . . . . . . . . . . . . . . . . . . . . .

● Office for Treatment Improvement . . . . . . . . . . . . . . . . . . . . . . . . . .

B. Centers for Disease Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. Center for Chronic Disease Prevention and Health

Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

—Division of Adolescent and School Health . . . . . . . . . . . . . . . . .

—Division of Reproductive Health . . . . . . . . . . . . . . . . . . . . . . . . . . .

Administers a wide range of programs related to health, welfare, and income security.

Administers various programs intended to strengthen the American family.

Administers the Aid to Families With Dependent Children (AFDC) program and the Job Opportunities

and Basic Skills Training (JOBS) program.

Supports State efforts to enforce support obligations owed by absent parents to their children.

Administers the community services blockgrant and discretionary grant programs, which assist poor

people.

Administers the Medicaidb and Medicare programs.

Oversees various human services programs for the elderly, children and youth, families, Native

Americans, persons living in rural areas, and people with disabilities.

Advises the Assistant Secretary for Human Development Services on matters related to American

Indians and other Native Americans. Administers a grant program and provides technical

assistance to Native American organizations to help them implement locally determined social

and economic development strategies.

Administers the Development Disabilities Act and supports the development and coordination of

programs for developmentally disabled persons of all ages.

Funds comprehensive services for young children and their families through the Head Start program.

Administers provisions of the Child Abuse Prevention and Treatment Act and manages a national

clearinghouse on child abuse and neglect. Provides Federal support for child welfare services

(including Federal funds for foster care maintenance). Administers the Runaway and Homeless

Youth Act and a drug abuse prevention program for runaway and homeless youth.

Supports a wide variety of efforts to improve the physical and mental health of Americans.

Supports efforts to increase knowledge about and to prevent and treat alcohol and drug abuse and

mental health disorders in the United States.

Conducts and supports research on alcohol abuse and alcoholism.

Conducts and supports research on drug abuse.

Conducts and supports research on mental health and the prevention and treatment of mental

illness.

Supports innovative prevention demonstration projects for individuals at high risk for drug or alcohol

abuse; supports an information clearinghouse with drug and alcohol abuse prevention materials;

provides technical assistance to States; supports training for substance abuse counselors.

Supports efforts by States and communities to improve drug and alcohol abuse treatment programs;

administers the alcohol, drug abuse, and mental health services block grant program.

Administers national programs for the prevention and control of communicable diseases; chronic

diseases; and environmental health problems.

Directs a national program aimed at the prevention of premature mortality, morbidity, and disability

due to chronic illnesses.

Administers programs to reduce health risks to adolescents through comprehensive school health

education and other means.

Administers programs and conducts research in areas related to contraception, pregnancy, human

reproduction, and infancy.

a~e Federal agen~es list~ in this table are primarily agenties that responded to a survey conducted by OTA in August 1989 to determine the -pe and level of adol=~nt-h~lth-relat~ acti~ty

at the Federal level.

bM~iaid ~= establi~h~ in 1965 under ~tle Xix of the s~ial Sewrity ~t to ~si~t states in ~ro~ding health ~re (e.g., inpatient and o~patient m~i~l Servicm, famiy planning SeWkXS,

prenatal care) to the poor.

Continued on next page
Chapter 19-The Role of Federal Agencies in Adolescent Health ● III-215

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Table 19-1—Primary Functions of U.S. Executive Branch Agencies With a Role in Adolescent Healtha

--Continued

Agency Primary function(s)

National Institute of Child Health and Human Development. .

National institute of Dental Research . . . . . . . . . . . . . . . . . . . . . . .

National Institute of Diabetes and Digestive and

Kidney Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

National Institute of Environmental Health Sciences . . . . . . . . .

Conducts and supports multidisaplinary behavioral and biomedical research on child health and

maternal health, on problems of human development (e.g., mental retardation) and on family

structure. Supports research on new contraceptives and AIDS.

Research aimed at eliminating tooth decay and an array of other oral-facial disorders.

Conducts and supports research into the causes, prevention, diagnosis, and treatment of various

metabolic and digestive diseases (e.g., juvenile diabetes, cystic fibrosis, sickle-cell anemia,

hemophilia).

Conducts and supports research to understand the effects of chemical, biological, and physical

factors in the environment on health.

● National Institute of Neurological and Communicative

Disorders and Stroke (NINCDS)d . . . . . . . . . . . . . . . . . . . . . . . . . . Conducts and supports research on neurological disorders (e.g., head and spinal cord injury) and

stroke.

● National Center for Nursing Research . . . . . . . . . . . . . . . . . . . . . . Administers programs and research training programs aimed at promoting the quality of research in

nursing and patient care, including care for adolescents.

F. Office of the Assistant Secretary of Health (OASH) .........,.. Aids the Secretary of Health with management responsibilities of the department.

● Office of Disease Prevention and Health Promotion . . . . . . . . . Supports and coordinates prevention programs within the Alcohol, Drug Abuse, and Mental Health

Administration, the Centers for Disease Control, the Food and Drug Administration, the Health

Resources and Services Administration, and the National Institutes of Health.

● Office of Minority Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ensures that DHHS funds are used to address minority health problems by organizing, and

assessing current programs for minority health problems; provides technical assistance to States

and local governments with respect to their efforts to address minority health issues.e

● Office of Population Affairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Carries out Public Health Service Act Title X and Title XX programs related to adolescent pregnancy,

family planning, and population research.

G. Social Security Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Administers the Old Age Survivors and Disability Insurance Program and the Supplemental Security

Income Program.

ACTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Administers several Federal domestic volunteer service programs, including VISTA, the Foster

Grandparents Program, and Student Community Service Projects.l

NATIONAL SCIENCE FOUNDATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Supports research in science and engineering through grants to universities and other research

organizations.

U.S. CONSUMER PRODUCT SAFETY COMMISSION . . . . . . . . . . . . . . Collects information on consumer-product related injuries, promotes research on the causes and

prevention of such injuries, develops voluntary or mandatory standards for consumer products,

and sometimes bans hazardous products.

U.S. DEPARTMENT OF AGRICULTURE (USDA) . . . . . . . . . . . . . . . . . . Administers a wide range of programs related to farms, nutrition, food, hunger, rural development,

and the environment.

1. Office of the Assistant Secretary, Food and Consumer Services

A. Food and Nutrition Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Administers several programs to make food assistance available to needy people, including the Food

Stamp Program, the School Breakfast Program, the Food Distribution Program, and the Special

Supplemental Food Program for Women, Infants, and Children. Also gives grants to States for

disseminating nutrition information to children.

B. Human Nutrition Information Service . . . . . . . . . . . . . . . . . . . . . . . . . Performs research in human nutrition; monitors food and nutrient consumption in the United States;

and disseminates information on nutrition.

dln lggo, the National ln~tit~e of Neuro@i~l and ~mmuni~tive D~orders and stroke split into two separate instit~es: 1 ) the National Institme of Neurologi@l Disorders and Stroke, and

2) the National Institute on Deafness and Other Communication Disorders.

e~ese were its ~nctions prior to the passage of Public Law 101-527, which established separate funding for an Office of Minority Health in DHHS.

fThese were its functions prior to passage of the National and Community Service Act (Public Law 101-610).
Chapter 19--The Role of Federal Agencies in Adolescent Health ● 111-217

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Table 19-1—Primary Functions of U.S. Executive Branch Agencies With a Role in Adolescent Healtha

-Continued

Agency Primary function(s)

6. Bureau of Justice Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Collects, analyzes, and disseminates information about crime, and the operation of the criminal

justice system at all levels of government.

C. National Institute of Justice.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Works to improve the criminal justice system, address crime prevention and control, and enhance

community safety and security.

D. Office of Juvenile Justice and Delinquency Prevention . . . . . . . . Administers programs and policies intended to improve the juvenile justice system; assists

communities in responding to the needs of juveniles; assesses the factors that contribute to

juvenile delinquency; and informs practitioners about research findings and successful

interventions.

E. Office for Victims of Crime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Carries out activities mandated by the Victims of Crime Act of 1984.

U.S. DEPARTMENT OF LABOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Fosters U.S. workers’ welfare, improves their working conditions, and promotes opportunities for

employment.

1. Employment and Training Administration . . . . . . . . . . . . . . . . . . . . . . . . . Has responsibilities related to employment services, unemployment insurance, and job training.

Administers the Job Training Partnership Act, which authorizes block grants to States for job

training programs for economically disadvantaged individuals and provides authority for the Job

corps.

U.S. DEPARTMENT OF TRANSPORTATION . . . . . . . . . . . . . . . . . . . . . .Develops coordinated national transportation policies and oversees a wide variety of transportation

programs carried out by nine operating administrations (aviation, highway, railroad; highway

traffic safety; urban mass transportation, etc.).

1. Federal Highway Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Administers the Federal-aid highway program of financial assistance to the States for highway

instruction and improvements, such as highway repairs and maintenance, which improve the

safety of the roads; exercises jurisdiction over commercial motor carriers in interstate commerce.

2. National Highway Traffic Safety Administration . . . . . . . . . . . . . . . . . . . Carries out programs and research related to the safety and performance of motor vehicles, and

related equipment.

NATIONAL TRANSPORTATION SAFETY BOARD . . . . . . . . . . . . . . . . . Conducts independent investigations of accidents and other safety problems, conducts studies, and

makes recommendations to Federal agencies, the transportation industry, and others on safety

measures and policies.

SOURCE: U.S. Congress, Office of Technology Assessment, 1991, based on National Archives and Records Administration, Offi- of the Federal Register, The United Statea Government

MarIua/ 1990/91 (Washington DC: U.S. Government Printing Office, July 1, 1990).
Table 19-2—How Adolescence Is Defined by Different Federal Agencies and Their Components

Distinctions between

Definition of early, middle, and Reason(s) for definition

Federal agency adolescence late adolescence or distinctions chosen

ACTION

U.S. CONSUMER PRODUCT SAFETY

COMMISSION

U.S. DEPARTMENT OF AGRICULTURE

Office of the Assistant Secretary, Science and

Education

● Extension Service’s 4-H Program

Office of Assistant Secretary, Food and

Consumer Services

. Food and Nutrition Service

U.S. DEPARTMENT OF COMMERCE

Bureau of the Census

U.S. DEPARTMENT OF DEFENSE

Civilian Health and Medical Program of the

Uniformed Services (CHAMPUS)

U.S. DEPARTMENT OF EDUCATION

Office of Elementary and Secondary Education

. Office of Indian Education

. Office of Migrant Education

Office of Special Education and Rehabilitative

Services

10 to 19

None. Often, age groups are related

to factors, such as product design

or physical characteristics, of the

population. Data are usually reported as ages 5 to 14 and 15 to

24.

Age guideline of 9 to 19. Most States

have adopted an earlier age for

participation.

None. Some data are collected by

single year of age or school grade.

For example, the Food Stamp Program reports on children and adolescents ages 5 to 17 receiving

food stamps.

Not specified. Data are reported by

single year of age and for various

age groups (i.e., 10 to 14 and 15 to

19); data user can pay for other

age breaks.

Two military services use 10 to 18.

Remaining two use 12 to 18.

None. Individuals less than age 21 are

considered children, and those over

21 are considered adults. Data are

collected for 10- to 14-year-olds

and 15- to 19-year-olds.

Although no Department-wide definition exists and definitions may

vary by program, adolescents are

generally considered to be in

grades 7 through 12.

None

None

Unofficially, 10 to 21.

None

None

None

Early: < 11.

Middle: 11 to 14.

Late: 15 to 19.

None

None. Data users can create their own

age groups.

Yesa

None

None

None

None

None

Executive policy decision

Not applicable

Lower age limit of 9 chosen because

of the need to work with younger

adolescents due to health-related

issues.

Not applicable

Requests from data users and the

judgments of the Census Bureau’s

professional staff.

Programs are geared to adolescents

based on their growth, development, and maturation levels.

Statutes determine age when it

factor for eligibility.

Traditional grouping

Not applicable

Not applicable

Not applicable

is a

aDefinitions nOt prOVkkd.

Continued on next page
Table 19-2-How Adolescence Is Defined by Different Federal Agencies and Their Components-Continued

Distinctions between

Definition of early, middle, and Reason(s) for definition

Federal agency adolescence late adolescence or distinctions chosen

● Office of Special Education Programs

● National Institute on Disability and Rehabilitation Research

. . U.S DEPARTMENT OF HEALTH AND HUMAN

SERVICES

Assistant Secretary for Planning and Evaluation

Family Support Administration

Health Care Financing Administration

Office of Human Development Services

Public Health Service

A. Alcohol, Drug Abuse, and Mental Health

Administration

● National Institute on Alcohol Abuse and

Alcoholism

. National Institute on Drug Abuse

● National Institute of Mental Health

None. Ages 12 to 17 and 18 to 21 are

used in the Annual Report to Congress.

None. Age groupings may or may not

be defined within project guidelines.

10 to 18

Not specified. For recipient children

under age 18, data are reported by

year, and parent recipients are

reported by age group 11 to 18.

None. Eligibility for Medicaid includes

individuals less than age 18.

Varies. Social services block grants:

varies.

Child welfare services: under 21.

Child welfare research: not specified.

Foster care: under 18.

Independent living program: over

16.

Runaway & homeless youth program: 10 to 18.

13 to 21

None. Research projects target the

range of 12- to 21-year-oIds.

No NIMH-wide definition, but the Child

and Adolescent Disorders Research

Branch defines adolescence as 10

to 18.

No specific distinctions. However,

States report child data as 6 to 11,

12 to 17, and 18 to 21.

Not unless done within a specific

project.

Yesa

Not provided

None

Sometimes made in discretionary priorities,

None

None. Studies test programs for adolescents of differing ages.

Does not code grants by these categories, but NIMH clinical investigators often use such categoriesEarly: 10 to 13.

Middle: 14 to 17.

Late: 18 to 24.

Legislatively mandatedb

Legislatively mandatedb

Age 10 generally marks the beginning

of puberty, and at age 18 individuals are no longer eligible for ASPE

social services.

Not provided

Not applicable

Required under legislative authority:

Adoption Assistance Act (Public

Law 92-272)--under age 18 except where mental or physical handicap warrants continuation until

age 21, Child Abuse Prevention

and Treatment Act (Public Law

93-247)--under age 18 or as specified by the State’s child protection

law.

Not applicable

Determined by study questions and

research subject eligibility.

Age groups make sense developmentally in terms of psychosocial stressors and role transitions.

aDefinitions not pmVkbcf.

bserv~= maybe provid~ until age 22 “tier the Edu@ti~n for Ail Handi~pp~ Children Act (publ~ ~W 94-142). Title I of the RehaNlitation Act proti~ for delive~ of service tO individuals

with potential vocational abilities with no set lower age limit. The Fair IAmr Standards Act, however, establ’~hecf the age of 14 ~ appropriate for employment. Most school districts target

the age of 16 as eligible for employment.
Table 19-2—How Adolescence Is Defined by Different Federal Agencies and Their Components—Continued

Distinctions between

Definition of early, middle, and Reason(s) for definition

Federal agency adolescence late adolescence or distinctions chosen

. Office for Substance Abuse Prevention Under age 21. Data age breaks ininclude adolescent ages 10 to 12, 13

to 15, 16 to 18, 19 to 21.

B. Centers for Disease Control

. Center for Chronic Disease Prevention

and Health Promotion

—Division of Adolescent and School 10 to 19

Health

—Division of Reproductive Health 12 to 19

● Center for Environmental Health and None

Injury Control

—Division of Injury Control None

—Disabilities Prevention Program None

. Center for Infectious Diseases

—Division of HIV/AIDS 13 to 19

. Center for Prevention Services

—Division of Immunization

—Division of STDs and HIV Prevention

—Division of Tuberculosis Control

—National AIDS Information and

Education Program

● National Center for Health Statistics

10 to 24

10 to 19. Data provided for adolescents ages 10 to 14 and 15 to 19.

10 to 19. Data provided for adolescents ages 10 to 14 and 15 to 19.

10 to 18

No uniform definition. NCHS does

collect data on all age groups, by

individual year.

Early: 10 to 14. Based on convenience of program

Middle: 14 to 17. administration, as with schoolLate: 17 to 20. based programs, and on findings

in developmental psychology literature. Under 21 age group defined

by OSAP’s authorizing legislation.

Yes c

Early: 12 to 14.

Middle: 15 to 17.

Late: 18 to 19.

None

None

None

None

Uses the World Health Organization

definition.

Very few births occur to adolescents

under age 12. Fifteen to 17-yearolds may still be in school and the

proportion married is different than

the 18- to 19-year-olds.

Not applicable

Not applicable

Not applicable

Children under age 12 unlikely to

become infected with the AIDS

virus through sexual contact. Age

19 is still considered an adolescent.

Early: 10 to 14. Standard age groups of the Census

Middle: 15 to 19. Bureau.

Late: 20 to 24.

None For STD morbidity purposes, there

are differences in infection rates

between 10- to 14-year-olds and

15- to 19-year-olds.

None Age groups used by other CDC surveillance programs.

None Selected on the advice of the Division

of Adolescent and School Health

and the advice of national youthserving organizations.

None Not applicable

cAlthough the Division of Adole~ent a~ wool Health dOeS not have a standard definition for early, middle, and late adole~ence, the Division does distinguish between age groups

in particular cases. For example! the “Guidelines for Effective School Health Education To Prevent the Spread of AIDS” includes information appropriate for early elementary, late

elementarylmiddle school, and juniortsenior high school students (18).

Continued on next page
Table 19-2-How Adolescence Is Defined by Different Federal Agencies and Their Components-Continued

Distinctions between

Definition of early, middle, and Reason(s) for definition

Federal agency adolescence late adolescence or distinctions chosen

C. Health Resources and Services

Administration

. Office of Rural Health Policy

. Bureau of Health Care Delivery and

Assistance

* Bureau of Maternal and Child Health and

Resources Development@

---Office of Maternal and Child Health

D. Indian Health Service

E. National Institutes of Health

●

●

●

●

●

●

●

●

●

●

National Cancer Institute

National Center for Nursing Research

National Center for Research Resources

National Eye Institute

National Heart, Lung, and Blood Institute

National Institute of Allergy and Infectious

Diseases

National Institute of Arthritis and Musculoskeletal and Skin Diseases

National Institute of Child Health and

Human Development

National Institute of Diabetes and

Digestive and Kidney Diseases

National Institute of Neurological and

Communicative Disorders aid Strokee

None. Does not collect data on adolescents.

Varies by program:

Community/Migrant Health

Center (C/M-HC): 10 to 19.

Homeless: 15 to 19.

Perinatal: <15 and 15 to 19.

Substance abuse: 13 to 19.

10 to 19

None. However, IHS health care providers accept the 10 to 19 definition. Data can be sorted by any

age grouping.

12 to 19

13 to 18

Puberty to maturitya

Not provided

Generally, ages 12 to 18 for schoolbased programs. Ages 10 to 12

are considered preadolescents.

13 to 20

12 to 21

Includes, but is not restricted to, ages

12 to 19.

12 to 21

Period between late childhood and

early adulthood. Most hospitals

and other clinical centers conducting research supported by the institute consider those under 16 as

children and those older than 16

as young adults.

None

None

Distinguished only within program

activities.

None

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

Not applicable

C/MHC age grouping is based on

those used by the Census Bureau.

Others are program specific.

Based on Title V (Maternal and Child

Health Services Block Grant) legislation and the recommendation of

adolescent health professionals.

Not applicable

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

dFollowina OTA’S ~urvev, the Bur~u of Maternal and Child H~lth and R~ourc~ Development split into the Bureau of Maternal and Child Health and the Bureau of Health Resources

Deveiop%ent (see fig. j9-1). Responses were received from the original Bureau.

eln 1 w(), the National lnstit~e of NeUrOlogi~l and ~rnrnuni~tive Disorders and st~ke split into two separate institutes: 1 ) the National Institute of Neuro@i~l Disotirs and Stroke, and 2) the

National Institute on Deafness and Other Communication Disorders.
Table 19-2-How Adolescence Is Defined by Different Federal Agencies and Their Components-Continued

Distinctions between

Definition of early, middle, and Reason(s) for definition

Federal agency adolescence late adolescence or distinctions chosen

F. Off ice of the Assistant Secretary for Health

* Office of Disease Prevention and Health

Promotion

● Office of Population Affairs

U.S. DEPARTMENT OF THE INTERIOR

U.S. DEPARTMENT OF JUSTICE

National Institute of Justice

Office of Juvenile Justice and Delinquency

Prevention

U.S. DEPARTMENT OF LABOR

Job Training Partnership Act Programs

Bureau of Apprenticeship and Training

U.S. DEPARTMENT OF TRANSPORTATION

Federal Highway Administration

National Highway Traffic Safety Administration

NATIONAL TRANSPORTATION SAFETY BOARD

None

None, but frequently targets 10- to

19-year-olds.

Not provided

None, but specific research projects

may address issues relevant to

particular groupings.

Nonef

Primarily ages 16 to 21. Limited programs for 14- to 15-year-olds.

Age 16 and over. Data can be obtained for different age groups, but

is not routinely summarized in a

report.

Ages 10 to 20. Data stored by age so

different age groupings possible.

None. Targets the 15- to 24-year-old

group, especially those under 21.

Age groups most frequently used

in data collection, <15, 15 to 17,

18 to 20.

None

None

None, but recognizes that adolescents

of different ages have varying degrees of need.

Not provided

None

None

Services for 14- and 15-year-olds are

different than for 16- to 21-yearolds.

None

Early: 10 to 14.

Middle: 15 to 17.

Late: 18 to 20.

None

None

Not applicable

Uses data compiled by other agencies, such as the Census Bureau.

Not provided

Not applicable

Not applicable

Legislatively mandated

Not applicable

Primarily because of driving/drinking

cutoffs. The 15- to 17-year-olds

are the learner/limited experienced

drivers; the 18- to 20-year-olds are

the more experienced drivers and

before 1987 were often legal drinkers.

Ages 15 to 24 represent the most

traffic fatalities, injuries, and years

of life lost in almost every motor

vehicle crash category.

Not applicable

flJn&r Title II of the 1974 J~enile Justi@ and ~linque~y Prevention Act, as amended, the of fi~ relies on State law- to define the age of ajuveniie for purpose of jwenile Or family COurt jurisdiction

over delinquent conduct and nonuiminal misbehavior (status offenses).

SOURCE: Office of Technology Assessment, 1991, based on Federal agency responses to the Office of Technology Assessment’s 1989 questionnaire regarding adolescent health initiatives.
///-224 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

in the U.S. Department of Commerce, the Civilian

Health and Medical Program of the Uniformed

Services (CHAMPUS) in the U.S. Department of

Defense, the U.S. Department of Education, and

programs within the U.S. Departments of Justice and

Agriculture. Some Federal agencies that do not

provide a specific adolescent defitition do collect

data on various age groups, allowing outside researchers the opportunity to use their own adolescent age groups; these include the Bureau of the

Census, the National Center for Health Statistics in

DHHS, and the National Highway Traffic Safety

Administration in the U.S. Department of Transportation.

Very few Federal agencies distinguish between

early, middle, and late adolescence. Among those

agencies that do have definitions, there appears to be

greater agreement on the definition of early adolescence than on the definitions of middle and late

adolescence (i.e., when one ends and the other

begins). Federal agencies, including the Division of

Immunization within the Centers for Disease Control of DHHS and the Office for Substance Abuse

Prevention within the Alcohol, Drug Abuse, and

Mental Health Administration of DHHS generally

agree that early adolescence spans the ages of 10 to

14. For the Division of Immunization, late adolescence begins at age 20; for the Office for Substance

Abuse Prevention, middle adolescence ends at age

17.

The reasons underlying Federal agencies’ choice

of definitions of adolescence (or lack thereof) are

diverse. In some instances, State and Federal law

require that adolescents of particular ages receive

services. Thus, for example, the Bureau of Maternal

and Child Health within the Health Resources and

Services Administration of DHHS bases its

definition of 10 to 19 years on Title V of the Social

Security Act, which authorizes the maternal and

child health block grant program.1 Other Federal

agencies, such as the Division of HIV/AIDS and the

Division of Reproductive Health within the Centers

for Disease Control, base their definitions of adolescence on their own practical experiences. The

Federal Highway Administration of the U.S. Department of Transportation defines middle adolescence

as ages 15 to 17 and late adolescence as ages 18 to

20, primarily because of the two age groups’

differing driving experiences (i.e., 15- to 17-yearolds are considered inexperienced drivers).

The use of differing definitions of adolescence by

Federal agencies is understandable and is not

necessarily indicative of a problem. As discussed in

Volume I, adolescence can be defined in physical,

psychological, or social terms. In any event, chronological age is not necessarily consistent with any

particular adolescent stage. Differing definitions of

adolescence may be troublesome, however, if Federal agencies should be coordinating their efforts, or

if some categories of adolescents (e.g., early adolescents, such as 10- and 11-year-olds) who should be

receiving attention from a particular agency are

excluded from their mission by definition.

Federal Programs and Expenditures

for Adolescents

Given the various definitions of adolescence used

by Federal agencies, and the way in which Federal

funds are spent and distributed at the national, State,

and local levels, determiningg the exact amount of

money the Federal Government spends on adolescents is impossible. Some Federal agencies serve

adolescents as part of a larger population group

receiving Federal funds, so their expenditures on

adolescents are unknown. The U.S. Consumer

Product Safety Commission and the U.S. Department of Agricultures Food and Nutrition Service,

for example, serve adolescents but do not have

specific funds set aside for them. In order to give

States greater control in planning, programmingg, and

spending for programs, some Federal funds are

distributed to States through block grants. Federal

block grant funding is provided for maternal and

child health services, social services, education, and

alcohol, drug abuse, and mental health services. The

provision of funding through block grant programs

limits the Federal Government’s ability to analyze

expenditures on services or programs targeted to

specific populations, such as adolescents.

Sometimes, Federal agency priorities are set by

the U.S. Congress. Recently, for example, congressional funding decisions have led DHHS to increase

its emphasis on activities related to the conseIflfock grants we SWIM of F~er~ funds allotted to State agencies (e.g., education, health) which maybe passed Onto local ageMieS. States det-e

the mix of services provided and the population served and are accountable to the Federal Government only to the extent tit funds are spent in accordance

with program requirements. Sometimes, however, set-asides are required for specitlc population groups.
Chapter 19--The Role of Federal Agencies in Adolescent Health ● III-225

quences of adolescent sexual intercourse and illicit

drug use. Activities related to the prevention and

control of other more prevalent conditions among

adolescents, such as injuries, have received relatively little emphasis.

Federal programs and expenditures targeting adolescents within DHHS and other selected Federal

agencies are discussed at greater length below. A

summary of estimated expenditures by the agencies

with the largest roles in adolescent health (broadly

defined) can be found in figure 19-1.

U.S. Department of Health and Human

Services: Programs and Expenditures for

Adolescents

Many DHHS agencies assist or have the potential

to assist adolescents through a wide range of social

services, health services, and welfare programs, as

well as through research and demonstration projects

(see figure 19-2). In terms of expenditures for

adolescents, however, the Office of Human Development Services and four agencies in the Public

Health Service-the Alcohol, Drug Abuse, and

Mental Health Administration, the Centers for

Disease Control, the Health Resources and Services

Administration, and the National Institutes of Health

—provide the bulk of adolescent services and programs (see table 19-3).2 Additional agencies within

DHHS, some of which are discussed below, support

activities that target or include adolescents.

Family Support Administration

The Family Support Administration of DHHS is

responsible for programs intended to strengthen the

American family. The Family Support Administration has six major programs, but the primary

program affecting adolescents is Aid to Families

With Dependent Children (AFDC).3

The AFDC program, established in 1935, is a cash

assistance program serving needy families with

children and is funded jointly by Federal and State

governments. States administer the program within

broad Federal guidelines, and the Federal Government provides quality control and compliance reviews. The fiscal year 1989 AFDC budget totaled

$17.245 billion (103).

To help families meet financial needs and become

self-sufficient, all States were required to implement

a Job Opportunity and Basic Skills (JOBS) training

program by October 1, 1990, under the Family

Support Act of 1988. The program gives families

receiving AFDC payments the opportunity to take

part in education, job training, and work experience

programs. As they do with AFDC, States have

flexibility to determine the types of services they

offer (59).

Under the Family Support Administration’s discretionary community service grants program, the

Office of Community Services provides an annual

grant to the National Collegiate Athletic Association

for the National Youth Sports Program, which is a

summer recreational program for adolescents from

low-income families (32).4 Hygiene and nutritional

information is presented as part of the program. In

fiscal year 1990, over $27 million was expected to

be awarded for new discretionary community service grants (55 FR 10297 ).5 Additionally, community

food and nutrition programs include adolescents as

part of their service group. Adolescents may also be

included as recipients under the emergency community services of the homeless grant program, which

distributes funds to 57 States and territories (60).

Under this program, States award all funds to

community agencies to meet the health needs (e.g.,

followup and long-term assistance and social services) of homeless individuals, including adolescents.

Health Care Financing Administration

One of the functions of the Health Care Financing

Administration of DHHS is to administer the Medicaid program. Medicaid was established in 1965

under Title XIX of the Social Security Act to assist

States in providing health care (e.g., inpatient and

outpatient medical services, family planning services, prenatal care) to the poor (80,81).

Within these agencies are specific programs having adolescents as a primary focus. These include tbe Division of Adolescent and School Health

within the Centers for Disease Control, the Bureau of Maternal and Child Health within the Health Resources and Services Admuu‘ “stratio~ and the

National Institute of Child Health and Human Development within the National Institutes of Health.

J~e o~er five pro- me Job Opportunity and Basic Skills (JOBS) Training, child support enforeemen~ refugee and entrant assistance,

community services block grant, and low-income home energy assistance (59).

d~o&m ~mt Progm is & cornmw@ scmices block grant program where grants are provided to States, territories, bdti ti&s, ~d ~M

organizations primarily for employment, educatio~ housing, health, and the poor.

- amount does not represent the amount being given to support continuation grants of past projects (103).
III-226 . Adolescent Health--Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Figure 19-1—Estimated Adolescent-Specific Expenditures by U.S. Executive Branch Agencies Responding to

OTA’s 1989 Survey (dollars are In millions)

NIAAA $6.1

NIMH $55.9 I

\/

CDC $61.4”

‘SAP ‘32”( \ / ?HCDA’HRSA$67”5’

I

.

A

\

f

“7 —ASPE

$0.250

/’”\ HCFA”

(Medicaid only)

$3,322

OESE $4,000’ OSERS $666

U.S. Department

of Educationg

S4,666

U.S. Department of n PHS

Health and Human Services = ADAMHA (In PHS)

$4,400.35 ~ Other DHHS

NOTE: Graphs are not drawn to scale. [differences in size are designed to provkie rough estimates of differences in adolescent-epedfic expenditures only.

~hefoilowing agencies within DHHSwere unable to provide OTAwith the amount spent on adolescents alone: Famity Support Adrninbtration, Sodal Security

Administration, Indian Health Service, National Institute on Drug Abuse (ADAMHA, PHS), Office of Treatment Improvement (ADAMHA, PHS), Nationai AIDS

Information Education Program (CDC, PHS), Office of Safety and Health (CCDPHP, CDC, PHS), Division of immunization (CPS, CDC, PHS), Division of

Tuberculosis Control (CPS, CDC, PHS), Office of Rural Health Policy (HRSA, PHS), Bureau of Maternal and Child Health (HRSA, PHS), Bureau of Health

Resources Development (HRSA, PHS), Office of Disease Prevention and Health Promotion (OASH, PHS), Office of Minority Health (OASH, PHS).

bThisfigureindudes $33.3 miilionspent bythe Division of Adolascentand School Health (CCDPHP),$O.45million spent bythe Diviskrnof Reproductive Heaith

(CCDPHP), $23.7 million spent by the [)ivision of STD/HtV Prevention (CPS), $0.525 miilion spent by the Division of HfVIAiDS (CID), $3.3 miliion spent by

Division of Injury Control (CEHiC), and $0.156 spent by the Division of Prevention Programs (CEHiC).
Chapter 19-The Role of Federal Agencies in Adolescent Health . III-227

U.S. Department

of Labor

$2,166.40

OJJDP $72.5 — NIJ $4.2

U.S. Department

of Justice

$76.70

/

CHAMP US /

o

U.S. Consumer

Product Safety

CommIssion

$17.30

\

\

‘\\

I

ES $90.3 — FNS $7.1h

,/

L“ U.S. Department

of Agriculture

U.S. Department

$97.40

of Defenee

$552.00

ACTION

$16.13

NHTSA O

U.S. Department

of Transportation’

$0.98

~his figure indudes expenditures by the Bureau of Health Care Delivery and Assistance only. Expenditures on adolescents by other subagencies (e.g., the

Bureau of Maternal and Child Health) vAthin HRSA were not provided to OTA.

dThisfigure indudes:$19.5 million spent by the National Cancer Institute, $0.148 million spent by the National Center for Nursing Research, $2.1 million spent

by the National Center for Research Resources, $15.4 million spent by the National Heart, Lung, and Blood Institute, $98.2 million spent by the National

Institute of Allergy and Infectious Diseases, $0.784 million spent by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, $25.1 million

spent by the National Institute of Child Health and Human Development, $26.6 million spent by the National Institute of Diabetes and Digestive and Kidney

Diseases, $1.3 million spent by the National Institute of Neurological Disorders and Stroke. All are estimates.

f3Note that the figure of &,322 million in~u~s ~th F+ral and State ~ntri~tions tO M~.&kf spending for ~Olescents. At OT/4’S request, HCFA OSti~tSd

the amount of Medicaid spending for adolescents in fiscal year 1988 (see app. C in this volume). However, HCFA did not calculate the Federal and State

shares separately. As discussed in ch. 16 in this volume, many factors could affect estimates of the State share.

fThis is a very rough estimate by OTA. The Office of Elementary and Secondary Education dispenses most of the funds that are spent by the U.S. Department

of Education. The Office has no specific line items for adolescents, because it distributes grants to schools and other organizations for various programs that

are not aimed at a particular age group. In 1989, the Office of Elementary and Sacmdary Education disbursed $6.6 billion for all activities. OTA’s estimate

is based on the assumption that 10-to 1 &year-oIds are attending grades 5 through 12, which constitute 66.6 percent of elementary and secondary grades,

not including kindergarten. Two-thirds of $6.6 billion is $4.4 billion. Since the percmtage of adolescents attending school is likely to be lower than the

percentage of younger children attending school, this estimate maybe too high. OTA estimates, therefore, that the Office of Elementary and Secondary

Education spends about $4 billion on education of adolescents. However, this estimate does not take into account that the cost of adolescents’ education

may be higher than that of younger students (e.g. more highly trained teachers, more sophisticated lab equipment).

9This figure does not indude spending by the following offices within the U.S. Department of Education that also serve adolescents: Office of Bilingual

Education and Minority Languages Affairs, Office of Planning, Budget, and Evaluation, Office of Postsecondary Education, Offica of Vocational and Adult

Education. These offices were not able to provide OTA with estimates of spending on adolescents.

hThis is a very rough estimate by OTA. The figure was tabulated by using the following percentages on how many adolescents were served in the respective

programs: 43percent of the participants in the National School Lunch Program are in grades 7through 12;24 percent of those in the School Breakfast Program

are in grades 7 through 12; 23 percent of those in the Summer Food Service Program are ages 13 to 18; 3 percent of those participating in the Supplemental

Food Program for women, Infants, and Children are pregnant, breastfeeding, or postpartum females underage 18; and 34 percent of participants in the Food

Stamp Program are between the ages of 15 and 17.

This figure does not include the Federal Highway Administration, which also serves adolescents.

SOURCE: Office of Technology Assessment, 1991, based on various responses to the Office of Technology Assessment’s 1989 questionnaire regarding

adolescent health initiatives, Washington, DC, 1989.
Figure 19-2—U.S. Department of Health

Secretar y

and Human Servicesa

—

Under Secretar y

chief of Staff ,

I

I I I 1 1 ———

Office of Human ~r

1 ’

Public Health I

Development Services ; Service

Administration:

-on Aging

-for ChiIdren, Youth,

and Families

-for Native Americans

-on Developmental

Disabilities

Office of Program

Coordination

and Review

Alcohol, Drug Abuse,

and Mental Health

Administration I

Food and Drug Admin. I

Centers for Disease I

Control I

Health Resources and

Services Admin.

Indian Health Service

National Institutes

of Health

Office of the Assistant ~ Secretary for Health

.J

..—

asgg texl ~werning April 1991 proposed reorganization.

.—.—.— —..

Health Care Financing

Administration

Office of Executiv e

Operation s

Office of the Associate

Administrator for:

-External Affairs

-Management and

Support Services

-Operations

-Policy

—.. ——

Social Security

Administration I

Office of:

-System s

-Field Operation s

-Hearings and Appeals I

-Operation Policy

and Procedures

-Assessment

-Management, Budget,

and Personnel

-The Actuar y

-Central Operations I 1

i -Pot ic y

~

I I

-— I

1.

‘ L . . L

Family Suppor t

Ad m i nitratio n

Office of :

-FamiIy Assistance

-Refugee

ResettIement I

1

~

-Child Support

Enforcement

I -Communit y

I Services

SOURCE: Based on U.S. Department of Health and Human Services, organizational chart, Washington, DC, 1990.
Chapter I9---The Role of Federal Agencies in Adolescent Health ● III-229

In fiscal year 1988, Federal and State spending on

Medicaid benefits was $48.4 billion, which includes

expenditures for adolescents.6 Adolescents ages 10

to 18 are eligible for Medicaid coverage if they meet

the requirements for AFDC, if they are deemed

‘‘medically needy” by their State, or if they meet

other conditions outlined by their particular State.

Therefore, which adolescents are eligible for Medicaid coverage varies a great deal from State to State.

In fiscal year 1988, 4.58 million adolescents between ages 10 and 18 made up 17.1 percent of all

Medicaid recipients; expenditures for adolescents in

fiscal year 1988 represented 6.9 percent or $3.32

billion of Federal and State Medicaid expenditures

(83).

Office of Human Development Services

The Office of Human Development Services of

DHHS is the primary social service agency with

programs for adolescents (see figure 19-3). In

addition to administering Social Security Act Title

XX social services block grants to the States,7 the

Office of Human Development Services supports

activities that affect adolescents through its Administration on Children, Youth, and Families. This

Administration provides Federal support for child

welfare services and supports runaway and homeless

youth centers.8 In 1989, the amendments to the Drug

Abuse Education and Prevention Act (Public Law

101-93) established and funded two new grant

programs under the Office of Human Development

Services for education and prevention efforts that

target runaway and homeless youth and members of

youth gangs.

The Office of Human Development Services’

Administration for Native Americans has supported

projects related to drug and alcohol abuse prevention

among Native Americans. The Office of Human

Development Services’ Administration on Developmental Disabilities supports the development and

coordination of programs for developmentally disabled persons, including adolescents. Recently, the

Office of Human Development Services has used a

portion of its discretionary money to support initiatives intended to help adolescents avoid alcohol and

drug use, complete high school, and postpone

pregnancy. In fiscal year 1989, the Office of Human

Development Services spent approximately 7.7

percent ($530 million) of its total budget of $6.82

billion on adolescents.

Public Health Service

As noted earlier, four agencies within the Public

Health Service of DHHS provide many of the

services and programs for adolescents: the Alcohol,

Drug Abuse, and Mental Health Administration, the

Centers for Disease Control, the Health Resources

and Services Administration, and the National

Institutes of Health.

Alcohol, Drug Abuse, and Mental Health Administration—Within the Alcohol, Drug Abuse, and

Mental Health Administration, five agencies fund

diverse activities concerning adolescents (see figure

19-4):

●

●

●

●

●

the National Institute on Alcohol Abuse and

Alcoholism,

the National Institute on Drug Abuse,

the Office for Substance Abuse Prevention,

the National Institute of Mental Health, and

the Office of Treatment Improvement.

1

Although the priority areas of the agencies within

the Alcohol, Drug Abuse, and Mental Health Administration address large societal problems (e.g.,

alcohol and drug abuse and mental health disorders),

the prevention and treatment of these problems

among adolescents is seen by the agencies as an

important goal.9

The National Institute on Alcohol Abuse and

Alcoholism, for example, has three priority areas

specific to adolescents: defining sociocultural factors that promote adolescents’ drinking, developing

and testing preventive interventions, and assessing

the impact of changes in the drinking age on alcohol

consumption (39,65). In fiscal year 1989, the National Institute on Alcohol Abuse and Alcoholism

cFor ~~ discussion of Medicaid, we cb. 16, ‘‘Financial Access to Health SeIViCeS,’ in this volume.

_lSemices suppofied by SWiaI sewices bl~k grants to States include protective and emergency s-icfX, employment ~u~tio~ and ~aining ~mic~

for disabled adolescents, foster care and adoption services, and health related services (e.g., prevention, intervention, inforrnatio% referral, and residential

care and treatment). Although service recipients may be of any age group, adokseents receive a si~lcant amount of these services (34).

8For ma discussion of ~ese centers, see ch. 14, ‘‘Hopelessness: Prevention and Semims, ’ in VO1. ~.

Zor a discussion of alcohol and drug abuse and mental health problems among adolescents, see ch. 12, “Alcohol, Tobacco and Dmg Abuse:

Prevention and Services, ” and ch. 11, “Mental Health Problems: Prevention and Services, ” in Vol. II.
lIl-230 . Adolescent Health-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Table 19-3-Components of the Expenditures on Adolescent Health by the U.S. Department

of Health and Human Services

DHHS agency with actual Estimated expenditures

or potential role in Total expenditures for adolescents Percent of expenditures

adolescent health (most current fiscal year) (most current fiscal year) for adolescents

ASSISTANT SECRETARY FOR PLANNING AND

EVALUATION

FAMILY SUPPORT ADMINISTRATION

HEALTH CARE FINANCING ADMINISTRATION

OFFICE OF HUMAN DEVELOPMENT SERVICES

PUBLIC HEALTH SERVICE

Alcohol, Drug Abuse, and Mental Health Administration

● National Institute on Alcohol Abuse and Alcoholism

. National Institute on Drug Abuse

. National Institute of Mental Health

● Office for Substance Abuse Prevention

● Office for Treatment Improvement

Centers for Disease Control

. Center for Chronic Disease Prevention and

Health Promotion

—Division of Adolescent and School Health

—Division of Reproductive Health

~-Office on Smoking and Health

● Center for Environmental Health and Injury Control

—Division of Injury Control

—Disabilities Prevention Program

● Center for Infectious Diseases

—Division of HIV/AIDS

● Center for Prevention Services

—Division of Sexually Transmitted Diseases and

HIV Prevention

—Division of Immunization

—Division of Tuberculosis Control

. National AIDS Information and Education Programg

$12,000,000 (1989)8

Not provided

$118,200,000,000 (1988)

$6,817,162,000 (1989)’

Not provided

$2,700,000,000 (1990)

$125,200,000 (1989)

$379,000,000 (1990)

$454,604,000 (1989)

$193,000,000 (1990)

$1,268,700,000 (1990)d

$978,781,000 (1989)

Not provided

$33,300,000 (1989)

Not provided

Not provided

Not provided

$21,800,000 (1989)C

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

$250,000 (1989)

Not provided

$3,322,000,000 b

$530,000,000 (1989)

Not provided

Not provided

$6,138,353 (1989)

Not provided

$55,947,000 (1989)

$32,800,000 (1990)

Not provided

$61,416,000 (1989)0

Not provided

$33,300,000 (1989)

$450,000 (1989)

Not provided

Not provided

$3,270,000 (1989)cg

$158,000 (1989)

Not provided

$525,000 (1989)

Not provided

$23,713,200 (1989)

Not provided

Not provided

Not specified

2 percent

Not provided

Not provided

7.7 percent

Not provided

Not provided

4.9 percent

Not provided

12 percent

17 percentc

Not provided

6.2 percent

Not provided

100 percent

10 percentf

Not provided

Not provided

15 percentc

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

Not provided

Not available

aAn addition~ $2 million is aikwated every 2 years to the Institute for Research on Poverty (36). The money is appropriated from Congress to the Institute

through the Assistant Secretary for Planning and Evaluation.

bFigure shorn is the ~mpfilon of Medic~d funding direet~ to a~l~~nts on~, ~ mi~lat~ for the Offi@ of Technology Assessment by the Health Cz3re

Finanang Administration. The figure includes both State and Federal Medicaid spending. For further discussion of Medicaid, see eh. 16, “Financial Aet.wss

to Health Serviees,” in this volume.

cEstimated amount.

dEighty.nine percent ($1.1 w billion) of these funds are distributed to States $s block 9rant$.

eA~l=~nt e~Penditure total in~u~s on& those ~nters for Di~a~ control agen~es pmvtiing this information in response to the Off iCe of Technology

Assessment’s survey. Severai surveyed agencies did not provide adolescent-specifie data, and the National AIDS Information and Education Program cmuld

not calculate an amount directed at adolescents.

fTen percent of the Division’s staff time is being devoted to evaluation or analysis of adolescent data.

9No budget line item specific to adolescents.

h,,Not spWifi~*? indi~te~ that ~ole~ont~ are i~lud~ ~ part of a larger target group. Thus, expenditures cannot be separated Od for that pafliCU[ar

group.

spent over $6 million (under 5 percent) of its overall intervention efforts and the impact of parentingbudget on activities aimed at adolescents. Current skills training (65,68). Other efforts address the

activities focus on adolescent risk-taking and alco- causes, consequences, and treatment of alcohol use

hol abuse, the effects of parental and family influ- (68).10

ences, peer pressure, decisionmaking skills, and The National Institute on Drug Abuse studied the

personality variables on high school and college causes, consequences, and treatment of adolescent

students’ drinking habits as well as preventive drug abuse throughout the 1980s and funded over

l~e Nati~~ ~ti~te on A]cohol ,4b~e ~d ~cohol~ r~ntly ~o~ced its bt~est in funding an AdolewetM Alcohol Research Center which

would integrate idendfhtion of interactions between adolescent development and alcohol use and testing behavioral and other technologies t

alcohol problems. Any non-Federal public or private nonprofit organization could request up to $1.5 million to be awarded annually for 5 years (66).

The stming date of the Center would be Dec. 1, 1990. Additionally, in 1988, the National Institute on Alcohol Abuse and Alcoholism announced

interest in studying norm-setting related to alcohol use by parents and families, physicians and their staff, youth peer groups, schools, and co

organiza tions, but did not allocate spec]tlc funds to this activity (64).
Chapter I9 The Role of Federal Agencies in Adolescent Health ● ///-231

Table 19-3-Components of the Expenditures on Adolescent Health by the U.S. Department

of Health and Human Services-Continued

DHHS agency with actual Estimated expenditures

or potential role in Total expenditures for adolescents Percent of expenditures

adolescent health (most current fiscal year) (most current fiscal year) for adolescents

Health Resources and Services Administration Not provided Not provided Not provided

● Office of Rural Health Policy $1,400,000 (1988) Not available Not provided

. Bureau of Health Care Delivery and Assistance’ $397,058,800 (1989)’ $67,500,000 (1989}j

17 percent

● Bureau of Maternal and Child Health and Not provided Not provided Not provided

Resources Development

Office of Maternal and Child Healthk

$573,848,000 (1989)l Not available Not provided

Indian Health Servicem$1 ,020,106,000(1 989) Not specified Not available

National Institutes of Healthn

$7,144,764,000 (1989) Not provided Not provided

. National Cancer Institute $1,468,435,000 (1988) $19,490,000 (1988) 1.3 percent

● National Center for Nursing Research $23,361,000 (1988) $148,000 (1988) 0.6 percent

. National Center for Research Resources $344,150,000 (1988) $2,054,000 (1988) 0.6 percent

● National Heart, Lung, and Blood Institute $965,283,000 (1988) $15,464,000 (1988) 1.6 percent

. National Institute of Allergy and Infectious $638,521,000 (1988) $98,150,000 (1988) 15 percent

Diseases

. National Institute of Arthritis and Musculoskeletal $147,543,000 (1988) $754,000 (1988) 0.5 percent

and Skin Diseases

● National Institute of Child Health and Human $377,167,000 (1988) $25,093,000 (1988) 6.6 percent

Development

● National Institute of Diabetes and Digestive and $534,400,000 (1988) $26,600,000 (1988) 5 percent

Kidney Diseases

● National Institute of Neurological and $458,792,000 (1988) $1,327,000 (1988) 0.3 percent

Communicative Disorders and Strokep

Office of the Assistant Secretary for Health

● Office of Disease Prevention and Health Promotion $4,900,000 (1989) Not provided Not provided

● Office of Minority Health $8,000,000 (1990) Not provided Not provided

● Office of Population Affairsq

$139,928,205 (1989) $54,572,000 (1989) 39 percent

SOCIAL SECURITY ADMINISTRATION Not provided Not provided Not provided

These data were obtained from R. Abrams, Bureau of Health Care Delivery and Assistance (l).

JAlthough specific funding is not available for adolescent initiatives, the adolescent-speeifie amount is based on the average number of adolescent medical

visits in community/migrant health center programs during 1988.

kFollWing OTAfS survey in 1 g8g, the Bureau of Maternal and Child Health and Resour@s Development spJit into the Bureau of Maternal and Child Health,

formerly the office of Maternal and Child Health, and the Bureau of Health Resources Development (see fig. 19-1). Responses were reeeivedfromthe original

Bureau.

IAppro~imately 80 percent of these funds are distributed to states as bl~k 9rants.

~hese data were obtained from G. Brenneman, Indian Health Servke (11) and J.M. Lyle, Indian Health Service (23).

nThe NIH total includes all NIH agencies, not just those able to estimate expenditures on adolescent health initiatives. The 1989 estimate for expenditures is

from the Budget of the U.S. Government (102a).

OThese data were obtained from D. Levenson, National Institute of Child Health and Human Development (21).

Pln 1990, the National Institute of Neurological and Communicative Disorders and Stroke split into two separate institutes: 1) the National Institute of

Neurological Disorders and Stroke, and 2) the National Institute on Deafness and Other Communication Disorders.

qThese data were obtained from R. Scholle, Office of Population Affairs (37).

SOURCE: Office of Technology Assessment, 1991, based on Federal agency responsas to the Office of Technology Assessment’s 1989 questionnaire

regarding adolescent health initiatives.

160 projects for 7- to 17-year-olds (68,70,73-75).11

In fiscal year 1990, appropriations for the National

Institute on Drug Abuse were $379 million (71).

Information on the proportion being spent on

adolescents was not available. Recently, the National Institute on Drug Abuse, in conjunction with

the U.S. Department of Education, released a

program announcement encouraging organizations

to study innovative and theory-based drug abuse

prevention programs in the schools or to evaluate

currently ongoing school-based programs. Additionally, the National Institute on Drug Abuse is

interested in granting money to a minority drug

abuse prevention research center targeting high-risk

children, adolescents, and young adults (74). Organizations can request support for up to 5 years.

First-year awards were to be for $600,000, and

$750,000 for each subsequent year.

Under the authority of the Anti-Drug Abuse Acts

of 1986 and 1988 (Public Laws 99-570 and 100-

1 l~e Natio~ ~timte on mug Abuse’s overall priorities, mandated by Congress, for Ilscal year 1991 are acquired iInmunOdefiCienCy syntiome

(AIDS) prevention improving drug abuse treatment and preventio~ and studying matemal drug abuse and its effect on children.
III-232 . Adolescent Health—-Volume Ill: Crosscutting issues in the Delivery of Health and Related Services

Figure 19-3-U.S. Department of Health and Human Services, Office of Human Development Servicesa

~-—

- ‘3 Assistant Secretary

.- —

I I I I 1

,

PoIicy,

[ ----- -

PIanning

and Legislation I

~ Managemen t

I S e r vices

I I

I

Ad m i n Is t rat i on

on Aging

IncIudes:

Management and

Policy Office

Pro g r a m

Development

State and

Communit y

Pro grams

I

Administration for

ChiIdren, Youth,

and FamiIies

IncIudes:

Head Start

Bureau

ChiIdren’s

----1-. ----

President’s Committe e

on Mental Retardation 1

1’ , —

Administration o n

D eve 10 p men t al

DisabiIities

Bureau ~ Administration for

FamiIies and Youth NatIve Americans

Services Bureau

a%e text concerning April 1991 proposed rwrganization.

SOURCE: Federal Organization Servix: Civil(Washington DC: Carroll Publishing Co., February/March 1990).

690), the Office for Substance Abuse Prevention’s

general priority areas for the May 1989 review cycle

(this includes fiscal year 1989 and the beginning of

fiscal year 1990) were high-risk youth, pregnant and

postpartum women and children, community youth

activities, and a community partnership prevention

program.

12 Office for Substance Abuse Prevention

grants are designed to identify promising strategies

for working with youth who are at high risk for

alcohol and other drug use.

13 Forty-five percent

($5.6 million) of the high-risk youth grants focus on

adolescents ages 12 to 20, and approximately 39

percent ($5.9 million) of the community youth

activities grants focus on adolescents who are at risk

of dropping out of school or being involved with

gangs. The Office for Substance Abuse Prevention’s

budget increased substantially from about $69

million in fiscal year 1989 to $193 million in fiscal

year 1990 (79).

The National Institute of Mental Health has

several programs with an interest in adolescents.

Two of the immediate goals of the National Institute

of Mental Health’s Division of Clinical Research are

to address all of the major mental disorders of

adolescents, such as affective and anxiety disorders,

youth suicide, learning disorders, and mental illness/

mental retardation, and to increase studies on the

effectiveness of treatment, particularly in the area of

adolescent depression. The Division also wants to

expand the availability of manpower in the area of

research on adolescent disorders by expanding

research training and research career development

support. 14 The National Institute of Mental Health’s

Child and Adolescent Service System Program

(CASSP) under the Division of Applied and Services Research (formerly the Division of Education

and Service Systems Liaison) tries to improve

systems for service delivery to severely emotionally

disturbed adolescents under age 18 by changing the

way communities and States deliver services (e.g.,

improving the availability of continuums of care and

involving parents and families) (76,78).15 In 1989,

lz~e office for subs~ce Abuse Prwmtion funds only demonstration projects. Individuals interested in research projects are encouraged to apply

to other agencies.

130ne offiW for Subs@@ Abu~ pr,~vention prom, tie comm~ty P~e~hip progr~ attempts to bring together ~ the knowledge gained from

grant programs focused on individual target groups and apply this knowledge systematically to entire communities using public/private partnerships.

Approximately $50 million was proposed in fiscal year 1990 for grants to 150 to 200 communities.

14~e ~tisW1~ ~d Violent Be~vi(~r B~ch of ~eDivision of Biometry ad Applied Sciaces has S.S a researchpriority the prevention of antisocial

and highly aggressive behavior in childhood and adolescence. The Division of Education and Semice Systems Liaison priorities included State-level

service system development and service delivery to all children and adolescents.

lsDemom~tion projw~~derCA$;SParetided~d~ four *S of ~ts: cqmity building, State and community-level SySkIrl development,

and strategy evaluation grants (77). IrI fiscal year 1989,$200,000 was available for 4 State capacity building projects, $2 million for 12 new State- and

community-level projects, $300,000 for 10 Nate-level strategy evaluation grants, $1.3 million for 8 renewal projects, and $900,000 for 31 strategy

evaluation supplements. No guarantee was available for funding beyond the fust yea (77).
Chapter 19--The Role of Federal Agencies in Adolescent Health . III-233

Figure 19-4--U.S. Department of Health and Human Services, Public Health Service,

Alcohol, Drug Abuse, and Mental Health Administration

Associate Administrator

-

-1- 1

Office of the

for Prevention Administrator

i;

Science Adviso r

I

1

1 -- I

~ 1 -

1

[-‘

I

I Off ice of Office of Office f o r

Extramural Management Treat men t

Pro grams Improvement

r— I - ‘- 11

National Institut e

National Institute National Institut e

Office for

on Alcohol Abuse on Drug Abuse of Mental Health Substance Abus e

and Alcoholism Prevent i o n

l-- ––- -- I . -- [ I

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, Rti”lle, MD,

organizational chart, 1990.

CASSP projects were in 42 States and 11 localities

for a total of $9.8 million, of which $1 million was

targeted to services research for the homeless (78).

Finally, the new Office for Treatment Improvement within the Alcohol, Drug Abuse, and Mental

Health Administration is responsible for improving

the quality of treatment services for individuals

suffering from drug abuse and other problems, such

as alcoholism and physical and mental illness (72).

The Office for Treatment Improvement administers

alcohol, drug abuse, and mental health services

block grants to States for application in the areas of

mental health and substance abuse. In fiscal year

1990, Congress appropriated $1.133 billion for such

block grants, $237.5 million for use in mental health

and $895.6 million for use in substance abuse (17).

Fiscal year 1990 appropriations for the Office for

Treatment Improvement, apart from block grant

funding, were $135.7 million. The Office is funding

a grant demonstration program which targets three

critical populations: adolescents, racial and ethnic

minorities, and residents of public housing projects.

The projects in this program are Model Comprehensive Treatment Programs for Critical Populations

($25 million in funding in 1990), cooperative

Agreements for Drug Abuse Treatment Improvement Projects in Target Cities ($28 million in

funding in 1990), and Model Drug Abuse Treatment

Programs for Non-Incarcerated Criminal Justice

Populations ($8 million in funding in 1990) (6).

Centers for Disease Control—Within the Centers for Disease Control, numerous programs, particularly the Division of Adolescent and School Health

within the Center for Chronic Disease Prevention

and Health Promotion, respond to various health

needs of adolescents (see figure 19-5).16 The Centers

for Disease Control agencies responding to OTA’s

survey

17 indicated that for fiscal year 1989, approximately $61 million was targeted specifically for

16~g1~y, tie Division of ~olexent and Schml Heal~ was the Office of School Health and sp~lal ~OJeCK whose mission was to develop a

national school health program for the prevention of human immunodeficiency virus (HIV)/AIDS. In October 1988, the Center for Chronic Disease

Prevention and Health Promotion was created, and the OffIce of School Health and Special Projects was elevated to become the Division of Adolescent

and School Health.

lTCaters for Dis~ Control agencies that responded to OTA’S questio nnaire included the Center for Chronic Disease Prevention and Health

Promotion, Center for Environmental Health and Injury Control, Center for Infectious Diseases, Center for Prevention Sewices, and the Deputy Director,

HIV.
III-234 ● Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

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Chapter 19--The Role of Federal Agencies in Adolescent Health . III-235

adolescents, representing about 6 percent of the

Centers for Disease Control’s total budget.18

Major adolescent-health related programs administered by the Centers for Disease Control include

the following:

●

●

●

●

●

●

●

●

●

the Youth Risk Behavior Surveillance System

that provides national, State, and local data

about the incidence and prevalence of risk

behaviors (e.g., behaviors resulting in unintentional injuries, human immunodeficiency virus

(HIV) infection and other sexually transmitted

diseases (STDs), alcohol and drug use, tobacco

use, improper diet, and insufficient physical

activity) among students in 9th to 12th grade;

reimmunization programs for the prevention of

measles, mumps, and rubella in junior high and

high school students;

initiatives for injury prevention and control;

activities to prevent or minimize complications

for adolescents with diabetes;

water fluoridation activities (not limited to

adolescents);

funding of the Southwest Center for Prevention

Research at the University of Texas at Houston,

focusing on the physical and psychological

health of children and adolescents;

support for the 1987 National Adolescent

Student Health Survey, which assessed 8th and

10th grade students’ knowledge, attitudes, and

behaviors related to health (e.g., nutrition,

alcohol and tobacco use, STDs, injury prevention, suicide, violence) (5);19

National Health and Nutrition Examination

Survey and the National Health Interview

Survey, which incorporate nutrition and health

data on adolescents (18);

cooperative agreements with national, State,

and local education agencies to implement HIV

education for in- and out-of-school adolescents;

●

●

●

adolescent health data collection by the National Center for Health Statistics;

HIV seroprevalence surveys to determine the

magnitude of infection within the adolescent

population; and

the phase of the ‘America Responds to AIDS

multimedia campaign targeting parents and

youth.

The Centers for Disease Control appears to be

spending most of its adolescent health-related money

addressing health problems associated with sexual

intercourse (e.g., pregnancy and the transmission of

HIV and STDs). For example, although the mission

of the Division of Adolescent and School Health is

to identify, monitor the prevalence of, and implement interventions to reduce health risks20 

among

adolescents, most of the Division’s funding has been

provided to prevent HIV infection. Therefore, its

current priority area is to help schools develop

effective educational programs to prevent the spread

of HIV. On the other hand, in 1989 the Division of

Injury Control within the Centers for Disease

Control’s Center for Environmental Health and

Injury Control was allocated much less money, only

$3.27 million (approximately 15 percent of the

Centers for Disease Control’s injury budget), for the

prevention and control of injuries among adolescents (e.g., youth suicide, homicide, and motorvehicle related injuries), by far the largest killer of

adolescents (24).

Health Resources and Services Administration—

The Bureau of Maternal and Child Health (formerly

the Office of Maternal and Child Health21), within

the Health Resources and Services Administration,

administers the maternal and child health block

grant program authorized by Title V of the Social

Security Act (see figure 19-6).22 Eighty-five percent

of the $526.6 million appropriation for the program

in fiscal year 1988 was allocated to States for

18~OPfion iS ~d~~y on thOSe agencies ~~he Centms for D~~e Control responding to OTA’S survey. These ~ the Division of ~V/~S,

Division of Adolescent and School HealtlL Division of Reproductive HealtiL Division of Injury Control, Disabilities Prevention Program, and the

Division of Sexually Transmi tted Diseases and HIV Prevention. Several surveyed agencies did not provide adolescent-specitlc data.

l~e Natio~ Adolewent Smdent He~th survq w= support~ by the HIu of D~eme prevention and Health Promotion within the Office of the

Assistant Secretary of Heal@ with additional support from the Centers for Disease Control and the National Institute on Drug Abuse within the Alcohol,

Drug Abuse, and Mentat Health Administration.

XIfionv fisks ~hose ~~vior~ r6~@ ~ ~tention~ ad ~tentio~ ~fi~, ~~hol ~d drug abuse, tOIMUO u*, improper diet, insufficient

physical activity, and HIV infection and other STDS.

zl~ my 1990, the Bureau of ~te~ ~d child H4th and Resources Development split into *O bUrMUS: the BWMU of ~te~ ~~d ‘~ti

and the Bureau of Health Resources Development. When expenditures made prior to May 1990 are discussed here, the term ‘‘Office’ will be used.

%Mablished in 1987, the Health Resources and Services Administration’s OffIce of Ruml Health Policy’s role in rural adolescent health has been

limited. The OffIce targeted adolescent suicide, pregnancy, and lack of access for health and mental health services in its Work Group on Health Semices

of the National Advisory Committee on Rural Health.
III-236 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Figure 19-6--U.S. Department of Health and Human Services, Public Health Service,

Health Resources and Services Administration

Office of the

Administrator

I

Office of I

RuraI HeaIth -

PoIicy i

L—

Office of

PoIicy

Coordination

,. 1

Office of

Operation and ~

Man age men t

l - -

Bureau of

Maternal and

Child Health

—

➤ ✍✍ ✍✍ -1

Bureau of

Health Resources

Development t

~....-.

-—

~ ---

Office of Equa l

Opportunity an d

Civil Right s

1

Office o f

C o m m u n i cation

— 1

Office of Planning,

Evaluation, and

Leg is I at i o n

I 1

Bureau of I

Heal t h ~ Professions ~

I

Bureau of Health

Care Deliver y

and Assistanc e

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, organizational chart, no

date.

programs to improve the health status of mothers

and children, especially those with low incomes and

living in areas with limited availability of health

services (85).23 24 Approximately 21 States have a

designated adolescent health care coordinator (16,

26).

25 26

Fifteen percent of the $526.6 million appropriation for the maternal and child health block grant

program in fiscal year 1988 was set aside to support

Special Projects of Regional and National Significance (SPRANS) (86).27 In fiscal year 1988, 57

projects addressed the health needs of adolescents

and children in various areas (e.g., research, training,

genetics, hemophilia) (86). Twenty-three of these

projects dealt specifically with injury prevention. In

1989,36 projects28 included adolescents specifically

or as part of a larger group (26). Although no new

projects targeting adolescents were begun in fiscal

~~ese Stite ~OBamS are sometimes called the Consolidated State Programs (86).

~~ fiw~ ya 1987, States transferred over 30 percent of their maternal and child health block grant funds to 10cxd hat.h departments (31).

zs~omtion on tie Pmwfion of Tifle v wte~ and child health services allocated spec~lcally to adolescents is not av~lable.

%~e 21 me ~ou Colorado, connmticu~ Dis~ct of Columb@ Delaw~e, ~ori@ ~wti, Iowa, In&~ N@swhusetts, Maine, Mktigq

Mississippi, Minnesota, New Hampshire, Ohio, Oklahoma, Oregoq South Carol@ Washington and Wisconsin (26). Preliminary survey results

indicate that two or three more States may have such a coordinator (16). It is unclear how States are paying for adolescent health care coordinator

positions. Because the position is typically located within a State’s Off7ce of Maternal and Child Hedt@ it may be that many, if not mos~ States are

funding the position with block grant f“imds (16).

~~ese projects me sometimes called Comolidated Ftitd ~ogrllms (86).

zs~ time Pmj=ts, 23 were demo~~ation projects, 7 were research related, and 6 were _projects (26).
Chapter 19-The Role of Federal Agencies in Adolescent Health . III-237

year 1990, approximately three new projects were

scheduled to begin in fiscal year 1991 (16).

The Health Resources and Services Administration’s Bureau of Health Care Delivery and Assistance supports the provision of primary health care

services to medically underserved populations by

providing Federal finds for community and migrant

health centers, as well as for comprehensive perinatal care programs for low-income women and

children, health care for the homeless programs, and

health care for substance abusers. In 1989, 814,000

adolescents received medical care in the community

and migrant health centers; of these adolescents

117,000 females ages 10 to 14 received family

pl anning services.

29 At least 121,000 adolescents

received dental care. During 1988, the comprehensive perinatal care programs provided perinatal

services to 6 percent of all U.S. pregnant adolescents

under age 20 and to 29 percent of pregnant adolescents 15 years of age and under (l).

Indian Health Service---The Indian Health Care

Improvement Act of 1976 (Public Law 94-437) gave

funding to the Indian Health Service for a 7-year

period to elevate the health status of American

Indians and Alaska Natives. Recently, amendments

(Public Law 100-713) to the Indian Health Care

Improvement Act were passed that extended this

funding. In fiscal year 1989, the Indian Health

Service spent over $1.02 billion on health services

(primarily clinical care for acute and chronic physical problems) to assist American Indians and Alaska

Natives. No specific funds of the agency are allotted

for adolescents, so it is difficult to assess the amount

spent by the Indian Health Service on health care for

adolescents.

In 1989, the Indian Health Service conducted an

Adolescent Health Survey to obtain a database on

adolescents for use in local programs. The Alcohol

and Substance Abuse Programs Branch of the Indian

Health Service funds three regional adolescent

treatment centers for substance abuse, which cost a

total of $2.4 million per year. The Indian Health

Service also helps to support adolescent health

centers in or near four schools in the Albuquerque,

New Mexico area (44a).

In fiscal year 1989, the Indian Health Service

targeted Indian adolescents as a priority group for

prevention efforts, planning to specifically emphasize prevention of teen pregnancy, alcohol/

substance abuse, mental health, violence, and suicide. However, only 7 percent of the total Indian

Health Service budget was devoted to preventive

health in fiscal year 1988 (44a).

National Institutes of Health—In fiscal year

1989, the various institutes and divisions of the

National Institutes of Health spent $7.1 billion (8) to

fulfill their mission of improving the health of

individuals through advancement of the state of

knowledge in biomedical science and health care

(see figure 19-7).

Within the National Institutes of Health, the

National Institute of Child Health and Human

Development, established in 1963, is the institute

most identified with behavioral and biomedical

research on adolescent development (e.g., cognitive,

emotional, and social development) and with research on reproduction, sexual behavior, the effects

of nutrition on development, and patterns of adolescents’ interaction with family, peers, and school (see

table 19-4).30

In fiscal year 1988, the National Institute of Child

Health and Human Development funded 147 projects (21). Between fiscal years 1980 and 1990,

however, approximately 7 percent of the National

Institute of Child Health and Human Development

budget was spent on research specific to adolescents

(see table 19-3). In fiscal year 1990, the Institute

estimated that $25.5 million will be spent on

adolescents, focusing on the physiological, psychological, endocrinological aspects of puberty,31 the

nutritional needs of adolescents, adolescent pregnancy, and acquired immunodeficiency syndrome

(AIDS) (21). As does the Division of Adolescent and

School Health in the Centers for Disease Control, the

National Institute of Child Health and Human

Development places heavy emphasis on research

dealing with adolescent sexual behavior and its

consequences (see table 19-4).

Eight other institutes within the National Institutes of Health sponsor research that pertains to

2~e Bumu of H~al~ c~~ @livev ad ASSiS~Ce does not co~~t dam on usage of comm~(y and II@WIt health centers by adolescents, ages

15 to 19. Data on this age group was collected eight years ago, but since tha it has been discontinued.

me National Institute of Child Health and Human Development does not deliver semices to adolescents.

slEndocfiolo@c~ aspect.s of puberty are those related to the functions of the endoaine glands (e.g., thyroid or pitUitary gl~d).
Figure 19-7—U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health

r

Nat

~ Office of the Director I

National Institute [National Institute on

of Child Health ] Deafness and Othe r

1,

and Human I Cornmunication i

L‘

eve’ O”men!L

~<

National Eye

Institut e !

. . ,-

Division o f

~ C o m p u te r Res e a rc h ~

I a n d Tech no 10 g y ,

(

Clinical

I Cente r

Disorders ;

National Institut e Ii

National Institut e

of Denta l

of Diabetes and

\

Research ~

Digestive and

Kidney Disease

(- )

(

\

National Institute I National H cart,

~ o f G e n era 1 M e d i c a I I Lung, and Bloo d

Scienices I n st i t u te

I

‘. . . —.

National Library

of Medicine

—— ~ ..— — .

I

1 Division of National Cente r

I Research for Research

I Grants Resources I

I

~

Fog art y ~

1

National Center

Inter national 1 for Human

Cente r

I Genome Researc h

‘~ (

II National Institut e

1

,, 0 f E n v iron me n ta I ~

~ Health Science s

J~J’

I National lnstitut e

of Neurological

, Disorders & Stroke

I Division of

Research I

Service s I

I National Center ,

for Nursing I

Research :

SOURCE: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, organizational chart, Bethesda, MD, no date.
Table 19-4-Adolescent Research Priority Areas of the Components of the National Institutes of Health

NIH agency Adolescent research priority areas Selected adolescent project descriptions

National Cancer Institute

National Center for Nursing Research

National Center for Research Resources

National Eye Institute

National Heart, Lung, and Blood Institute

National Institute of Allergy and Infectious

Diseases

Cancer prevention and control, improving the health of

minorities and the underserved, and increasing patient

accrual to clinical trials.

Nursing care of prospective mothers at risk of having low

birth-weight babies, focusing on preventing pregnancy

complications and care of low birth-weight babies. Prevention and physiological/psychosocial factors relating to the

care of individuals with human immunodeficiency virus

(HIV) infection and acquired immunodeficiency syndrome

(AIDS).

Does not set priorities in specific research areas as do the

other institutes. The Center ensures availability of resources to the NIH community.

Research is not specifically targeted to adolescents.

Risk factors for cardiovascular disease, particularly hypertension, smoking, and blood cholesterol levels. Programs for

adolescents with cystic fibrosis and sickle cell anemia

Sexually transmitted diseases (STDs), AIDS, type I diabetes

mellitus, asthma and allergy, chronic granulomatous disease.

Smoking cessation interventions (e.g., school-based intervention research studies and a public information campaign to

prevent adolescents from racial and ethnic minority groups

from using tobacco); influence of smoking and drinking by

families on Hispanic youth; adolescent v. adult diets on

breast cancer risk; association of adolescent alcohol

consumption, oral contraceptive use, dietary patterns,

hormonal levels with breast cancer risk; school-based

nutrition education project; adolescents’ risk of developing

Leukemia; therapies for sarcomas; improving the survival of

adolescent cancer patients through clinical studies by

expanding eligibility criteria; improving adolescent cancer

patients’ psychological well-being (e.g., stress reduction,

increasing school attendance).

Causes, consequences, and patterns of loneliness during

adolescence; personality and environmental aspects of

health compromising behaviors (e.g., cigarette smoking,

drug and alcohol use, early sexual activity, eating behaviors, and excessive caffeine consumption) among young

adolescents; improving communication within families of

early adolescents using parenting styles and knowledge

about adolescent and adult growth and development.

Hormonal aspects of growth and sexual maturation, psychosocial aspects of adolescence (e.g., effects of the government school breakfast program v. short-term fasting on

adolescent cognition, behavior, and exercise; depression

in adolescent males focusing on endocrine responses),

diabetes and obesity (i.e., appropriate insulin levels), renal

disease, urethritis, adolescent development using nonhuman primates, role of ethnicity in adolescent identity

development, relationship of depression in children and

adolescents, treatment program for adolescent substance

abusers, aggressive conduct disorder, street youths’ knowl -

edge and attitudes toward AIDS prevention, history of

immunization as a predictor of measles.

Not provided

Not provided

Vaccine development for chlamydia, gonorrhea, syphilis, and

herpes simplex virus type 2; diagnostic and therapeutic

approaches for pelvic inflammatory disease and understanding the natural history of human papillomavirus;

various aspects (e.g., epidemiologic and clinical) of individuals with AlDS, including prevention and treatment; mechanisms in the development of type I diabetes mellitus and

chronic granulomatous disease; Self-Management of Asthma

Educational Programs.

Continued on next page
Table 19-4-Adolescent Research Priority Areas of the Components of the National Institutes of Health-Continued

NIH agency Adolescent research priority areas Selected adolescent project descriptions

National Institute of Arthritis and Systemic lupus erythematosus, particularly in minority populaMusculoskeletal and Skin Diseases tions, Lyme disease, juvenile arthritis, and osteoporosis

(i.e., impact of diet and exercise during adolescence).

National Institute of

Human Development

Child Health and Physiological, psychological, and social consequences of

adolescent pregnancy for mothers, their children, and

other family members; endocrinological aspects of puberty, nutritional needs of the adolescent, and adolescent

AIDS.

National Institute of Diabetes and

Digestive and Kidney Diseases

National Institute of Neurological

Disorders and Stroke

Not planning specific initiatives on adolescent health.

Head and spinal cord injury, stroke, juvenile epilepsy, lipid

storage diseases, Tourette’s syndrome, muscular dystrophies, autism, ataxias, Batten Disease, Reye’s syndrome,

tuberous sclerosis, learning disorders/attention deficit disorders, Charot-Marie-Tooth syndrome, spinal muscular

atrophies, juvenile myasthenia gravis, neurofibromatosesPain treatment for adolescents with juvenile arthritis; psychological effects of pain on adolescents with juvenile arthritis;

risk factors (e.g., diet, exercise, scoliosis development)

during adolescence for the onset of osteoporosis .

New contraceptives development (e.g., skin patch, implanted

drug delivery system); preventing sexually transmitted

diseases; understanding the transmission of HIV and its

natural history in mothers and their children to prevent

AIDS as well as developing age-appropriate educational

strategies; investigation of the molecular basis for normal

and abnormal male development and reproduction; role of

genetics and environment (e.g., early family experiences)

in development; female reproductive cycle disorders (e.g.,

pelvic inflammatory disease, severe premenstrual syndrome, interrelationship of nutrition and exercise with

ovulation); sexual behavior and contraceptive use for

contraception and disease prevention among adolescent

females and their partners; consequences of adolescent

childbearing; relationship between sexually transmitted

diseases, including AIDS, and fertility-related behavior.

Treatment of diseases (e.g., juvenile diabetes (insulindependent diabetes), cystic fibrosis, juvenile liver disease,

inflammatory bowel disease, Cooley’s and sickle cell

anemia, hemophilia and growth abnormalities) often diagnosed and treated initially during adolescence.

Incidence and duration of loss of consciousness in newly

injured patients; natural history of adolescents following

first epileptic seizure and risk factors for reoccurrence;

development of skills (e.g., gestures) in developmentally

disordered adolescents.

SOURCE: U.S. Department of Health and Human services, Public Health Service, National Institutes of Health, unpublished data cwovided in rewonss to the Office of Technology Assessment’s

questionnaire regading adolesmnt health initiatives, 1989.

-.
Chapter 19--The Role of Federal Agencies in Adolescent Health .111-241

adolescent health. In general, their emphasis tends

not to be related to adolescent sexual behavior but on

various aspects of specific diseases. Although it is

important to note that it is difficult for these

institutes to disaggregate adolescent-specific research because of their disease-specific approach,

the institutes were only able to identify a research

budget of 2 percent ($1 14.93 million) that was

clearly specific to adolescents in fiscal year 1989.

It appears that the National Institute of Allergy

and Infectious Diseases places a greater emphasis on

adolescents than do the other Institutes and divisions, including the National Institute of Child

Health and Human Development. In fiscal year

1988, for example, the National Institute of Allergy

and Infectious Diseases estimates that it spent

approximately 15 percent of its overall budget on

adolescents, as compared with only about 7 percent

of the National Institute of Child Health and Human

Development’s budget. Like the National Institute

of Child Health and Human Development, however,

the National Institute of Allergy and Infectious

Diseases primarily studies consequences of adolescent sexual behavior (i.e., STDs and AIDS).

Office of the Assistant Secretary for Health—

Three agencies within the Office of the Assistant

Secretary for Health are involved in matters related

to adolescents and their health:

. the Office of Disease Prevention and Health

Promotion,

. the Office of Minority Health, and

. the Office of Population Affairs (see figure

19-8).

Office of Disease Prevention and Health Promotion—

Established by the National Consumer Health Information and Health Promotion Act of 1976 (Public

Law 94-3 17), the Office of Disease Prevention and

Health Promotion is responsible for supporting and

coordinating prevention programs within the Alcohol, Drug Abuse, and Mental Health Administration,

the Centers for Disease Control, the Food and Drug

Administration, the Health Resources and Services

Administration, and the National Institutes of Health

(89).

The overall budget of the Office of Disease

Prevention and Health Promotion in fiscal year 1989

was close to $5 million. Although the amount spent

on adolescents is not known, the Office of Disease

Prevention and Health Promotion has several ongoing activities that affect adolescents. Examples

include awarding grants to national private sector

organizations under the National Health Promotion

Cooperative Agreements Program and the coordination of a broad-based public service initiative to

develop the agenda for “Healthy People 2000:

National Health Promotion and Disease Prevention.” This initiative developed objectives targeted

to adolescents.32 The Office of Disease Prevention

and Health Promotion has cooperative agreements

with the Association of American School Administrators, as well as the American Medical Association

to help promote the “Healthy People 2000: National

Health Promotion and Disease Prevention’ objectives as they relate to adolescents.

Office of Minority Health—The Office of Minority Health is the agency within DHHS which was

originally established to be responsible for coordinating and monitoring the implementation of the

recommendations from The Report of the Secretary’s Task Force on Black and Minority Health.

That report identified six health priority problem

areas among minorities: cancer, cardiovascular disease and stroke, chemical dependency, diabetes,

homicide and accidents, and infant mortality. In

1988, the Office of Minority Health added AIDS to

the list of major health problems. Three major

demonstration grant programs funded by the Office

of Minority Health directly address the seven

minority health priority areas. The Minority Community Health Coalition Program provides grants to

develop community health coalitions which can

effectively demonstrate risk reduction efforts among

minority populations (91). In 1989, the Office of

Minority Health awarded seven demonstration

grants of approximately $200,000 each, two of

which were directed at adolescent minorities. In

addition, the HIV/AIDS Education and Prevention

Grant Program awarded 24 grants of approximately

$50,000 each in 1989 to both national and communitybased minority organizations that provided education and information to minorities on the prevention

of the spread of HIV (91). Three such grants on

HIV/AIDS education and prevention directly affect

adolescents (93). In 1990, the Office of Minority

Health announce a three-part grant program to

address the health and human service needs of
111-242 ● Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

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Chapter 19-The Role of Federal Agencies in Adolescent Health ● III-243

minority males of all ages. One program, funded at

$450,000, was to support meetings and conferences

on problems confronting high-risk minority males;

a second, funded at $1.05 million, was to provide

limited resources to plan and develop community

coalitions to address the needs of high-risk minority

males in specific communities; and the third, funding for which had not been announced, was intended

to demonstrate methods of implementing community coalition intervention activities involving multiple organizations (55 FR 22312). In early 1990, a

report by the U.S. General Accounting Office

criticized the Office of Minority Health and later in

1990, the potential role of the Office was expanded

when the U.S. Congress statutorily established such

an Office, to be headed by a Deputy Assistant

Secretary for Minority Health (Public Law 101-527,

the “Disadvantaged Minority Health Improvement

Act of 1990,” section 2). Public Law 101-527 also

authorized an increase in funding for the Office of

Minority Health, to $25 million per year for fiscal

years 1991 through 1993. The potential role of the

Off-ice in the health of minority adolescents is as yet

unknown.

Office of Population Affairs-Within the Public

Health Service’s Office of the Assistant Secretary

for Health, the Office of Population Affairs carries

out activities related to adolescent pregnancy, family

planning, and population research. The Office of

Population Affairs has responsibility for administering Title X (Family Planning Services and Research

Program) and Title XX (Adolescent Family Life

Program) of the Public Health Service Act.33

The Office of Population Affairs provides Title X

funds to public or private nonprofit organizations

operating family planning projects for low-income

families and encouraging family participation when

possible. There are currently approximately 86

States, organizations, or independent family planning agencies receiving Title X moneys throughout

the country (37). Services they provide include

education, counseling, and medical services related

to contraception as well as training for family

planning personnel in general and nurse practitioners in particular to help improve the delivery of

family plannin g services. Organizations which receive Title X money may not provide counseling and

referral for abortion services except in medical

emergencies. 34 In fiscal year 1990, $130 million was

available for family planning service grants, 22 of

which were awarded competitively (54 FR 35440);

the remaining 64 awards represented continuations

of projects which had competed in one of the prior

2 years. Current Title X priority areas are:

●

●

●

●

●

●

●

the involvement of families of adolescent

clients in Title X clinics,

infertility services,

natural family planning services,

male involvement,

sexually transmitted diseases,

AIDS, and

sexual abstinence for adolescents.

Approximately one-third of all Title X money is

specific to adolescents. The last new reauthorization

of funds for Title X was in 1984 (Public Law 98-512)

(19). However, organizations continue to receive

Title X funds through congressional appropriation

acts.

The Office of Population Affairs provides Title

XX (Adolescent Family Life Program) funds to

support research and demonstration projects aimed

at the alleviation, elimination, or resolution of

negative consequences of adolescent premarital

sexual intercourse. Specifically, abstinence from

premarital sexual intercourse and adoption as an

alternative to abortion are encouraged. Additionally,

demonstration projects under the Adolescent Family

Life Program attempt to establish innovative, comprehensive, and integrated health care services for

pregnant and parenting adolescents under age 19. As

with Title X funds, Title XX money cannot be used

to provide abortions, abortion counseling, or abortion referrals, and adolescents must obtain parental

consent before participating in any Title XX program (94). An average of 60 demonstration grants

are funded under Title XX each year. In fiscal year

1986, Title XX demonstration projects served approximately 60,000 adolescents in both prevention

and care programs. In addition, Title XX funds

supported research on adolescent sexual activity and

ggFor ~ more in-de~~ dlSmSSi~n of ~miw~ provided to pregnant and parenting ado]e~ents by be WIU of population AffairS under Titles X and

XX of the Public Health Service A@ see ch. 10, “Pregnancy and Parenting: Prevention and Services,” in Vol. II.

34~ ~ 5-4 decl~lon on my 23, 1991, tie U.S. Supreme Court upheld ~s ~gu~tio~ despite&e conmm of some dissenting judges that the regukltion

‘‘raises serious First Amendment [free speech] concerns’ (The New York Times, ‘‘Excerpts From Court Ruling Curbing Family Planning Clinics, ’ May

24, 1991, p. A19; L. Greenhouse, ‘ ‘Five Justices Uphold U.S. Rule Curbing Abortion Advice, ” The New York Times, p. A19, May 24, 1991).
III-244 . Adolescent Health-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

the effectiveness of available services. The funding

for Title XX in 1990 was $9.5 million, all of which

was for adolescents.

Agencies Other Than DHHS: Programs and

Expenditures for Adolescents

There are agencies other than those in DHHS that

provide funding aimed at improving the lives of

adolescents (see table 19-5). Many of these agencies,

such as the U.S. Consumer Product Safety Commission and the U.S. Departments of Agriculture,

Defense, Education, and Transportation, do not

provide set-asides for adolescents but do include

adolescents as a subgroup of larger populations

served. Again, this factor makes determining expen -

ditures for adolescents difficult.

ACTIO N

ACTION administers several Federal domestic

volunteer service programs that provide human

services to disadvantaged, poor, and elderly Americans.

35 Within ACTION, the Office of Domestic

Operations administers several programs that affect

adolescents. These include the Retired Senior Volunteer Program, the Foster Grandparent Program,

Volunteers in Service to America (VISTA), the

Student Community Service Program, and the Office of Program Demonstration and Development.

The Foster Grandparent Program provides direct

benefits (e.g., stipend, transportation, meal assistance, annual physical examination) to low-income

individuals ages 60 and over who work 20 hours a

week with children and adolescents with special

needs (2). In fiscal year 1988, the Foster Grandparent Program sponsored 252 projects with a budget of

$57.4 million. That year, it served about 70,000

young people, including about 25,500 ages 6

through 12 and 15,400 ages 13 through 20 (4).

Typically, the young people assisted are at risk of

drug or alcohol use, are in the delinquent detention

system, are pregnant or parenting, or are mentally,

physically, or emotionally disabled (2).

The VISTA program tries to help low-income

people become self-sufficient by supporting projects

sponsored by local public and private nonprofit

organizations (2). In fiscal year 1988, 244 VISTA

projects focused on youth (2). As of August 31,

1989, 66 VISTA volunteers were involved in 15

projects focusing on juvenile health, including the

prevention of adolescent pregnancy, substance abuse,

suicide, and violence (3). The Student Community

Service Program funds projects that enable high

school and college student volunteers to work as

volunteers to help eliminate poverty-related problems. The estimated budget for the Student Community Service Program for fiscal year 1990 was

$893,000 (7). In 1988, an estimated 28,000 students

provided more than 850,000 hours of community

service in various settings, such as Head Start

programs, juvenile diversion programs, shelters, and

soup kitchens (2).

The program Demonstration and Development

Division within the Office of Domestic Operations

was created, in part, to award demonstration grants

to organizations that have the potential to generate

volunteer activity within a community and have the

ability to serve as a model for other organizations. In

fiscal year 1988, the Division awarded $2.6 million

in demonstration and other grants for 79 projects

(2). 36 Because Congress earmarked all fiscal year

1990 demonstration grants for illicit drug use

prevention activities (7), ACTION gave top priority

to drug prevention initiatives for at-risk youth in

fiscal year 1990. These grants ($1.3 million for

1990), handled through the Office of Program

Demonstration and Development’s Drug Alliance

Office, are awarded to community drug prevention

projects that include enlisting volunteers from corporations to serve as mentors and organizing parent

groups to prevent drug abuse.

U.S. Consumer Product Safety Commission

The U.S. Consumer Product Safety Commission

typically does not focus on adolescents as an age

group, but focuses on product-related hazards. For

example, priority areas in fiscal year 1990 include

indoor air quality, playground surfacing, diving

injuries, choking hazards, and lead in water coolers.

Although no projects are specifically aimed at

adolescents, some projects do have a direct impact

Js~e role of ACTION in organizing and coordinating domestic volunteer service activities may have been affected by passage in late 1990 of the

Nationat and Community Service Aet of 1990 (Public Law 101-610). While the law intended to “build on the existing organizational framework of

Federal, State, and locat programs and agencies to expand fidl-time semice opportunities for all citizens. . . .“, it also established a Commission on

National and Community Service to administer most of the programs established by the act. The programs established by the aet are deseribed briefly

in Volume l+onmury and Policy Options and more fully in ch. 4, ‘‘Schools and Discretionary Time, ” in Vol. II.

ss~ese projec~ Wme mppfied witi $1.074 million in non-Federal contributions.
Chapter 19--The Role of Federal Agencies in Adolescent Health . III-245

Table 19-5-Expenditures on Adolescent Health by Federal Agencies Other Than the U.S. Department of

Health and Human Services

Agency with actual Estimated expenditures

or potential role in Total expenditures for adolescents Percent of expenditures

adolescent health (most current fiscal year) (most current fiscal year) for adolescents

ACTION

U.S. CONSUMER PRODUCT SAFETY COMMISSION

$170,417,000 (1990)’

$34,500,000 (1989)

$16,127,000 (1990)”

Not provided

9.4 percent

Estimated at 50 percent for all children.

Not provided

25 percent

Not provided

Not providedb

Not provided

Not provided

23 percent of CHAMPUS benefit costs

are provided to adolescents ages 10

to 19.

Not provided

Not provided

U.S. DEPARTMENT OF AGRICULTURE

Extension Service

Human Nutrition Information Service

Food and Nutrition Service

Not provided

$361,370,000 (1989)

Not provided

$21,264,955 (1989)

Not provided

$90,342,500 (1989)”

Not provided

No specific line items for

adolescents.

Not provided

Not provided

$552,000,000 (1989)”

U.S. DEPARTMENT OF DEFENSEc

Force Management and Personnel

Office of Civilian Health and Medical Program of

the Uniformed Services (CHAMPUS)

Not provided

Not provided

$2,400,000,000 (1989)

U.S. DEPARTMENT OF EDUCATION

Office of Planning, Budget, and Evaluation

$22,467,400,000 (1989)

Not provided

No specific line items for

adolescents.

Generally, no specific line

items for adolescents. Ado

Iescents receive Federal

money through funds provided to State and local

educational agencies and

other organizations.

No specific line items for

adolescents.

Not provided

$123,193,500 (1986-87)

Not provided

Office of the Assistant Secretary for Elementary

and Secondary Education

--Office of Indian Education

--Office of Migrant Education

Office of the Assistant Secretary for Educational

Research and Improvement

Office of the Assistant Secretary for Special

Education and Rehabilitative Services

--Office of Special Education Programs

-National Institute on Disability and Rehabilitation

Research

Office oft he Assistant Secretary for Vocational and

Adult Education

Office of Bilingual Education and Minority

Languages Affairs

Office of the Assistant Secretary for Postsecondary

Education

U.S DEPARTMENT OF JUSTICE

National Institute of Justice

Office of Juvenile Justice and Delinquency

Prevention

U.S. DEPARTMENT OF LABOR

$6,600,886,000 (1989) Not provided

Not provided

45 percent

Not provided

Not provided

Not provided

32 percent

Not provided

Not provided

Not provided

Not provided

20 percent

100 percemt

Not provided

58 percent

Not provided

Not provided

1 percent

$71,553,000 (1 989)

$269,029,000 (1988)

$78,200,000 (1989)

$3,558,500,000 (1988) Not provided

$2,109,982,000 (1988)

$53,525,000 (1989)

Not provided

$17,461,006 (1989)d

$1,080,614,000 (1989) Not provided

$197,394,000 (1989) Not provided

$5,814,320,000 (1989) Not provided

Not provided

$21,000,000 (1989)

$72,482,000 (1990)

Not provided

$4,200,000 (1989)’

$72,482,000 (1990)

$24,900,000,000 (1990) No line items specific for

adolescents.

$2,166,367,000 (1989)g

Not provided

No line items specific for

adolescents.

$975,000 (1989)”

$3,728,431,000f

Not provided

$13,308,000,000 (1988)

Employment and Training Administratione

U.S. DEPARTMENT OF TRANSPORTATION

Federal Highway Administration

National Highwav Traffic Safetv Administration $103,500,000 (1989)

. .

aEstimated amount.

bFofly.three ~ercent of the ~afiicipants in the National school Lunch program are in grades 7 through 12; 24 percent of those in the .%hOO1 Breakfast Program

are in grades 7 through 12; 23 percent of those in the Summer Food Service Program are ages 13 to 18; 3 percent of those participating in the Supplemental

Food Program for Women, Infants, and Children are pregnant, breastfeeding, or postpartum females less than age 18; and 34 percent of those in the Food

Stamp Program are between the ages of 15 and 17.

CQuestionnaire is from the perspective of the youth activities programs which are part of the Morale, Weifare, and Recreation Division. However, the

Department’s commitment to adolescents is not limited to these programs. Other agencies, such as Medical Programs, Mental Health Division, Drug and

Alcohol Abuse Programs, and Chaplains Programs, sponsor activities for military youth.

dA&lescent projects are included within larger research efforts and are not specifically for adolescents.

~hese data were obtained from E. Kolodny, U.S. Department of Labor (20).

fFunds are allocated for program year July 1, 198Wune 30, 1990 and not for the fiscal year (2’0).

gForty percent of Title II-A, all of Title II-B, and all of Job Corps funding is allotted to youth, primarily ages 16 through 21 (20).

SOURCE: Office of Technology Assessment, 1990, based on Federal agency responses to the Office of Technology Assessment’s survey on adolescent

health, 1989.
III-246 . Adolescent Health--Volume III: Crosscutting Issues in the Delivery of Health and Related Services

on adolescents. These include projects related to

all-terrain vehicles, fireworks, bicycles, lawn darts,

water coolers with lead components, amusement

rides, diving injuries, and playground surfacing. It is

estimated that about 50 percent ($17.3 million) of

the Commission’s budget in fiscal year 1989 went

toward activities that protected children37 (40).

U.S. Department of Agriculture

Four of the U.S. Department of Agriculture

Extension Service’s nine priority areas include

substantial adolescent cornponents.38 These initiatives are human nutrition, youth at risk, building

human capital, and family and economic well-being.

More specifically, building human capital involves

helping adolescents develop self-confidence and the

ability to think independently as well as helping

communities accept adolescents as responsible and

valuable members of society (45). Youth-at-risk

research and demonstration projects include a model

youth-at-risk program with the University of Arizona and adolescents as advocates for youth with

Colorado State University. Within the Extension

Service’s 4-H program, adolescents ages 10 to 18

make up 66 percent of those individuals enrolled in

the program, with 10- to 13-year-old adolescents

making up 50 percent of those enrolled (45). In fiscal

year 1989, approximately 25 percent of the Extension Service’s budget of” over $361 billion was

dedicated to programs devoted to adolescent issues.

39

The U.S. Department of Agriculture’s Human

Nutrition Information Service conducts and interprets applied research in food and nutrition (35).

Other responsibilities include monitoring the food

and nutrient content of diets, assessing dietary status

and trends in food consumption, increasing understanding of the factors that influence consumer food

choices, providing appropriate dietary guidance for

the public, and developing techniques to help people

make informed food choices.

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,

various child nutrition programs, and the Special

Supplemental Food Program for Women, Infants,

and children (WIC) (22). Adolescents ages 15 to 17

make up an estimated 34 percent of the participants

in the Food Stamp Program (22).40 Child nutrition

programs, such as the National School Lunch and

School Breakfast Programs, and the Summer Food

Service Program, provide food services to children

and adolescents in public and nonprofit, private

schools. Adolescents in grades 7 through 12 makeup

an estimated 24 percent of the participants in the

School Breakfast Program and 43 percent of the

participants in the National School Lunch Program

(22). 41 Pregnant, breastfeeding, or postpartum adolescents make up an estimated 2.8 percent of WIC

participants (22).

U.S. Department of Defense

The Civilian Health and Medical Program of the

Uniformed Services (CHAMPUS) is a health benefits program provided by the Federal Government

under public law primarily to dependents and

retirees of the Air Force, Army, Coast Guard, Marine

Corps, Navy, Public Health Service, and the National Oceanic and Atmospheric Administration

(49). CHAMPUS covers residential treatment for

certain mental disorders, family planningservices,

42

general inpatient and outpatient care that is considered medically necessary, and general treatment for

alcohol/drug abuse or dependency and detoxification, without complications or comorbidity. In

addition, the program for the Handicapped provides

benefits for individuals, who are primarily adolescents, with moderate or severe mental retardation or

serious physical disabilities. Under CHAMPUS,

adolescents are covered if they are unmarried and

under age 21, full-time students under age 23, or age

21 and over and severely disabled (49). In fiscal year

1989, $2.4 billion was spent on CHAMPUS (36).

37~e com~er product and Safety Commission does not specify what age groups this term encompasses.

38~e Pfionw ~M me dete~l~ by ex~tive and legislative directives with Iocal and State input.

39Most projm~ wv limited to a single yea of fi~.

@The Food Stamp Program supplements household income by improving families’ food purchasing power.

41pm1c1pats me hose ~~l&en ~d adolescent smdents who ate a ~+ast or ]Uch at lwt onm during a w~k as determined by a l-w~k survey

(47).

4~US covers measurement for contraceptive diaphragms and birth control pills but does not cover abortions except in very limited

circumstances (49).
Chapter 19--The Role of Federal Agencies in Adolescent Health ● III-247

CHAMPUS estimates that approximately 23 percent

of CHAMPUS benefit costs are provided to adolescents ages 10 to 19.

U.S. Department of Education

Generally, 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. For example, the

Education of the Handicapped Act programs provide

special education and related services for children

and adolescents with disabilities, and programs

authorized by the Drug-Free Schools and Communities Act target high-risk youth, many of whom are

adolescents. For most programs, counts of individuals served with U.S. Department of Education funds

are done by grade level rather than by age.

In 1989, the Department had a budget of approximately $22 billion and was responsible for 187

programs spanning six different offices (figure

19-9). It is impossible to determine total adolescent

expenditures, 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 own priority

areas are determined through legislative mandates,

reviews of current literature, and State-identified

needs. Priorities include increasing educational services to economically and educationally disadvantaged children.

In terms of research and demonstration projects,

the U.S. Department of Education programs are

currently interested in dropout prevention, secondary education and transitional services for disabled

youth, bilingual aid, compensatory education, Indian youth, homeless youth, and drug abuse prevention. Funding for compensatory education, Indian

education, and education of homeless children and

adolescents is estimated to account for 21 percent of

the U.S. Department of Education’s budget (34), but

only selected programs could specify funds for

adolescents.

Within the Department, three offices fund more

projects and activities for adolescents than do the

others (table 19-5). These are the Office of the

Assistant Secretary for Educational Research and

Improvement, the Office of the Assistant Secretary

for Elementary and Secondary Education, and the

Office of the Assistant Secretary for Special Education and Rehabilitative Services.

Office of the Assistant Secretary for Educational Research and Improvement—Under the

Secretary’s Fund for Innovation in Education (Public Law 100-297), the Office of the Assistant

Secretary for Educational Research and Improvement administers funds to both public and private

institutions to improve health education for elementary and secondary students. In 1989, 18 projects were funded with approximately $3 million.

The projects funded included various health education programs (on nutrition, fitness, disease prevention), State and local education reform models, and

evaluations of health education programs. In 1990,

$4 million was allotted to the Comprehensive

School Health Education Programs, with a primary

emphasis on models of health education programs

and training needed to implement such programs

(55).

Office of the Assistant Secretary for Elementary and Secondary Education—For the 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 the Grants for the Disadvantaged

programs authorized by Chapter 1 of the Education

Consolidation and Improvement Act of 1981 under

the Office of the Assistant Secretary for Elementary

and Secondary Education (53). In 1988, the Education Consolidation and Improvement Act was repealed and replaced by Title I of the Elementary and

Secondary Education Act of 1965, enacted as part of

the Augustus F. Hawkins-Robert T. Stafford Elementary and Secondary School Improvement Amendments of 1988 (Public Law 100-297). The purpose

of the amendment was to strengthen parental involvement and to improve access to high quality

education for adolescents in areas with a high

proportion of low-income families and for neglected

or delinquent adolescents in State institutions (53,54

FR 21752).

The Office of the Assistant Secretary for Elementary and Secondary Education has one of the

largest appropriations in the U.S. Department of

Education, approximately $6.6 billion in fiscal year

1989 (56). Although the proportion allocated to

adolescents cannot be precisely determined, major

programs that provide adolescent-related efforts

include the following:
Figure 19-9--U.S. Department 10

Chief of Staff ~

I 1

r

I Executive ~

~ Secretary ~

I

Secretary o f ~

., Education

I

~ ---

Executive Assistant

Private Education T

I

I~ General Counsel I Deputy Unde r

—, Secretary fo r

Planning, Budget,

and Eval uat ion

I ~ - -

Assistant Secretary I I Assistant Secretar y

for E Iementary for Postand S e c o n d a r y ~ Second ar y

Education Education

L–-_—..——

I Assistant secretary I Asslstanf secretary

for Vocational , for Legislation

and Adult ~—

Education

L.

-— — —. ,

I Deputy Unde r

Secretary fo r

Man age men t

I

I Assistant Secretar y

for Educationa l

Research and

I I m p rove me n t

I

. . — ~-—. —–-—AL------ . . .

~ Assistant Secretar y

I~

for Civil Right s 1

I Deputy Under

Secretary for

I Intergovernmental a n d

Interagency Affairs

— —

1

I Assistant Secretar y

for Special

Education and

Rehab i I i tat i ve

Service s

-.——— —— .

r— ~- .– -

Director of

~ BiIingual Education

I and Minority

Languages Affairs

SOURCE: U.S. Department of Education, organizational chart, Washington, DC, Sept. 15, 1989.
Chapter I9--The Role of Federal Agencies in Adolescent Health . III-249

●

●

●

●

●

●

●

●

Chapter 1 grants to provide financial assistance

to State and local educational agencies to meet

the special educational needs of disadvantaged

children and adolescents;43

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;

migrant education program to address the

educational needs of migratory agricultural

workers and fishers ages 3 to 21, as authorized

by Chapter 1 of Title 1 of the Elementary and

Secondary Education Act of 1%5;

drug abuse education and prevention coordination in States and communities, as authorized

by the Drug-Free Schools and Communities

Act of 1986;

dropout prevention demonstration projects conducted by local education agencies, educational

partnerships, and community-based organizations to increase the number of children and

adolescents remaining in school, as authorized

by Title IV-A of the Elementary and Secondary

Education Act of 1965 (56); and

distribution of books to high school students

under the Inexpensive Book Distribution Program to encourage adolescents to read, as

authorized by the Education Consolidation and

Improvement Act of 1981 and Chapter 2 of

Title 1 of the Elementary and Secondary

Education Act of 1965 (34).

Office of the Assistant Secretary for Special

Education and Rehabilitative Services-Under

the authority of Part B of the Education of the

Handicapped Act (Public Law 94-142) and Chapter

1 of the Education Consolidation and Improvement

Act as part of the Omnibus Budget Reconciliation

Act of 1981 (Public Law 97-35), the Office of

Special Education Programs (within the Office of

the Assistant Secretary for Special Education and

Rehabilitative Services) supplies funds primarily to

State education agencies to provide special education and related services to children and adolescents

ages 3 through 21 with disabilities (57).44 I n

1987-88, a total estimate of $574.14 million or 44

percent of the total appropriation of approximately

$1.3 billion was spent to reach close to 1.7 million

students ages 12 to 17 (13).45

Under Chapter 1 Handicapped Programs (of the

Education and Consolidation Improvement Act),

State-operated programs provide special education

to children and adolescents with disabilities who are

in or have transferred from State-operated or Statesupported programs. Over 83,000 students ages 12

to 17 received services through this program at an

estimated cost of $48 million in the 1987-88 school

year.

46

One priority area within the Office of Special

Education Programs is secondary education and

transitional services for handicapped youth. This

activity assists adolescents with disabilities and their

families in making the adolescents’ transition from

secondary school to work life or postsecondary

education settings. About $7.3 million was spent on

this program in fiscal year 1988. Further, the

Program for Severely Handicapped Children attempts to involve families in the planning and

delivery of services and increase the number of

children and adolescents with severe disabilities

being served in regular school settings (54 FR 3945).

Finally, the Office of Special Education Programs is

supporting research projects for interventions to

retain junior-high-school-aged students with disabilities, who are at risk of dropping out of school (54

FR 30642).

dqNo age ~~omme av~ble for c~~t- of Chapter 1. However, in the 1987-88 school y-, 21 percent (1,037, 127) of tk population

served were students in grades 7 through 12 in both public and private schools, with funding for these adolescents totaling $3.8 billion (56).

44- ~ucation of tie H~icap@ ~t (~blic ~w 94-142) r@res tlMI W childIcn and adolescents between tlw ages of 3 through 21 & ~td

However, States are not required to serve 3- to 5-year-olds or 18- to 21-year+lds if the semice is inconsistent with State law or practice (57). Additionally,

the statute requires that at least 75 percent of the funds must be passed through State education agencies to local education agencies and other agencies

seining children direetly. Up to 25 percent of the funda may be spent on direct and support services and administration at the State level.

d5bfisc~ y= 1989, of tie $2.1 billion appropriated to the Office of Special Education Programs, 93 pement of the funds ($1 .94 billion) were award~

to State education agencies under five gmnt programa (57).

~k the 1987-88 school year, appro ximately40percent of children and adolescents with disabilities sewed were between the ages of 12 and 17. Most

of these adolescents had 1 earning disabilities (50).

292-872 0 - 91 - 9 QL 3
111-250. Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Another branch of the Office of the Assistant

Secretary for Special Education and Rehabilitative

Services, the National Institute on Disability and

Rehabilitation Research, administers a number of

research activities that affect adolescents, although

adolescents are not specifically targeted. For fiscal

year 1989, $17.46 million was spent on initiatives

that would affect adolescents. The priority areas for

fiscal years 1989 and 1990 include research on

children with severe emotional problems, a pediatric

center for study of children’s needs, spinal cord

injury centers, and persons with orthopedic disabilities.

U.S. Department of Justice

Office of Juvenile Justice and Delinquency

Prevention—The Office of Juvenile Justice and

Delinquency Prevention was created under the

Juvenile Justice and Delinquency Prevention Act

(Public Law 93-415) and was authorized to administer programs and policies to improve the juvenile

justice system, assist communities in responding to

the needs of juveniles, assess the factors that

contribute to juvenile delinquency, and inform

practitioners about research findings and successful

interventions (see figure 19-10). Additionally, the

Office provides support and assistance to State and

local juvenile justice agencies and delinquency

prevention programs and facilitates cooperation and

coordination among the Federal agencies funding

juvenile delinquency programs. In fiscal year 1989,

the office’s budget was $66.69 million. The Office’s

fiscal year 1990 priorities are serious juvenile crime,

illegal drug use, youth gangs, and missing and

exploited children. Additionally, Congress mandated the following studies:

●

●

●

determination of the extent to which confinement conditions in juvenile detention and

correctional facilities comply with national

standards;

obstacles to legal custodians’ recovery of

children who have been removed by a noncustodial parent;

village and tribal justice systems’ treatment of

American Indian and Alaska Native juveniles

●

●

accused of committing crimes on or near

reservations, and the availability of communitybased alternatives to incarceration for these

youth;

extent to which minority juveniles are disproportionately detained or confined in secure

juvenile detention or correctional facilities,

jails or lockups; and

improvement of national statistical data on

juveniles taken into custody.

The Office of Juvenile Justice and Delinquency

Prevention awards an estimated 115 to 120 discretionary grants each year, ranging from $15,000 to $4

million, with an average of approximately $215,000

per award in fiscal year 1989.47 In 1988, Congress

authorized that substantial portions of discretionary

funds be shifted from discretionary to formula grants

to States (34).48 In fiscal year 1989, the funds

allocated to States totaled $45.75 million.

National Institute of Justice—The National

Institute of Justice within the U.S. Department of

Justice works to improve the criminal justice system, addresses crime prevention and control, and

enhances community safety and security. Although

approximately 20 percent ($4.2 million) of the

National Institute of Justice’s overall budget of $21

million is spent on research and demonstration

projects that include adolescent components, the

National Institute of Justice generally does not target

adolescents specifically. Its fiscal year 1990 priorities include examiningdrug marketing and associated crime, violent crime, effective policing strategies, white-collar and organized crime, and the

prosecution and incarceration of offenders. Current

adolescent projects include grants on drug use

patterns of inner-city youth, drug testing of juvenile

offenders, and helping fund the National Academy

of Sciences Panel on Understanding and Controlling

Violence which will examine adolescent data on

violence. Additionally, the program of research on

Human Development and Criminal Behavior will

examine developmental factors that influence delinquency, crime, and other antisocial behavior.

471n fiscal ~ca 1988 86 initiatives were funded, including 24 on il]eg~ drug use, 18 on missing and exploited childre~ 6 on violence m the schools,

and 3 on juvenile gang ~iolence (97).

4S1n order t. ~ ellgible for th~sc grmts, states must comply with s~tion 223(a)(l 2)(A)( 13) and ( 14) of the Juvenile Justice and Delinquency

Prevention Act rqulring the demstitutionalization of status offenders and nonoffenders, the separation of juveniles from adults within secure

confinement facilihcs, and the removal of juveniles from adult jails and lockups.
Chapter 19-The Role of Federal Agencies in Adolescent Health . ///-251

Figure 19-10--U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention

Off ice

of the

~

Ad m I n is t r a to r

I

I

1

Offic e

of the

Deputy Administrator

‘1

I I

,

I

State Relations

Research and

Pro g ram

and Assistanc e

Development

Division Division

I

1 1 J

Center for Special

Emphasis, Training, and

TechnicaI Assistance

Special

Emphasis

Division

1

Training,

Dissemination, and

TechnicaI Assistance

Division

SOURCE: U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention, Twetfttt Anaiysis and Evaluation: Federal Juvenile Delinquency

Programs 1988 (Washington, DC: 1988).

U.S. Department of Labor Act affect adolescents ages 16 to 21: Titles 11-A,

II-B, and IV.

Within the U.S. Department of Labor, the Employment and Training Administration is the agency Titles H-A and II-B of the Job Training Partnermost directly supporting activities affecting adoles- ship Act authorize block grants to States. Under Title

cents. In program year 1989, funding for youth was II-A, training services are offered throughout the

estimated to account for 58 percent ($2.2 billion) of year to economically disadvantaged adults and

the budget. Employment and Training Administra- youth. Forty percent ($715.1 million) of the total

tion projects for youth typically focus on adolescents budget in program year 1989 for Title II-A was

and young adults ages 16 and over. The Employment earmarked for adolescents.49 Title II-B establishes a

and Training Administration supports employment summer employment program for low-income youth.

and training programs for economically disadvan- All of the funding for Title II-B, $709.4 million for

taged youth under the 1982 Job Training Partnership summer 1990, was designated for adolescents, and

Act. Three sections of the Job Partnership Training $12.9 milllon of this total was used to Support

—. — -- —

l~/s[nt<.$ ~.~c ~c<lulrcd 10 ;iIloc:itc funds ~ccordlng t. ii set f[lrnlul;~. so (h:~t 78 percent of the funds tare dislnbufcd to scrv ICC dcllver~r areas (L!csi~~~tU~

by Governors) and [he rcmalnlng 22 percent IJ for State fct-as]dcs,
III-252 . Adolescent Health–-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

summer employment opportunities for Native American youth (99).

Title IV authorizes various federally administered

programs affecting adolescents, such as Job Corps

and programs designed for Native Americans and

migrant workers. 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

disadvantaged adolescents and young adults ages 16

to 21 (100). 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.

In addition, Title IV 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 for

the following: 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 (98). Currently, 35 such

research projects are underway, and the average cost

per project is 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

(25). 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).

U.S. Department of Transportation

Federal Highway Administration—The Federal Highway Administration does not typically

target individuals of any age group, but supports

programs, such as highway repairs and maintenance,

which improve the safety of the roads for everyone.

Within the Federal Highway Administration, however, the Office of Highway Safety sponsors a

number of research and demonstration projects that

indirectly affect both adolescent drivers and pedestrians. For fiscal years 1987-91, $10 million was

allocated for safety research and development,

which includes research on accidents among young

drivers, pedestrians, and bicyclists (102).

National Highway Traffic Safety AdministrationAlthough the National Highway Traffic Safety

Administration does not have any adolescentspecific priorities for fiscal years 1989 and 1990, the

agency does fired several programs that include

adolescents. Because motor vehicle accidents are the

greatest cause of death for adolescents and young

adults ages 15 to 24, this age group is targeted by the

National Highway Traffic Safety Administration.

Activities for adolescents and young adults under

age 21 include alcohol and drug accident prevention,

passenger protection, and motorcycle safety; these

activities take place in a variety of settings, such as

schools, offices, and other places in the community.

In addition, within the National Highway Traffic

Safety Administration, the Office of Traffic Safety

Programs has formed a Youth Committee to coordinate its highway safety activities for young adults.

The National Highway Traffic Safety Administration also supports workshops in colleges and media

announcements dealing with alcohol and drug and

highway safety policies. Research priorities include

accident prevention techniques for use by States and

communities.

The National Highway Traffic Safety Administration also funds activities aimed at individuals

younger than age 15, which primarily affect adolescents in the 10- to 14-year-old age group. These

activities include pedestrian safety programs, a

bicycle education program, dissemination of educational kits for schools and communities, and informational guides related to car air bags, alcohol, and

safety belt use. As an example, ‘‘The Car Club,’ an

instructional kit for junior high and middle school
Chapter I+ The Role of Federal Agencies in Adolescent Health . III-253

students, provides information on car occupant

protection.

In 1989, the National Highway Traffic Safety

Administration programs were estimated to reach

over 30 million elementary, junior high, and high

school adolescents. But in 1989, less than 1 percent

($975,000) of the Adrninistration’s budget was

estimated to target adolescents. Estimates for research programs targeting adolescents are not available; however, total research funding is estimated at

$775,000 for 1989.

Coordination at the Federal Level

Currently no one agency, department, or executive office formally coordinates Federal activities

related to adolescents, but some coordination does

take place within and between organizations in the

form of Committees and memoranda of agreement.50

For example, within the Alcohol, Drug Abuse, and

Mental Health Administration, the National Institute

on Alcohol Abuse and Alcoholism and the National

Institute on Drug Abuse together fund grants for

drug and alcohol abuse prevention research. The

U.S. Department of Justice’s National Institute of

Justice and the Office of Juvenile Justice and

Delinquency Prevention fund a project on Drug Use

Patterns of Inner City Youth. Examples of current

efforts between agencies are listed below.

● The Ad Hoc Committee on Health Promotion

Through the Schools, which is coordinated

through the Office of Disease Prevention and

Health Promotion and involves about 10 Federal agencies (e.g., U.S. Environmental Protec-

●

*

●

●

tion Agency, the Indian Health Service, Bureau

of Maternal and Child Health, and the U.S.

Departments of Agriculture, Defense, Education, Health and Human Services, and Transportation) (14).

The multi-agency collaboration with the Centers for Disease Control’s Division of Adolescent and School Health in the development of

a Youth Risk Behavior Surveillance System.

The Coordinating Council of Juvenile Justice

and Delinquency, created by Section 206 of the

Juvenile Justice and Delinquency Prevention

Act, coordinates Federal juvenile delinquency

Programs 51 and is composed of cabinet-level

representatives from 18 member Federal agencies. In fiscal year 1988, Coordinating Council

agencies supported 72 initiatives to prevent

juvenile delinquency (97).

The Ad Hoc Federal Interagency Working

Group, which was developed to bring about a

more coordinated governmental response to the

drug problems within individual communities.

Agencies include the National Highway Traffic

Safety Administration, and the U.S. Departments of Education, Health and Human Services, Housing and Urban Development, Justice,

and Labor.

The Interagency Panel on Children and Adolescents meets monthly to share information and

coordinate research efforts on issues affecting

children and adolescents. Member agencies

report on current research, demonstration projects and various programs; in addition, they

discuss interagency joint research. The panel

%April 1991, the Secretary of Health and Human Services announced a reorganization of some DHHS programs for children and families within

DHHS (61a). The purpose of the reorg tition was ‘to place greater emphasis and greater focus on the needs of America’s children and families” (61a).

The reorg aniz.ation would combine all programs of the Family Support Administration and the Ofilce of Human Development Services, and the maternal

and child health block grant program in the Health Resources and Semices A&mm‘ “stration of the Public Health Serviu, into a new ‘‘ Administration

for Children and Families.’ The new AdmmI “ “stration for Children and Families would be on an@ level with the Public Health Service, the Health

Care Financing A&mm“ ‘S~dtiOU and the Social Security Administration. Programs in the new operating division would include programs such as Head

Start, Job Opportunities and Basic Skills, Aid to Families With Dependent ChildrerL Child Support Enforcement Adoption Assistance, Foster Care, the

Social Services Block Grant, Child Care and Development Block Grant, and child abuse programs, as well as the maternal and child health block grant

(61a). The combined budget of the new Administration was estimated by DHHS to be $27 billion and the size of the staff 2,000. According to the

announcemen~ no funding or staff cuts will take place as a result of the change. Although the reorg anization was said to be effective immediately, the

DHHS announcement indicated that the change will involve extensive followup implementation. Consequently, a task force to direct the implementation

had been formed (61 a). Thus, although one of the intended divisions of the new Administration for Children and Families was an office of ‘ChiMrerL

Youth and Families,’ the role of adolescent health issues in the new Adnuru“ ‘stration was not immediately clear. It is important to note that many of the

appro ximately 60 U.S. executive branch agencies with a role in adolescent health (some of them in departments other than DHHS; see figure 19-1) were

not included in the reorganization.

51cwr~tion ~cws ~ong tie U.S. ~p~ent of Justi~ ~atio~ kstimte of J~tice dk Hlce of Juvenile Justi~ ~d Delinquency

Prevention], U.S. Department of Health and Human Services [Administration for Chitdren, Youth and Families; Family and Youth Services Bureau;

Office of Community Semices; Alcohol, Drug Abuse, and Mental Health Administration], U.S. Ofllce of National Drug ConEol Poticy, U.S. Department

of Educatio% U.S. Department of Transposition ~ational Highway Traffic Safety Administration], U.S. Department of Labor, U.S. Department of the

Interior ~ureau of Indian Affairs] rU.S. Department of Housing and Urban Development ACI’ION, and the U.S. Environmental Protection Agency

(97).

292-872 0 - 91 - 10 QL 3
III-254 ● Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

also conducts an annual conference to discuss

topics in depth, inviting experts from outside

the Federal government. Twenty-eight government agencies are represented at the monthly

panel meetings. Agencies include ACTION

and the U.S. Department of Agriculture, Defense, Education, Health and Human Services,

Justice, Labor, State, and Transportation (12).

Examples of past and current Memoranda of

Agreement follow:

Parent education to low-income parents (including adolescents), expectant parents, and

care givers of children ages O to 36 months in

at-risk families: Office of Human Development

Services, U.S. Department of Health and Human

Services; Extension Service, U.S. Department

of Agriculture;

Community-based mental health services for

youth: National Institute of Mental Health,

Alcohol, Drug Abuse, and Mental Health

Administration; Bureau of Maternal and Child

Health, Health Resources and Services Administration;

Assignment of medical students to youth shelters to help enhance coordination of health

services: Bureau of Health Care Delivery and

Assistance, Health Resources and Services

Administration; Office of Human Development Services, U.S. Department of Health and

Human Services;

Demonstration projects in consumer education

for public housing residents on nutrition and

decisionmaking in eight sites: U.S. Department

of Agriculture, Extension Service’s 4-H Youth

Development Program; U.S. Department of

Housing and Urban Development; Kraft General Food Foundation (48);

Support for the Cities in School project: U.S.

Department of Health and Human Services,

U.S. Department of Labor, U.S. Department of

Justice, U.S. Department of Education;

Programs for American Indian youth related to

alcohol and drug abuse: education and prevention services for Indian children and adolescents attending elementary and secondary

schools on reservations: U.S. Department of

Education, U.S. Department of the Interior

(14);

Supporting and mobilizing national resources

for young children and youth with HIV infection and AIDS-related complex: Office of

●

●

●

●

●

●

Human Development Services, U.S. Department of Health and Human Services; Public

Health Service, U.S. Department of Health and

Human Services;

Conducting 1988 National Health Interview

Survey’s Child Health Supplement; National

Health and Nutrition Examination Survey III

Child Health Component: National Center for

Health Statistics, Centers for Disease Control;

Health Resources and Services Administration;

Conducting National Adolescent Student

Health Survey: Centers for Disease Control;

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration; Office of Disease Prevention and Health

Promotion, Office of the Assistant Secretary for

Health;

National Longitudinal Survey of Youth: U.S.

Department of Labor; U.S. Department of

Defense; National Institute of Child Health and

Human Development, National Institutes of

Health; National Institute on Alcohol Abuse

and Alcoholism and National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Administration (30);

Plan and implement cooperative program activities related to the provision of services, education, and treatment to pregnant and postpartum

women and to infants in the area of drug abuse

prevention, education, and treatment via women

in the Special Supplemental Food Program for

Women, Infants, and Children (WIC) program:

Office for Substance Abuse Prevention, Alcohol, Drug Abuse, and Mental Health Administration; Food and Nutrition Service, U.S. Department of Agriculture;

Market research study conducted by S.W.

Morris & Co. to determine what high-risk

adolescents know about certain issues, such as

AIDS, teenage pregnancy, and substance abuse,

and how they received this information: Office

of Disease Prevention and Health Promotion,

U.S. Department of Health and Human Services; U.S. Department of Education; U.S.

Department of Justice; U.S. Department of

Transportation (29);

Demonstration grant program to develop model

programs for pregnant and postpartum women

(including adolescents) and their infants: Office for Substance Abuse Prevention, Alcohol,

Drug Abuse, and Mental Health Administra-
Chapter 19-The Role of Federal Agencies in Adolescent Health . III-255

●

●

●

●

●

●

●

●

●

tion; Bureau of Maternal and Child Health,

Health Resources and Services Administration;

Supporting the reduction of crime in schools,

Drug Prevention Education in the Schools, and

D.C. Drug Free School Zone (Z-1000 Program:

Office of Juvenile Justice and Delinquency

Prevention, and National Institute of Justice,

U.S. Department of Justice; U.S. Department of

Education (54);

Children in Custody Census of Juvenile Detention, Correctional and Shelter Care Facilities:

Office of Juvenile Justice and Delinquency

Prevention, and National Institute of Justice,

U.S. Department of Justice; Bureau of the

Census;

Wilmington Delaware Public Housing Initiative: Office of Juvenile Justice and Delinquency Prevention, and National Institute of

Justice, Bureau of Justice Assistance, U.S.

Department of Justice; U.S. Department of

Housing and Urban Development;

Supporting programs on military installations:

Extension Service, U.S. Department of Agriculture; U.S. Department of Defense;

Improve breastfeeding promotion: Food and

Nutrition Service, U.S. Department of Agriculture; Office of Maternal and Child Health,

Health Resources and Services Administration,

in the U.S. Department of Health and Human

Services;

Identification of ways to integrate food assistance services into migrant health care programs: Food and Nutrition Service, U.S.

Department of Agriculture; Migrant Health

Programs;

Smoking Cessation in Pregnancy demonstration project: Food and Nutrition Service, U.S.

Department of Agriculture; Centers for Disease

Control, U.S. Department of Health and Human

Services;

Facilitating the transfer of nutrition education

to American Indian households: Food and

Nutrition Service, U.S. Department of Agriculture; Indian Health Service, Public Health

Service, U.S. Department of Health and Human

Services;

Cooperation on bicycle safety issues: U.S.

Consumer Product Safety Commission; National Highway Traffic Safety Administration,

U.S. Department of Transportation.

In addition, some Federal agencies have become

involved in promoting coordination at the local

level. These efforts include the following:

●

●

●

●

Division of Children, Youth, and Families

within the Office of the Assistant Secretary for

Plannin g and Evaluation of the U.S. Department of Health and Human Services.

The Division has undertaken a study that will

evaluate the feasibility of reorganizing local

existing social services for at-risk children,

youth, and families into a comprehensive

community-based system. This effort, funded

at $135,000, ties into local initiatives sponsored

by the Annie E. Casey Foundation.

Regional Offices of the Employment and Training Administration within the U.S. Department

of Labor and the U.S. Department of Health and

Human Services.

These offices coordinate Youth 2000, a

project designed to mobilize local efforts to

address problems with at-risk youth, including

illiteracy, incompletion of high school, teenage

pregnancy, and alcohol and drug abuse (98).

Child and Adolescent Service System Program

within the National Institute of Mental Health.

The Child and Adolescent Service System

Program tries to promote change in the ways in

which communities and States deliver health

services to severely emotionally disturbed children. Two Research and Training Centers

under the Child and Adolescent Service System

Program are funded through an interagency

agreement with the U.S. Department of Education’s National Institute on Disability and

Rehabilitation Research, and a Technical Assistance Center is funded through an agreement

with the Health Resources and Services Administration’s Bureau of Maternal and Child

Health and Resources Development (76).

High Risk Program within the Child and

Family Support Branch of the National Institute of Mental Health.

The High Risk Program is helping to integrate HIV-infected children and adolescents

into State service networks for children and

adolescents with severe emotional disturbance

(78).

Additionally, several agencies have agreements

with private businesses. For example, through the

national Cooperative Extension System, the U.S.

Department of Agriculture and professionals at
III-256 . Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

land-grant universities are trying to extend research

and technology into the communities (45). Additionally, discussions are being conducted with the U.S.

Department of Housing and Urban Development’s

Division of Indian and Low Income Housing, the

U.S. Department of Agriculture’s Extension Service, and private industry to target youth programs in

selected locations of high-risk factors.

A common theme among the reports reviewing

Federal policies toward children and adolescents

and among representatives at OTA’s meeting with

representatives of U.S. executive branch agencies

with a role in adolescent health is the need for

leadership and coordination at the Federal level,

although the mechanism to provide for this coordination is not uniformly agreed upon.

In 1980, a report from the National Commission

on Youth recommended the development of a

comprehensive national youth policy at the Federal

level to serve the needs of all young persons rather

than targeted segments of the population (26a).

Furthermore, the Commission suggested that the

policy should be long-term with a startup period to

build experienced personnel for program supervision. In addition, the Commission recommended

both a presidential commission to study youth

problems and the establishment of a White House

youth office to coordinate policies and programs.

Given the gaps in and between adolescent services, fragmentation and duplication in both programs and services, and conflicts among various

levels of government and among a variety of

programs, the 1981 report Better Health for our

Children (96) recommended that an Administration

on Maternal and Child Health be created that would

have abroad role in coordinating programs for youth

and children.

In 1988, the National Commission to Prevent

Infant Mortality recommended that a permanent

national council on children’s health and well-being

be established to provide coordination and collaboration among Federal agencies to promote the health

of both pregnant women and children (27).

In both 1987 and 1989, the W.T. Grant Foundation stated that the Federal Government has not

provided a ‘‘coordinated, comprehensive direction

for youth” ages 16 through 24 (33,34).

Most recently, the Institute of Medicine reviewed

the level of implementation of recommendations by

over 20 major commission and panel studies on

children, youth and families published between

1983 and 1988. The review, Social Policy for

Children and Families, noted that ‘there is no entity

taking responsibility or catalyzing the nation into

action. No coordinating mechanisms exist to ensure

that the necessary services are provided effectively

and efficiently to those in need. . ..[There is] no

public leadership on children’s issues” (28). The

history of the Children’s Bureau provides an illuminating example of the way Federal policy on

children and youth has developed in the past (see

box 19-A).

Most of these reports have not distinguished

between children and adolescents. The Federal

agency representatives who came to OTA for

discussion in October 1989 agreed that there was

little coordination on adolescent issues. Some of the

responsibility for the isolation and fragmentation

these representatives experienced was attributed to

the legislation that guides executive branch programs. In fact, the fragmentation of services maybe

due in part to the many authorizing congressional

committees from which agencies take direction

(table 19-6). As just one example, 53 House

committees and subcommittees and 21 Senate committees and subcommittees exercise some jurisdiction over controlling drug use in the general

population (41). Still, the U.S. Executive Branch

representatives did not believe that an agency

devoted specifically to adolescent issues would be

the preferred method to improve adolescent health,

especially in these times of fiscal restraint. They

favored incentives to increase cooperation and

coordination among the current Federal agencies.

Conclusions and Policy Implications

The response to OTA’s August 1989 survey of

Federal agencies suggest that many Federal agencies

support a range of activities directed toward improving the health of adolescents. As reflected in Federal

agency budgets, however, adolescent health issues

generally do not receive much emphasis. Among

DHHS agencies, for example, it is rare for an agency

to devote more than 10 percent of its expenditures

specifically to adolescents (see table 19-3). DHHS

agencies responding to OTA’s survey that do devote

more than 10 percent of their expenditures to

adolescents were the Centers for Disease Control’s

Division of Adolescent and School Health (100

percent), the Health Resources and Services Admin-
Chapter 19-The Role of Federal Agencies in Adolescent Health ● III-257

Box 19-A—History of the Children’s Bureau

The idea of a central coordinating body for programs and policies related to children and youth in the United

States is not new. The Children’s Bureau was established in 1912. The issues surrounding the development of the

Bureau are not at all dissimilar to some of the issues facing the Nation today.

In the late 1800s, with the rapid growth of industrialization and migration to cities, communities were faced

with a lack of foster care for abandoned children, high infant mortality rates, problems of gangs of homeless youth

roaming the streets, juvenile delinquency, education, and child labor. It was becoming more and more critical that

both national and local policies relating to children be developed. There was also the need for more accurate

information on the condition of children.

The editors of a multi-volume history of children and youth in America noted that the Children’s Bureau was:

The single most important development in the public provision of services to children during the early 20th

century. . . The founding of this agency signified acceptance by the Federal government of responsibility for

promoting health and welfare of the young. The Bureau was not organized as a reearch and information center and

did not initially perfom any child welfare services. Its function was to investigate and report upon all matters

pertaining to the welfare of children and child life among all classes of our people including questions of infant

mortality, the birth rate, orphanage, juvenile courts, desertion, dangerous occupation, accidents and diseases of

children, employment, and legislation affecting children in the several states and territories (10).

Grace Abbott, a former director of the Children’s Bureau, noted that “the whole child was made the subject

of the research. ” The interrelated problems of child health, dependency, delinquency, and child labor were to be

considered and interpreted in relation to the community program for all children” (10). This theme is one heard time

and again in relation to the health problems of today’s adolescents.

The development of the Children’s Bureau from its initial conception in 1903 until it was signed into law in

1912 was not without controversy. The themes expressed by opponents of the Bureau seem remarkably familiar

today. Opposition to the 1909 bill was in part based on the view that such a bureau would be unconstitutional as

it purported to exercise jurisdiction over State and local agencies concerned with child welfare. It was also felt that

such programs in the children’s Bureau would be duplicative of efforts by either the Department of Census or the

Department of Education. Surprisingly, opposition was also expressed by the New York Society for the Prevention

of Cruelty to Children which felt that the Bureau would ‘inevitable interfere with the work of our Societies where

they exist through the entire United States” (10). One senator speaking out against the Bureau noted that”. . .While

upon the face of this measure it merely provides for the taking of statistics, the accumulation of knowledge, yet we

know from other measures which have been introduced, some from the same source, that it contemplates the

establishment of a control, through the agencies of government, over the rearing of children” (10).

Despite these objections, a Children’s Bureau was signed into law. In its first 10 years, the activities of the

Bureau resulted in an increase in the number of States with special units concerned with child health from 1 to 46.

Some of the issues brought to the fore by the Children’s Bureau and localbureaus again are germane today. A report

in 1927 by the Children’s Bureau of Cleveland indicated that” . . .no other dependency of children is so great a tax

on the financial resources and on the skill of the staffs of social welfare agencies as that of divorce, separation and

desertion. The difficulties in families broken by divorce or desertion are so complex that the work of medical and

social agencies of community must be well coordinated in order to salvage as many of these wrecked families as

possible” (10).

In 1934, a report by the Bureau to the Committee on Economic Security on the impact of the depression noted

that “.. among adolescents were found evidences of increasing mental instability and inability to meet the

problems that arise from unemployment and depleted family resources.”

And finally, in 1938, Grace Abbott, then director of the Bureau, noted that “programs should be tailored for

children and they cannot be merely an adaptation of the program for adults. . nor should the programs for children

be curtailed during periods of depression or emergency expansion of other programs” (10).

Organizationally, the children’s Bureau was initially placed in the U.S. Department of Labor. In 1930, the

Preliminary Committee Reports of the White House Conference on Child Health and Protection recommended that

the Division of Child Hygiene and Maternity and Infancy of the Children’s Bureau be moved to the Public Health

Service (10). In 1946, the Children’s Bureau was moved from the U.S. Department of Labor to the Federal Security

Continuedon next page
///-258 ● Adolescent Health-–Vo/urne III: Crosscutting issues in the Delivery of Health and Related Services

istration’s Bureau of Health Care Delivery and Most Federal agencies surveyed by OTA do not

Assistance (17 percent), the National Institutes of

Health’s National Institute of Allergy and Infectious

Diseases (15 percent), the Alcohol, Drug Abuse, and

Mental Health Administration’s National Institute

of Mental Health (12 percent).

In non-DHHS agencies responding to OTA’s

survey, adolescents tend to receive a larger proportion of appropriated money, although the total

amounts are small (see table 19-5). The U.S.

Department of Justice, for example, directs approximately 20 percent of its National Institute of Justice

funds and all of its Office of Juvenile Justice and

Delinquency Prevention funds to adolescents. In

addition, the U.S. Department of Agriculture’s

Extension Service, and the U.S. Department of

Education’s National Institute on Disability and

Rehabilitation Research direct over 20 percent of

their funds specifically to adolescents.

A very rough estimate by OTA, based on data able

to be provided by the range of U.S. executive branch

agencies with a role in adolescent health, is that, in

fiscal year 1988, adolescent health initiatives accounted for perhaps 2 percent of the $533 billion in

Federal expenditures (102a) for domestic “human

resources’ or ‘‘social welfare’ programs.52

provide specific set-asides for adolescents. Instead,

they often include adolescents as part of a larger,

more general, research or service focus. Because

adolescents require comprehensive, continuous, developmentally appropriate, labor-intensive interventions, they may not receive the services they need

when they are included as part of populations

serving children in general or adults.

Federal agency priorities are often determined by

authorizing legislation or executive directive. In

some cases, the result is that resources available to

serve the needs of adolescents are quite limited.

Federal agency representatives at OTA’s meeting

indicated that direction for changing agencies’

short- and long-term priorities must come from the

President or Congress. To make adolescent health a

priority, Federal agency representatives expressed

the need for additional appropriated funds or for

current funds to shift from other areas and suggested

Congress could heighten awareness of adolescents

and their health needs through a series of hearings.

Currently, the Federal Government places heavy

emphasis on supporting programs and projects

related to the consequences of adolescent sexual

52$ ~Hmm ~tiouc~~$ or “Wi~ we~~e” programs include the budget “tict.iOm” of educatio% tmining, unemployment and social services;

healti Medicare; income security; sccird security; and veterans benetlta and semices (414102a), Recent changes in the Federal budget as they pertain

to domestic spending, and the potential consequences for adolescent health initiatives, are discussed more fully in Volume I-Summury and Policy

Options of this Report (44b). The budget share would be higher if the adolescent share of AFDC payments were known.
Table 19-6-Congressional Committees With a Role in

AP = Handles appropriations AU = Authorizes major program areas

B = Sets fundinga guidelines A = Authorizes specific programs

Adolescent Healtha

O = Oversight of programs

— . T = Jurisdiction over funding sources such as trust funds

Health and Financial Future

Congressional Work, related services access to competitiveness

committees and Schools and recreation, Special (delivery and health and defense

subcommittees Families education and fitness Nutrition groups access) services readiness Other

Senate committees

Agriculture, Nutrition, and Forestry AU/O A/o

Nutrition and investigations

Appropriations d

, , AP/O AP/O AP/O AP/O AP/O AP/O AP/O AP/O AP/O

Armed services” A/o A/O A/o

Banking, Housing, and Urban Affairs’ A/o A/O

Housing and Urban Affairs

Budget o 0 0 0 0 0 0 0 0

Commerce. Science. and Transportationg AU/O AU/O

Environment and Public Worksh A/o AU/O

Financei T/O T/O AU/T/O

Social Security and Family Policy

Health for Families and the Uninsured

Governmental Affairsj

o 0 0 0 0 0 0 0 AU/O

a~~pt where “ot~, thecongre~ionai committees shown in this tabie are standing committees. S?andingcummittees are committees that are permanent bodies of either the House or the Senate!

have responsibtiity for broad areas of legislation (e.g., agncuiture), and are responsible for most of the legislation considered by Congress. The Senate has 16 standing committees, and the House

has 22 standing committees. Sekctcommitfeesare committees created to study particular probiems or concerns (e.g., Seiect Committee on Chiidren, Youth, and Famiiies). These committees

make recommendations but are usuaily not permitted to report legislation to congress (the one exception is the Seisct Inteiiigence Committee). Joint committees are committees composed of

members from both the House and the Senate. The Joint Econom k Committee is the only joint committee which has a poiicy roie v. an administrative roie, and reports its findings to Congress.

b~iy su~ommittees that ~ai efiensiveiy with legislation reiat~ to adolescent heaith are noted. A suf)co~mjffee is an offshoot of a standing or joint committee and deais with a particular area

covered bythefuii committee. There are usuaiiy a number of subcommittees within a particular comm ittee. Members of the subcommittee are also members of the fuii mmm ittee. Subcommittees

hoid hearings and amend biiis relating to their particular topic area. The amendments must be voted on in the fuii committee before returning to the House or Senate fioor.

~he Senate Agriculture, Nutrition, and Forestry Committee authorizes and exerases oversight over numerous programs administered by the U.S. Department of Agncuiture, inciuding food and

nutrition programs (e.g., the Food Stamp Program, schooi nutrition programs) and programs reiated to rurai development.

%efoiiowingsubcmmm ittees of the Sanate Appropriations Committee deai with programs reievanttoadoiescent healt h: Agriculture, Rurai Development, and Reiated Agencies ;Commerce, Justice,

and State, the Judiciary, and Reiated Agencies; Defense; interior and Reiated Agenaes; Labor, Health and Human Services, Education and Reiated Agencies; and Transportation and Reiated

Agencies.

e-rhe ~nate Arm~ SerMms ~mmittx authorizes ad exercises oversight over numerous programs administered by the U.S. Department of Defense, incitiing the Civiiian Heaith and Medi~l

Program of the Uniformed Services (CHAMPUS), aciviiian heaith and medicai program for retirees and the spouses and dependent ckuidren of actwe duty, retired, and deceased m iiitary personnei.

~he Senate Banking, Housing, and Urban Affairs Committee authorizes and exerasesoversight over programs administered by the U.S. Department of Housing and Urban Development, inciuding

pubiic and private housing programs and community development block grants.

9The Senate Commerce, Science, and Transportation Committee authorizes and exercises oversight over programs administered by the U.S. Department of Transportation, inciuding programs

reiated to highway and motor vehicie transportation safety.

h~esenate Environment and PuNic wok Committee authorizes and exercisesoversight over programs adm inistered by the Environmental i%Oh3CtiOn Agencytkit alleviate Or r~ucenoisetwater,

and air poiiution.

ine Senate ~nance Committee authorizes heaith programs under the Social s~urity Act. Inciuding Medicaid.

Jl_he Senate Governmental Affairs Committee has jurisdiction over programs of the Census Bureau, and over the organization of Congress and the U.S. executive branch.

Continued on next page
1.

Table 19-6-Congressional Committees With a Role in Adolescent Healtha-Continued

Judiciaryk AU/O AU/O

Labor and Human Resources’ AU/O AU/O AU/O AU/O AU/O AU/O AU/O AU/O AU/O

Labor

Education, Arts, and Humanities

Employment and Productivity

Disability Policy

Children, Family, Drugs, Alcoholism

Select Committee on Indian Affairs o 0 0

House committees

Agriculturem A/O AU/O

Conservation, Credit, and Rural Development

Domestic Marketing, Consumer Relations, and

Nutrition

Appropriations n AP/O AP/O AP/O AP/O AP/O AP/O AP/O AP/O AP/O

Armed Serviceso A/O A/O A/O

Banking, Finance, and Urban Affalrsp A/o A/o

Housing and Community Development .

Budget o 0 0 0 0 0 0 0 0

kThe Senate ~di~ary Committee authorizes and e~ercisesoversight over programs administered by the lJ.S. Department of Justice, including Office of Justice andotherprograms related to juvenile

justice and delinquency prevention.

l~e Senate ~bora~ Human R~our~s Committee authoriz~ and exer~ses oversight over a wide mnge of programs related to health, education, labor, and public welfare. It has jurisdiction over

the Public Health Service Act, substance abuse programs, education programs, and numerous other programs related to children and families.

ml%e House Agriculture Committee authorizes and exerases oversight over programs administered by the U.S. Department of Agriculture, including food and nutrition programs (e.g., the Food Stamp

Program, school nutrition programs) and programs related to rural development.

n~e fo{~~ng su~ommittws of the House committee on Appropriatio~ deal ~th programs reievant to adolescent health: Commerce, Justice, and State, the Judidary, and Related Agencies;

Defense; Interior and Reiated Agencies; labor, Heaith and Human Services, Education, and Related Agenaes; Rural Development, Agriculture, and Related Agencies; and VA, HUD, and

independent Agencies.

One House Armed Services committee authorizes programs administered by the us, Department of Defense, incl~ing CHAMpUS (see Senate Arm~ Services Committee abOVO).

pThe House Banking, Finance, and Urban Affairs Committee authorizes and exerases oversight over programs administered by the U.S. Department of Housing and Urban Development, including

housing and community development programs.
Table 19-6-Congressional Committees With a Role in Adolescent Healtha—Continued

AP - Handles appropriations AU = Authorizes major program areas O = Oversight of programs

B - Sets funding guidelines A = Authorizes specific programs T = Jurisdiction over funding sources such as trust funds

Congressional

Health and Financial Future

Work, related services access to competitiveness

committees and Schools and recreation, Special (delivery and health and defense

subcommittees Families education and fitness Nutrition groups access) services readiness Other

Education and Laborq AU/O AU/O AU/O A / O A / o AU/O

Elementary, Secondary, and Vocational Education

Health and Safety

Employment Opportunities

Select Education

Energy and Commercer AU/O AU/O AU/O AU/O AU/O A / O A / o

Health and the Environment

Government OperationsS

o 0 0 0 0 0 0 0 AU/O

Interior and Insular Affalrst AU/O AU/O AU/O AU/O AU/O

Judiciary U AU/O AU/O AU/O

Post Office and Civil Servicev A/O A/o A/o A/o A/O

Science, Space, and Technologyw A/O AU/O AU/O

Ways and Meansx AU/O A/O AU/O AU/O

Health

Human Resources

Select Committee on Children, Youth, and Families O 0 0 0 0 0 0 0 0

Select Committee on Hunger o 0 0 0 0 0

Select Committee on Narcotics Abuse and Controly O 0 0 0 0 0

Joint committee

Joint Economic Committee o 0 0 0

Economic Resources and Competitiveness

Education and Health

ql%e House Education and Labor Committee authorizes and exercises oversight overa wide range of programs related to education, labor standards, human resources programs for the elimination

of poverty and thacare and treatment of children (e.g., Head Start, community services block grants, juveniie justica and delinquency prevention, and programs for runaway youths), andjobtraining.

The House Energy and Commerce Committee authorizes and exercises oversight over a wide range of programs related to health and the environment. It has jurisdiction over the Public Health

Service Act and biomedical programs and health protection in general (including Medicaid and national health insurance). it also has jurisdiction over the Clean Air Act and the Safe Drinking Water

Act.

sThe House Government Operations Committee has oversight responsibilities related to the organization and reorganization of the U.S. executive branch.

~he House Interior and Insular Affairs Committee authorizes and exercises oversight over programs administered by the U.S. Department of the Interior, including programs that deal with national

parks and severai programs that affect Native Americans.

UThis House Judiciary Committm authorizes and exercises oversight over programs administered by the U.S. Department of Justice, inciuding Office of Justice and other programs related to juvenile

justice and delinquency prevention.

Whe House Post Office and Civil Service Committee has jurisdiction over programs of the Census Bureau and authorizes programs that deai with health and related services for Federal emplowes

and their families.

WThe House Science, Space, and Technology Committee authorizes research and development In science and technology.

XThe House Ways and Means Committee authorizes and exercises oversight over numerous programs of the social Security Act, inciuding AFDC.

YThe House Select Committee on Narcotics Abuse and Control investigates issues relating to substance abuse and the criminal justice system.

SOURCE: Office of Technology Assessment, based on material from U.S. Congress, Library of Congress, Congressional Ye//ow Book 16(3) (Washington, DC: Monitor Publishing Co., Fall 1990).

I

-.3
III-262 ● Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

intercourse, especially focusing on AIDS and HIV

infection and on adolescents’ use of illicit drugs. The

Division of Adolescent and School Health, for

example, spends most of its $33 million on HIV

education. The National Institute of Allergy and

Infectious Diseases, which spends about $98 million

on adolescents, is concentrating primarily on research related to vaccine development and therapeutic approaches for sexually transmitted diseases and

AIDS.

With the Federal Government’s heavy emphasis

on efforts related to adolescent sexual activity and

drug use, other more prevalent health problems, such

as unintentional injuries, the greatest killer of

adolescents, receive less attention.53 The Centers for

Disease Control’s Division of Injury Control, for

example, targets just over $3 million on injury

control for adolescents, less than a tenth of the funds

that the Centers for Disease Control spends on HIV

education. Adolescents’ own subjective distresses

are also little attended to.

Perhaps one reason health issues, other than those

related to sexual intercourse and substance use,

receive relatively little Federal funding is the current

lack of data on adolescent health defined broadly

and the limited availability and dissemination of

data that are both relevant and timely.54

The Office of Treatment Improvement, the U.S.

Departments of Education and Justice, the Health

Resources and Services Administration, and the

Family Support Administration award most, if not

all, of their physical and mental health education,

prevention, and social service activities funds

through block grants. Because the Federal Government does not determine the mix of services that

States provide under block grant programs (except

within broad guidelines), the Federal Government’s

ability to affect the health of adolescents is limited.

States receiving block grant awards, even maternal

and child health block grants, do not necessarily

choose to allocate funds to adolescents and their

health problems. The Federal Government could

earmark funds to adolescents within block grants,

but the procedure has the disadvantage of limiting

States’ ability to control services.

The other primary way the Federal Government

provides funding related to adolescent health also

presents a dilemma. Funds are often limited to

research or demonstration projects awarded on a

competitive basis.55 As with block grant programs,

it is often difficult to know whether those adolescents most in need of will be reached by the

demonstration projects that survive the Federal

grantmaking process. However, there is reason to

believe that the needs of adolescents may not be

adequately met by such a relatively passive approach, for several reasons. The overall grant

amounts are generally small; adolescents are not

specifically mentioned in many authorizing legislation or grant announcements; and the most adept at

writing grant proposals, rather than those most in

need, are most likely to receive funding.

This limited Federal role is a consonant with the

overall current Federal approach to domestic issues,

53s= Ch. s, “~iden~ Injuries: Prevention and Service&” in VO1. ~.

‘Volume I<umma ryandPolicy Options includes discussions of crosscutting issues in the detin.itionof adolescent health (box A) and in the collection

and dkse rnination of data on adolescent health and health semices (app. C) (44b). Further, data collection issues related to specitlc adolescent health

concerns (e.g., accidental injuries, chronic physical illness, mental healb delinquency, hopelessness) are discussed in the chapters in Volume II of this

Report, to be released later in 1991.

ssR~ent ex~pl~ include:

● Grants authorized under the Education of the Handicapped Act Amendments of 1990 (Public Law 101-476) to institutions of higher education

and local educational agencies (acting in collaboration with mental health entities) to improve seavices to students who are in special education

programs as a consequence of having a serious emotional disturbance; this progmrn is designed to address the longstanding need of such students

for the mental health semices that are not explicitly mandated by the original Education for All Handicapped Children Act (Fublic Law 94-142).

For further discussion see ch. 11, “Mental Health Services: Prevention and Services,” in Vol. II.

. Grants authorized by the National and Community Semice Act of 1990 to States or local applicants for the creation or expansion of service

opportunities for students (Title 1, Subtitle B); and the creation or expansion of full-time or summer youth service corps programs focusing on

conservation and human resources (Title I, Subtitle C), among other provisions. These programs are designed to ffl several purposes, including:

build self-esteem; teach tearnwor~ deeisio nmaking, and problemsolving; and tap youth as a resource for community service. For further

discussion see ch. 4, “Schools and Discretionary Time,” in Vol. II.

● Grants authorized by Title V of the Stewart B. McKinney Homeless Assistance Amendments Act of 1990 (Fublic Law 101-645) to support

demonstration projects regarding outreach and comprehensive primary health services for homeless children. For further discussio% see ch. 14,

“Hopelessness: Prevention and Services, ” in Vol. II.
Chapter 19-The Role of Federal Agencies in Adolescent Health . III-263

which is far less active than it has been at other

times.56 Further, with limited direct Federal involvement in social programs, a competitive approach to

grantmaking helps to ensure that Federal dollars are

well spent. Given the critical needs of adolescents,

however, it is not clear that such an approach is

sufficient.

Certain Federal policies specific to adolescents

have the effect of limiting the types of services

adolescents receive. For example, the Government

emphasis on abstinence from sexual intercourse

provides important limitations to the type of services

that adolescents engaging in these activities can

receive (67). If pregnancy occurs and an abortion is

desired, no Title X or Title XX funds can be used to

provide abortions, education and counseling for

abortion services, or abortion referral (54 FR 35440)

(19,94).

Given Federal agencies’ limited ability to fund

activities and the potential for duplication of or gaps

in efforts, many Federal representatives expressed

their desire to collaborate and coordinate more

frequently with other agencies serving adolescents.

Although there is some coordination ongoing within

and between Federal agencies through interagency

agreements, particularly in the areas of drug education and juvenile justice issues, many representatives were unaware of other Federal agencies’

projects and programs. Barriers to collaboration

include constraints inherent in congressional enabling legislation, the lack of a consistent definition

of adolescence, agencies’ disagreement as to what is

needed to improve the health of adolescents, lack of

incentives to cooperate, and lack of leadership on

adolescent issues.

Currently, there are no incentives or rewards for

Federal agencies to collaborate, and no mechanism

has been established through which information is

shared. There are several ways in which greater

collaboration could be encouraged. First, Congress

could establish a reward structure to encourage

collaboration or could set up a separate fund for

collaborative efforts. Additionally, an individual in

each Federal agency could be responsible for

coordinating adolescent issues within and between

agencies. In fact, the idea of having an adolescent

health coordinator is not a new one. Some State

governments recognize the need to have a health

coordinator for adolescents. The Bureau of Maternal

and Child Health within the Health Resources and

Services Administration supports coordination among

the various State adolescent health care coordinators, although it does not directly support the

coordinating function in any one State. However, no

such level of coordination exists between Federal

agencies. Instituting one Federal adolescent coordinator responsible for coordination across all agencies could improve adolescent services and programs as well as create a strong national advocate for

addressing the health needs of adolescents.

Mere coordination may not be sufficient. In fact,

several observers suggested that a new Federal

agency may be needed to organize the resources

necessary to improve the health of adolescents.

Clearly, the Federal Government has an important

role in improving the health of adolescents. Although funding research and demonstration projects

is an essential component of that role, the coordination of Federal efforts is and can be a more important

component of the Federal Government’s responsibility to approximately 12 percent of the Nation’s

population. Specific policy options on the Federal

role in adolescent health-across a broad range of

issues-can be found in Volume I of OTAs

Adolescent Health Report.

Chapter 19 References

1. Abrams, R., Director, Office of Program and Policy Develop

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U.S. Department of Health and Human Services, Rockville, MD,

personat communication, June 4, 1990.

2. ACTION, ACTION Annual Repoti 1988 (Washington DC:

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3. ACTION, “VISTA Juvenile Health Projects, ” unpublished

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4. ACTION, “Surnmary 1988 FGP Program: Project Profile and

Volunteer Activity Sumey, ’ unpublished mirneo, Sept. 7, 1989.

fiAs SUmmatiZ ed by Brindis and Lee intheirdiscussion of public policy issues affecting the health care delivery system for adolescents,”. . the United

States evolved from a pattern of dual federalism, with a limited role in domestic affairs for the federal govemmen~ to cooperativefederalisrn, with a

strong federal role in the 1930s. . .The term creativefederalism was applied to policies developed during [the early and middle 1960s] that extended the

traditional federal-state relationship to include direct federal support for local governmems (cities and counties), nonprofit org titions, and private

business and corporations to carry out healthi educatiou tr aining, social semices, and community development programs. During the 1970s, President

Richard M. Nixon coined the term newfederalism to describe his efforts to move away from the categorical programs of the Johnson years. . .President

Reagan cxtcndcd the idea in the 1980s to limit further the role of government, transferring authority and responsibility to the States, with a reduction

in federal funding. . .“ (ifalics uulied) (1 la). For further discussion, see Volume l-$ummury and Policy Options (44b).
III-264 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

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1990.

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Chapter 19-The Role of Federal Agencies in Adolescent Health . III-265

39.

40.

41.

41a.

42.

43.

44.

44a.

44b.

45.

46.

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no date.

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AdministratiotL Off3ce of Community Services, ‘‘Emergency

Community Services Homeless Grant pro- WashingtorL

DC, no date.

U.S. Department of Health and Human Services, Family Support

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Human Development Services, Administration for childre~

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Service, Alcohol, Drug Abuse, and Mental Health AdministratiorL National Institute on Alcohol Abuse and Alcoholism,

‘‘Research on the Prevention of Alcohol Abuse Among childre~

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“Research on Economic and Socioeconomic Issues in the

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U.S. Department of Health and Human Services, Public Health

Service, Alcohol, Drug Abuse, and Mental Health Administration% National Institute on Alcohol Abuse and Alcoholism,

“Alcohol Research Center Grants, ” request for application%

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National Institute on Drug Abuse, “Drug and Atcohol Abuse

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///-266 . Adolescent Health—Volume III: Crosscutting Issues in the Delivery of Health and Related Services

69.

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1989/1990.

U.S. Department of Health and Human Services, Public Health

Semice, Alcohol, Drug Abuse, and Mental Health A&mm“ “stratiom National Institute on Drug Abuse, ‘ADAMHA Gets Record

Budget Increase, ” NfDA Notes 5(1):9, Winter 1989/1990.

U.S. Department of Health and Human Services, Public Health

Service, Alcohol, Drug Abuse, and Mental Health A&mm‘ “stratio% National Institute on Drug Abuse, ‘‘Research Demonstration Applications on Drug Abuse Treatment for Women of

Child-Bearing Age and Offspring,” request for applications,

Rockville, MD, January 1990.

U.S. Department of Health and Human Services, Public Health

Service, Alcohol, Drug Abuse, and Mental Heatth Administration% National Institute on Drug Abuse, ‘‘Minority Drug Abuse

Prevention Research Centers,’ request for applications, Rockville, MD, January 1990.

U.S. Department of Health and Human Services, Public Health

Service, Alcohol, Drug Abuse, and Mental Health A&mm‘ “stratiou National Institute on Drug Abuse, “Projects Involving

Adolescents (7-17): 198G1990,” unpublished table, Rockville,

MD, Feb. 21, 1990.

U.S. Department of Health and Human Services, Public Health

Service, Alcohol, Drug Abuse, and Mental Health Admuu“ “strat.iom National Lnstitute of Mental Healti Division of Education

and Service Systems LiaisorL “The Child and Adolescent Service

System PmgrarrE- FY ’88 Report,” Rockville, MD, May 12,

1988.

U.S. Department of Health and Human Services, Public Health

Smice, Alcoho~ Drug Abuse, and Mental Health Administration National Institute of Mental Heala ‘‘Mental Health

Services Demonstration Grants: Child and Adolescent Service

System program, ” request for applications, Rockville, MD,

January 1989.

U.S. Department of Health and Human Services, Public Health

Service, Alcohol, Drug Abuse, and Mental Health Mrmms “ “ trationj National Institute of Mental HealQ “Update on CASSP,”

Rockville, MD, June 1989.

U.S. Department of Health and Human Services, Public Health

Service, Alcohol, Drug Abuse, and Mental Health A&mm“ “stratiou Otllce of Substance Abuse Preventio@ C)filce of Planning,

Budget and Evaluatio~ Dear Colleague letter from M.G.DDeputy Associate Director, WashingtorL DC, June 1990.

U.S. Department of Health and Human Semices, Health Care

Financing Adrmru“ “stratioq “Medicaid: ABnef S ummary of Tifle

XIX of the Social Security Act,” Baltimore, MD, September

1989.

U.S. Department of Health and Human Services, Health Care

Financing Administration “HCFA Fact Sheet: Medicaid, ”

Baltimore, MD, Apr. 15, 1989.

U.S. Department of Health ami Human Services, Health Care

Financing Administration organizational CM Baltimore, MD,

Aug. 1, 1989.

U.S. Department of Health and Human Services, Health Care

Financing Administration Office of the Actuary, unpublished

84.

85.

86.

87.

88.

89.

90.

91.

92.

93.

94.

95.

%.

97.

98.

data on Medicaid expenditures and enrollment in fiscal year 1988,

Baltimore, MD, June 1990.

U.S. Deparixnent of Health and Human Sewices, Public Health

Service, Health Resources and Services Adrmms “ ‘ tratiom Bureau

of Maternal and Child Health and Resources Development

organizational chart, Rockville, MD, no date.

U.S. Department of Health and Human Services, Public HeaJth

Semice, Health Resources and Services Admuus o “ tmtio~ Bureau

of Maternal and Child Health and Resources Development

“Understanding Title V of the Social Security Act: A Guide to

the provisions of Federal Maternal and Child Health Servicm

Legislation’ no date.

U.S. Department of Health and Human Services, Public Health

Service, Health Resources and Services Admuus “ o tratiow Bureau

of Maternal and Child Health and Resources Development

‘‘Fifth Report to the Congress on the Consolidated Federal

Programs Under the Maternal and Child Health Block Gran~”

Rockville, MD, May 1989,

U.S. Department of Health and Human Services, Public Health

Service, National Institutes of Healt& organizational ~

Bethex MD, no date.

U.S. Department of Health and Human Services, Public Health

Service, National Institutes of Heal~ unpublished daa provided

in response to the U.S. Congress, Ofllce of Tkdmology

Assessment’s questionnaire regarding adolescent health initiatives, 1989.

U.S. Department of Health and Human Services, Public Heatth

Semice, Office of the Assistant Secretary for Heal~ Office of

Disease Prevention and Health Promotio% “ODPHP: A Decade

of Progress,” WashingtoIL DC, December 1986.

U.S. Department of Health and Human Semices, Public Health

Service, OffIce of the Assistant Secretary for Heala Office of

Disease preventio~ and Health promotio~ Prevention ‘89/’ 90:

Fe&ralPrograms and Progress (Washingto~ DC: U.S. Government Printing Office, 1990).

U.S. Department of Health and Human Services, Public Health

Service, Ofilce of the Assistant Secretary for Heal~ Office of

Minority Hedt& ‘‘OfIlce of Minority HealtlL” Washington DC,

no date.

U.S. Department of Health and Human Services, Public Health

Service, Office of the Assistant Secretary for HealtlL Office of

Minority Health, “Minority Community Demonstration

Grants,” Washington, DC, 1989.

U.S. Department of Health and Human Services, Public Health

Service, Mice of the Assistant Secretiuy for HealtlL office of

Minority Heal~ “HIV/AIDS Education and Prevention

Grants,” June 24, 1990.

U.S. Department of Health and Human Services, Public Health

Service, Ofilce of the Assistant Secretary for Healt.lL Office of

Population Affairs, Deputy Assistant Secretaq for Population

Affairs, ‘‘Family Planning and Five Year Pw’ memorandum

to the Assistant Secretary for Heal~ Planning, and Evaluation

Washingto~ DC, Sept. 9, 1988.

U.S. Department of Health and Human Services, Public Health

Semice, Office of the Assistant Secretary for Heal~ Office of

Population AfYairs, The Adolescent Fam’ly Life Restwrch Project

Summaries, Washington DC, 1989.

U.S. Department of Health and Human Services, Public Health

Service, ~lce of the Assistant Secretary for Heal~ Otllce of the

Surgeon General, Better Health for Our Children: A Natioml

Strategy, Vol. 1, DHHS (PI-IS) Pub. No. 79-55071, (Washington

DC: 1981).

U.S. Department of Justice, Office of Juvenile Justice and

Delinquency Prevention Twelfth Analysis and Evaluation:

Federal Juvenile Delinquency Programs 1988 (Washington, DC:

1988).

U.S. Department of Labor, Employment and Training Administration Training and Employment Report of the Secretary of
Chapter 19-The Role of Federal Agencies in Adolescent Health . III-267

Labor, DOL Pub. No. 209- 109-814/’94907 (waShhgtO~ ~:

Us. Gov ernment Printing Office, 1988).

99. U.S. Department of Labor, Employment and Training Adrninistratiou Budget OffIce, Washing-tom DC, personal communicatiOrlS, Sept. 13 and 14, 1990.

100. U.S. Department of Labor, Employment and Trainin g Administration OffIce of Job Training Programs, Oft3ce of Job Corps,

“Job Corps in Brief,” Washington, DC, 1987.

101. U.S. Department of Labor, Employment and Training Adrninistratiom Office of Job Training Programs, Bureau of Apprenticeship and Training, “The Bureau of Apprenticeship and Training:

A Brief Ovemiew,” Washington DC, August 1989.

IW. U.S. Department of TransportatiorL Federal Highway Administration% Office of Highway Safety, An Overview of FHWA

Highway Safety Programs, Pub. No. FI-IWA-SA-89-047 (Washington DC: U.S. Government Printing Ofi7ce, April 1989).

102a. U.S. Executive OffIce of the President, Office of Management

and Budgeg Budget of the U.S. Government, Fiscal Year 1991

(WashingtorL DC: U.S. Government Printing Ofllce, 1990).

103. Washnitzer, M., Famdy !hppOrt Alrninistration, U.S. Department of Health and Human Services, Washington DC, personal

communication% May 9, 1990.
APPENDIxEs
Appendix A

GLOSSARY OF ABBREVIATIONS AND TERMS

Abbreviations

AAP —American Academy of Pediatrics

ACOG —American College of Obstetrics and

Gynecology

ADAMHA-Alcohol, Drug Abuse, and Mental Health

Administration (Public Health Service)

AFDC —Aid to Families With Dependent Children

AIDS —acquired immunodeficiency syndrome

AMA —American Medical Association

CASSP —Child and Adolescent Service System

Program (National Institute of Mental

Health)

CDC —Centers for Disease Control (Public Health

Service)

CFR —Code of Federal Regulations

CHAMPUS —Civilian Health and Medical Program of

the Uniformed Services (U.S. Department

of Defense)

CHC -community health center

CPO —Center for Population Options

DHHS —U.S. Department of Health and Human

Services

DSM-III —Diagnostic and Statistical Manual, 3 r d

edition

EPSDT—Early and Periodic Screening, Diagnosis,

and Treatment program (Medicaid)

ERISA —Employee Retirement and Income Security

Act (Public Law 92-104)

FR —Federal Register

FSA —Family Support Administration (U.S.

Department of Health and Human

Services)

HCFA —Health Care Financing Administration (U.S.

Department of Health and Human

Services)

Hispanic —Hispanic Health and Nutrition

HANES Examination Survey (National Center for

Health Statistics)

HIV —human immunodeficiency virus

HMO —health maintenance organization

HRSA —Health Resources and Services

Administration (Public Health Service)

IHS —Indian Health Service (Public Health

Service)

IQ —intelligence quotient

JOBS —Job Opportunity and Basic Skills training

program (Family Support Administration)

NAMCS —National Ambulatory Medical Care Survey

(National Center for Health Statistics)

NCHS —National Center for Health Statistics

(Centers for Disease Control)

NHANES —National Health and Nutrition

Examination Survey (National Center for

Health Statistics)

NHIS —National Health Interview Survey

(National Center for Health Statistics)

NIH —National Institutes of Health (Public

Health Service)

NIMH —National Institute of Mental Health

(Alcohol, Drug Abuse, and Mental Health

Administration)

NSFG—National Survey of Family Growth

(National Center for Health Statistics)

OASH -Office of the Assistant Secretary for Health

(U.S. Department of Health and Human

Services)

OB/GYN -obstetrics/gynecology

OBRA-81 -Omnibus Budget Reconciliation Act of

1981 (Public Law 97-35)

OBRA-89 --Omnibus Budget Reconciliation Act of

1989 (Public Law 101-239)

OBRA-90 -Omnibus Budget Reconciliation Act of

1990 (Public Law 101-508)

OHDS -Office of Human Development Services

(U.S. Department of Health and Human

Services)

OJJDP -Office of Juvenile Justice and Delinquency

Prevention (U.S. Department of Justice)

OTA --Office of Technology Assessment (U.S.

Congress)

PHS —U.S. Public Health Service (U.S.

Department of Health and Human

Services)

PPO —preferred provider organization

SAM-The Society for Adolescent Medicine

SLHC —school-linked health center

SPRANS —special projects of regional and national

significance

SSI —Supplemental Security Income program

(U.S. Department of Health and Human

Services)

STD —sexually transmitted disease

VISTA —Volunteers in Service to America

(ACTION)

WIC —Special Supplemental Food Program for

Women, Infants, and Children (U.S.

Department of Agriculture)

-111 -271-
III-272 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Terms

Access: Potential and actual entry of a population into the

health care delivery system. Elements of access

include availability, affordability, and approachability.

Acute condition: A problem or disease of limited

duration, as opposed to chronic. According to the

DHHS National Center for Health Statistics, a condition is considered acute if: 1) it was first noticed no

longer than 3 months before the reference date of the

interview and 2) it is net one of the conditions

considered chronic regardless of the time of onset.

However, any acute condition is not associated with

either at least one doctor visit or at least 1 day of

restricted activity is considered to be of minor consequence and is excluded from the final data produced by

the DHHS National Center for Health Statistics’

National Health Interview Survey.

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. See early adolescence, middle

adolescence, late adolescence, younger adolescents,

older adolescents.

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. 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.

Adolescent medicine: A certified medical subspecialty

of pediatrics, focusing on the care of adolescents. See

pediatrician.

Advocacy: Refers to support, coordination and linkage to

experts, individuals, groups, and institutions who may

help adolescents. May be provided by parents or others

known to an adolescents.

Age of majority: The age at which by law a person is

entitled to the management of his or her own affairs

and to the enjoyment of civic rights. Currently, the age

of majority is set at age 18 in every State but Alaska,

Nebraska, and Wyoming, where the age is 19.

AIDS (acquired immunodeficiency syndrome): A disease caused by human immunodeficiency virus (HIV)

and characterized by a deficiency of the immune

system. 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).

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 parent is dead, disabled, continually absent from the home, or unemployed. Eligible

families must meet income and resource criteria

specified by the State.

Alcohol abuse: See substance abuse.

Alcohol, drug abuse, and mental health (ADM) block

grant: 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 XIX of the Public

Health Service Act). The ADM block grant is administered by the Office of Treatment Improvement in the

Alcohol, Drug Abuse, and Mental Health Administration in DHHS,

Ambulatory care: Health care services provided to

patients who are not inpatients of hospitals or other

residential facilities (e.g., residential treatment centers,

nursing homes). May include care provided in a

hospital on an outpatient basis. But see National

Ambulatory Medical Care Survey, National Health

Interview Survey, office visit, and physician contact.

Anticipatory guidance: The provision of health education, information, or counseling about topics important

to health, optimally before problems have arisen.

Block grants: Sums of Federal funds allotted to State

agencies (e.g., education, health) which may be passed

onto 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.

Case law: The body of law created by judicial opinions

rendered in legal cases in contrast to statutory law

generated by legislatures.
Appendix A-Glossary of Abbreviations and Terms . III-273

Chronic condition: A problem or disease that is lingering

and lasting, as opposed to acute. For purposes of

DHHS’ National Health lnterview Survey, a condition

is considered ‘‘chronic’ 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 conditions that are considered chronic

regardless of their time of onset are diabetes, heart

conditions, emphysema, and arthritis.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS): A health insurance

program, administered by the U.S. Department of

Defense, that provides health benefits to military

dependents and retirees who are unable to receive

services through uniformed service medical treatment

facilities.

Civilian noninstitutional 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.

Coinsurance payment: A specified percentage, usually

20 percent, that a person with health insurance must

pay for each covered service up to an annual limit (e.g.,

$1,500) after which the plan pays 100 percent of

covered benefits. Compare deductible.

Common law: As distinguished from statutory law

created by a legislature, the body of principles and

rules of action which derive their authority solely from

long-standing usages and customs (in particular,

Anglo-American usages and customs) or from the

judgments and decrees of the courts recognizing,

affirming, and enforcing such usages and customs.

Common law rule: A rule grounded in common law (see

above) rather than in statutory law.

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 undeserved.

Competence (to make health care decisions): Having

sufficient knowledge, judgment, or skill to make

health care decisions. The legal concept of competency

is central to existing laws governing health care

decisionmaking with respect to minors, and the

parental consent requirement is partially an outgrowth

of the presumption that minors are incompetent to

make health care decisions.

Comprehensive centers for adolescents: School-linked

or community-based centers provide comprehensive

services for adolescents.

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, child care services and parenting education

for adolescent parents. Not all services are available at

all centers, but a well-functioning comprehensive

services center would provide for the coordinated

delivery of care both within the center and between the

center and outside agencies and providers.

Confidentiality (of the physician/patient relationship):

The state or quality of being confidential, that is

intended to be held in confidence or kept secret. Courts

and legislatures have established a physician-patient

privilege to protect the confidentiality of communications between physicians and their patients and have

established similar privileges to ensure the confidentiality of communications between other types of health

care providers and their patients or clients. By and

large, the confidentiality of the relationship between

health service providers and minors and the disclosure

of confidential information by health service providers

to the parents of minors or other third parties are not

addressed in case or statutory law.

Consent: See informed consent, parental consent requirement,

Constitutional law: The branch of law that involves the

U.S. Constitution.

Contraception: The prevention of conception or impregnation by any variety of means, including periodic

abstinence (rhythm method); control of ejaculation

(coitus interrupts); 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 (e.g., the oral

contraceptive pill); and sterilization of the male or

female partner.

Contract: An agreement, express or implied, between

two or more persons which creates an obligation to do

or not to do a particular thing. Its essentials are
III-274 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

competent parties, subject matter, legal consideration,

mutuality of agreement, and mutuality of obligation.

The relationship between a. physician and an adult

patient is usually considered a contractual relationship.

Contract law: Law pertaining to contracts (see above).

Conventional health insurance plan: A traditional

indemnity or fee-for-service health insurance plan that

typically reimburses the health provider on a “reasonable and customary’ basis or as billed. Distinguished

from health maintenance organizations (HMOs) and

preferred provider organization (PPOs). Compare

managed fee-for-service plan.

Copayment: See coinsurance payment.

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.

Culturally competent: A set of congruent behaviors,

attitudes, and policies that come together in a system,

agency, or among professionals and enables that

system, agency, or those professionals to work effectively in cross-cultural situations. A culturally competent system of care acknowledges and incorporates-at

all levels-the importance of culture, the assessment

of cross-cultural relations, vigilance towards the dynamics that result from cultural differences, the

expansion of cultural knowledge, and the adaptation of

services to meet culturally unique needs. See culture.

Culture: Implies the integrated pattern of human behavior that includes thoughts, communications, actions,

customs, beliefs, values, and institutions of a racial,

ethnic, religious, or social group.

Current Population Survey (CPS): A household sample

survey of the civilian noninstitutionalized population

that provide estimates of employment, unemployment,

and other characteristics of the general labor force, the

population as a whole, and various other subgroups of

the population. The survey is conducted monthly by

the Bureau of the Census within the U.S. Department

of Commerce. Annual data on the number of people

living in poverty and their characteristics, based on

income during the previous year and families’ status as

of March of the current year, are obtained in the March

supplement to the Current Population Survey, which

surveys a sample of households from the most recent

decennial census.

Deductible: A specific dollar amount, usually about $400

per family, that must be paid. before a health insurance

plan begins paying benefits.

Demonstration project: An intervention that is typically

in an experimental (unproven) stage of effectiveness

and is supported for a limited: period with an evaluation

component.

Diagnosable mental disorders: Disorders included in

the American Psychiatric Association’s Diagnostic

and Statistical Manual of Mental Disorders, 3rd cd.,

revised.

Discretionary spending programs (in the Federal

budget): Those spending programs subject to the

annual appropriations process. Compare entitlement

programs.

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.

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program: A State and federally

funded, State-administered program under Medicaid

that is intended to provide preventive screening exams

and followup services for illnesses, abnormalities, and

treatable conditions to Medicaid-eligible children under

age 21. The EPSDT benefit was enacted in 1967; with

changes introduced in 1989, EPSDT offers the most

comprehensive child and adolescent preventive care

package currently available in any private or public

financing plan. As such, it is potentially the most

important primary care benefit available to adolescents

covered by Medicaid.

Emancipated minor: A minor who has been legally

freed from the control and authority of his or her

parents. Under the common law doctrine of emancipation, emancipation may be expressed, as by voluntary

agreement of the parent and child, or implied from

such acts and conduct as import consent (e.g., a

minor’s marriage or establishment of a home away

from that of his or her parents); it may be complete or

partial; and it may or may not result in a minor’s having

the right to consent to health services. About half the

States have enacted statutes that allow for courtordered emancipation. In some States, these statutes

explicitly state that emancipation removes the disabilities of minority, including the requirement of parental

consent to health services.

Employer mandate: A requirement imposed by the

Federal Government on the States that employers offer

group health insurance policies and pay a significant

amount of the premiums for all employees who work

more than a specified number of hours per week.

Employment-based group health plans: A group

health plan that is offered to employees by an

employer. The terms private health insurance, private

health plans, and group health plans are often used

interchangeably in this volume to refer to employmentbased group health plans.

Entitlement programs: Programs that provide benefits

paid out automatically to all who qualify unless there

is a change in underlying law (examples include

Federal employee retirement benefits, Medicare, Med-
Appendix A--Glossary of Abbreviations and Terms . III-275

icaid, unemployment compensation, Aid to Families

With Dependent Children).

Ethnicity: A term used to indicate national origin (e.g.,

Hispanic). Most census and health status information

is available for individuals of Hispanic origin. Compare race.

Family autonomy: Noninterference by the state in the

right of families to make important decisions concerning family life and family members. A tradition of

family autonomy is deeply embedded in AngloAmerican law and can be traced back to Roman law,

the Judeo-Christian tradition, and Anglo-Saxon customary law. Family autonomy is often, but not always,

equated with parental authority.

Family composition: See family structure.

Family counseling: Counseling provided to an entire

family rather than solely to an individual.

Family planning: A range of services intended to help

individuals plan when to have children, from counseling concerning the advisability of initiating sexual

intercourse to the provision of contraceptive methods.

Services may be provided in freestanding family

planning clinics or in more general health services

settings. See contraception, Title X of the Public

Health Service Act,

Family structure: Used to describe the relationship

between dependent children and the adult head(s) of

household with whom they reside. In this report,

typically includes: a family consisting of children and

a single parent (a single parent family); children living

with their biological parents (sometimes called an

“intact” family); dependent children living with a

biological parent and a stepparent (stepfamily or

blended family); and dependent children not living

with a parent.

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.

Fee-for-service: See conventional health insurance plan.

Financial access (to health services): In this Report,

used to refer to aspects of access that have to do with

health insurance coverage and ability to pay for

services. Compare legal access.

Freestanding (comprehensive) services centers (for

adolescents): Those comprehensive services centers

not located within a school, health maintenance

organization, hospital, or other facility.

Group health plan: A health insurance plan that is

obtained, not on an individual or family basis, but

through an employment or other membership contract.

Also see employment-based group health plan. The

terms private health insurance, private health plans,

and group health plans are often used interchangeably

in this volume to refer to employment-based group

plans.

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 care provider: Any of the broad range of

disciplines that specialize in providing health care

services. Includes, but is not necessarily limited to,

health educators, nurses, nurse-midwives, nursepractitioners, psychiatric nurses, clinical psychologists, clinical social workers, and physicians.

Health education: Activities aimed at influencing behavior in such a way as it is hoped will assist in the

promotion of health and the prevention of disease.

Health maintenance organization (HMO): An organization that, in return for a prospective per capita

(cavitation) payments, acts as both insurer and provider of comprehensive but specified health care

services to a voluntarily enrolled population. Prepaid

group practices and individual practice associations

are types of HMOs.

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: Most broadly, a philosophy of health

or a set of activities that takes as its aim the promotion

of health, not just the prevention of disease. Sometimes

narrowly defined as the set of prevention efforts aimed

at changing individual behavior: Compare health

education, health protection, and preventive health

services.

Health protection: Strategies for health promotion and

disease prevention related to environmental or regulatory measures that confer protection on large population groups.

Health services system: Traditionally, the aggregation of

diagnostic and treatment services delivered by health

care professionals, including physicians, physician

assistants, nurses, nurse-practitioners, psychologists,

and health educators.

Hispanics: Persons who identify themselves as of Hispanic origin, or, less typically, individuals with Hispanic surnames identified by others (e.g., health care

providers identifying patients in surveys) as of Hispanic origin. Hispanics can be those whose families

have emigrated directly from Spain, or from Cuba,

Central or South America. Persons of Hispanic origin

can be of any race (white, black, American Indian);

most have been found to be white. See ethnicity.

Human immunodeficiency virus (HIV): The virus that

causes AIDS.
///-276 . Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Human resources programs: In the U.S. Federal budget,

includes the following broad categories of Federal

expenditures: education, training, employment, and

social services; health; Medicare; income security;

social security; and veterans benefits and services.

Human resources programs are referred to by some as

‘‘social welfare programs. Does not include Federal

expenditures related to: national defense; physical

resources (i.e., energy; natural resources and environment; commerce and housing credit; transportation;

and community and regional development); net interest; and ‘‘other functions’ (i.e., international affairs;

general science, space and technology; agriculture;

administration of justice; general government; and

allowances).

Indian: In this Report, refers to Native Americans in the

continental United States, and Indians, Aleuts, and

Eskimos in Alaska.

Informed consent: A person’s agreement to allow

something to happen (e.g., a medical procedure) that is

based on a full disclosure of facts needed to make the

decision intelligently. Informed consent is also the

name for a general principle of law that a physician has

a duty to disclose information about the risks of a

proposed treatment to a patient so that the patient may

intelligently exercise his or her judgment about

whether to undergo that treatment.

Informed consent doctrine: A legal doctrine, developed

in judicial opinions and codified by legislation, that

imposes a legal duty on physicians to give their adult

patients information necessary for the patients to make

an informed and voluntary choice regarding proposed

medical treatment or surgery; a physician’s failure to

obtain a patient’s informed consent may give rise to

civil liability. Although the doctrine of informed

consent is based on the premise that every person has

a right to determine what is done to his or her body, the

focus of the doctrine as it has been articulated and

applied is on the duty of health professionals to

disclose information to patients rather than on the

patients’ understanding of the information.

Inpatient care: Care that includes an overnight stay in a

medical facility.

Internist: A physician who specializes in the diagnosis

and medical, as opposed to surgical and obstetrical,

treatment of diseases of adults.

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.

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.

Managed fee-for-service plan: A conventional health

insurance plan which requires patients to obtain prior

approval before admission to a hospital and prospective utilization review.

Managed health care: Care provided to enrollees in

managed for-fee service plans, health maintenance

organizations (HMOs) and preferred provider organizations (PPOs). Patients in managed health care plans

do not have open access to physicians or hospitals and

usually must obtain prior approval before admission to

a hospital. HMOs and PPOs may also require that the

health provider’s treatment plan be reviewed to ensure

that it is necessary. Patients who do not follow the

HMO or PPO guidelines may face larger out-of-pocket

costs or be denied payment altogether. Some managed

health care plans contain ‘‘individual benefits management” programs that allow payment for otherwise

uncovered benefits (e.g., home- and community-based

services) in order to avoid the utilization of more costly

covered services.

Maternal and child health block grants: Under the

authority of Title V of the Social Security Act, funds

made available to States for the purpose of assuring

‘‘access to quality maternal and child health services,

especially for those with low incomes and living in

areas with limited availability of health services. ”

Distributed and overseen by the Bureau of Maternal

and Child Health in DHHS' Health Resources and

Services Administration.

Maternity care: Medical services provided from conception, through labor and delivery, and during the

postpartum period (through the sixth week after birth).

Medicaid: A federally aided, State-administered program

that provides medical assistance for low-income people meeting specific income and family structure

requirements.

Medically needy Medicaid recipients: People who

receive Medicaid under State “medically needy”

programs. States have the option to offer Medicaid to

medically needy people who would be categorically

eligible for Medicaid but whose income and resources

lie above the standards for Aid to Families With

Dependent Children, (AFDC). Each State sets its own

medically needy resource and income standards up to

133 percent of State AFDC income standards.

Medium and large firms: Firms with at least 100 or 250

employees, depending on the industry.

Mental disorders: See diagnosable mental disorders.

Mental health problems: See diagnosable mental disorders, and subjective distress.

Mental health services: Care for the treatment of mental

health problems, third-party payment for which is

usually limited to diagnosable mental disorders, and

not available for subjective distress without an accompanying diagnosable mental disorder.

Middle adolescence: Typically, a time of increasing

independence. Generally takes place during the period

from ages 15 through 17. For those adolescents who do
Appendix A-Glossary of Abbreviations and Terms . III-277

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.

Minor: A person who has not reached the age of majority,

either age 18 or 19, depending on the State. Currently,

the age of majority is set at age 18 in every State but

Alaska, Nebraska, and Wyoming, where the age is 19.

Morbidity: The condition of being diseased or otherwise

afflicted with an unhealthful condition. See also new

morbidities.

National Ambulatory Medical Care Survey (NAMCS):

A continuing national probability sample of ambulatory medical encounters. The survey covers physicianpatient encounters in the offices of nonfederally

employed physicians classified by the American

Medical Association or American Osteopathic Association as ‘‘office-based, patient care’ physicians. It

excludes visits to hospital-based physicians, visits to

specialists in anesthesiology, pathology, and radiology. It also excludes telephone contacts and nonoffice

visits. NAMCS is conducted by the National Center for

Health Statistics in DHHS.

National Health and Nutrition Examination Survey

(NHANES): A survey in which data on the status of the

population are obtained by means of direct physical

examinations, clinical and laboratory tests, and related

measurement procedures, NHANES is the successor to

the National Health Examination Survey, which was

conducted from 1%6 to 1970, and which oversampled

adolescents. NHANES I was conducted from 1971

through 1974, NHANES II, from 1976 through 1980,

and NHANES III is expected to completed in 1994.

NHANES is conducted by the National Center for

Health Statistics in DHHS.

National Health Interview Survey (NHIS): A continuing nationwide sample survey in which personal

household interviews are used to obtain information on

personal and demographic characteristics, illnesses,

injuries, impairments, chronic conditions, utilization

of health resources, and other health topics. 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 Survey of Family Growth (NSFG): A fivestage area probability sample of civilian noninstitutionalized women ages 15 to 44 and living in the

United States. NSFG is conducted by the National

Center for Health Statistics in DHHS.

Native American: Typically used to refer to American

Indians or Alaska Natives, but may also refer to Native

Hawaiians.

Near-poor: A term defined in relation to the Federal

poverty level, a cash income level which varies with

family size and the age of the family members. In this

Report, near-poor families are families with incomes

from 100 percent to 149 percent of the Federal poverty

level. The Federal poverty level for a family of three

was $10,560 in January 1990.

New morbidities: Illnesses and conditions caused by

social and behavioral (rather than organismic) factors

(e.g., outcomes of sex, drugs, and violence).

Nonphysician providers: Health care providers other

than physicians. They include nurse practitioners,

psychologists, clinical social workers, clinical nurse

midwives, and drug addiction counselors.

of Office visit: For purposes of the National Center for

Health Statistics’ National Ambulatory Medical Care

Survey, a physician’s office is defined “premises

identified by physicians as locations for their ambulatory practices, customarily including consultation,

examination, or treatment spaces the patients associate

with a particular physician. Excludes hospital-based

outpatient departments; family planning clinics; government-operated clinics for sexually transmitted diseases and maternal and child health; and hospital

emergency facilities.

Older adolescents: As defined in most DHHS National

Center for Health Statistics data analyses, adolescents

ages 15 to 19.

“one-stop’” shopping: A setting for health care services

that delivers an entire set of comprehensive health

(and, often, related) services. Currently an ideal rather

than an actuality.

Out-of-pocket expense: Personal expenditures for the

portion of health care services not covered by thirdparty payment.

outpatient care: Care that is provided in a hospital and

does not include an overnight hospital stay. Sometimes

(as in mental health services) used to refer to all

ambulatory care.

Parens patriae: Literally “parent of the country,” refers

traditionally to the role of the state as sovereign and

guardian of persons under legal disability (e.g., minors, adults who have been declared legally incompetent).

Parental authority: The deference of the state to the right

of parents to make decisions about childrearing. Under

common law, minor children were in effect the chattels

or property of their parent, who had virtually the

unfettered right to rear them as they saw fit. Overtime,

minor children increasingly have been recognized as

having independent rights, yet they are still largely

subject to the authority of their parents. In a line of

decisions over 50 years, the U.S. Supreme Court has

held that parents have a Federal constitutional right to

direct the upbringing of their children free from state

intervention in the absence of a constitutionally

acceptable justification for such intervention. In more

recent decisions, however, the Supreme Court has

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III-278 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

begun to confront conflicts between a parent’s asserted

right to direct a minor child’s upbringing and the

minor’s assertion of his or her own independent rights

and has issued several decisions involving actual or

potential parent-child conflicts with respect to the

access of minors to contraceptives and abortions and

the civil commitment of minors.

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.

This requirement reflects the application to minors of

the tort law doctrine of informed consent, as well as

principles under contract law. Traditionally, minors

have been deemed incompetent as a matter of law to

give informed consent to medical and surgical care and

incompetent to enter into binding contracts, including

contracts with physicians and surgeons. The rationales

for parental consent requirements in the area of health

care include the need to protect minors from their own

improvident decisionmaking (based on the assumption

that minors as a class lack the requisite capacity to

make health care decisions), to promote family autonomy and privacy, to promote parental authority and

control of minor children. Over the years, the number

of exceptions to the parental consent requirement

applicable to the health care of minors has grown

significantly.

Parental notification requirement (applicable to

health care of minors): A requirement that the parents

of minors be notified of the decisions of their minor

children to obtain health services. In carving out

exceptions to the common law requirement for parental consent to the provision of health services to minors

(see above), courts and legislatures have sometimes—

though not always-replaced the parental consent

requirement with a parental notification requirement.

Thus, many parental notification requirements appear

in laws that create exceptions to parental consent

requirements by allowing minors to consent to health

services related to sexual activities, health services for

drug and alcohol abuse, or mental health services.

Pediatrician: A physician who specializes in the branch

of medical science concerned with the hygienic,

physiologic, and pathologic conditions of children.

Physician contact: As defined by the DHHS’ National

Center for Health Statistics for the National Health

Interview Survey, any contact with a physician directly

or with a nurse or other person acting under the

physician’s supervision, whether in person or by

telephone, for the purpose of examination, diagnosis,

treatment, or advice, excluding physician contacts with

hospital inpatients or for the purpose of mass screenings (e. g., in a trailer). Compare office visit.

Poor: A term 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

families with incomes below 100 percent of the

Federal poverty level. The Federal poverty level for a

family of three was $10,560 in January 1990. Compare

near-poor.

Preferred provider organization (PPO): A group of

health providers that contracts with employers, insurers, third party administrators, or other sponsoring

groups to provide services on a discounted fee-forservice basis; health plan participants who use these

providers pay lower deductible and coinsurance payments.

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, or related medical conditions as they cover other medical care.

Prenatal care: Medical services related to fetal, infant

and maternal health, delivered from time of conception

to labor.

Preventive health services: Services intended to prevent

the occurrence of a problem (e.g., disease or condition). Primary prevention is aimed at reducing the

incidence of a disease or health problem; secondary

prevention is aimed at reducing the prevalence of a

problem by shortening duration among those who have

the problem; and tertiary prevention is aimed at

reducing complications. 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. Longitudinality 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 preventive health services.

Private health plan: See employment-based group

health plan.

problem behavior theory: The thesis that a variety o f

deviant or problem behaviors are all manifestations of

a general dimension of conventionality versus uncon-
Appendix A-Glossary of Abbreviations and Terms . III-279

ventionality. In turn, the tendency toward conventionality or unconventionality is seen as arising out of three

interacting systems of psychosocial influence: the

personality system, the perceived environment, and

the behavior system.

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 behavior, substance abuse).

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 may be initiated by an adolescent him or

herself.

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.

Race: Races can be distinguished by usually inherited

physical and physiological characteristics without

regard to language or culture (caucasoids, negroid,

mongoloid). By Census Bureau definition, the term

race is used to distinguish among peoples who are

white (caucasoid), black (negroid), or Asians or Pacific

Islanders or American Indians (mongoloid). See ethnicity, Hispanic, Indian.

Racial and ethnic minorities: In this Report, anyone is

who not ‘‘white, non-Hispanic. ” Includes black

Asian American, Hispanic and other adolescents.

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.

Restricted-activity day: As defined by the DHHS

National Center for Health Statistics’ National Health

Interview Survey, any day on which a person cuts down

on his or her usual activities for more than one-half day

because of an illness or an injury. Resticted-activity

days are unduplicated counts of: 1) bed-disability

days (days on which a person stayed in bed more than

half a day because of illness or injury or was in a

hospital as an inpatient); 2) work-loss days (days on

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 (days on which a

student 5- to 17-years-old missed more than half a day

from the school); and 4) cut-down days (days on

which a person cuts down for more than half a day on

the things he or she usually does). Work-loss, school10SS, and cut-down days refer to the short-term effects

of illness or injury. Bed days are a measure of both

long- and short-term disability, however, because a

chronically ill bedridden person and a person with a

cold could both report having spent more than half a

day in bed due to an illness. See restriction of activity.

Restriction of activity: As used in the DHHS National

Center for Health Statistics’ National Health Interview

Survey, ordinarily refers to a relatively short-term

reduction in a person’s activities below his or her

normal capacity. See restricted-activity day.

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. (Census-recognized ‘places’

are either: 1) incorporated places such as cities,

boroughs, towns, and villages; or 2) closely settled

population centers that are outside of urbanized areas,

do not have corporate limits, and (unless they are in

Alaska and Hawaii) have a population of at least

1,000.) The term “rural” is often used to refer to

nonmetropolitan statistical areas (i.e., any area not in

a metropolitan statistical area, which, 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).

School-linked health center (SLHC): Refers to 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. May also

include a wider range of services (e.g., child care,

employment training, tutoring, social services, recreational opportunities). Compare comprehensive services for adolescents.

School-loss day: A day in which a student missed more

than half a day from the school in which he or she was

currently enrolled.

Secondary prevention: See preventive health services.

Self-insured (health insurance) plan: A health benefit

plan in which the financial risk for providing medical

services is assumed by the employer or sponsor instead

of purchasing health insurance from an insurance

company. The employer or sponsor may continue to

contract with an insurance company or other organization for claims processing and administrative services,

as well as stop-loss insurance to limit the amount of

their liability for medical claims.

Sensitivity: One measure of the validity (or accuracy) of

a diagnostic or screening test: the percentage of all

those who actually have the condition being tested for
111-280. Adolescent Health-–Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

who are correctly identified as positive by the test.

Operationally, it is the number of true positive test

results divided by the number of patients that actually

have the disease or condition (true positives divided by

the sum of true positives plus false negatives).

Compare specificity.

Sexually transmitted disease (STD): Any infectious

disease transmitted through sexual intercourse or

genital contact. Examples are gonorrhea, chlamydia,

herpes, and AIDS. Formerly (and sometimes, in law)

called venereal disease.

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 services: Service 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).

Socioeconomic status: Used in this Report as a synonym

for income levels, typically those of an adolescent’s

family of origin, because adolescents are unlikely to

have their own independent sources of income. See

poor, near-poor.

Specificity: One measure of the validity (or accuracy) of

a diagnostic or screening test: the percentage of all

patients that do not have the condition being tested for

that are correctly identified as negative by the test.

Operationally, it is the number of negative test results

divided by the number of” patients that actually do not

have the condition (true negatives divided by the sum

of true negatives plus false positives). Compare

sensitivity.

State: In this Report, the capitalized term State (whether

used as an adjective or a noun) refers to 1 or more of

the 50 United States. The term state (not capitalized)

refers more generally to the body politic.

Statutory law: The body of law created by acts of the

legislature in contrast to law generated by judicial

opinions and administrate bodies.

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 abuse: What constitutes adolescent substance

abuse (any use at all or “problem’ use) is a matter of

controversy. The DHHS Office of Substance Abuse

Prevention is of the view that any use by adolescents

of psychoactive substances by adolescents should be

considered abuse; the American Psychiatric Association distinguishes between substance use, substance

abuse, and substance dependence, although does not

make distinctions by age. According to the American

Psychiatric Association’s diagnostic manual (DSM-IIIR), substance abuse is characterized by maladaptive

patterns of substance use that have never met the

criteria for dependence for that particular class of

substance, that results in harm to the user, and that the

user continues despite persistent or recurrent adverse

consequences.

Substance dependence: A mental disorder in which a

person has impaired control of psychoactive substance

use and continues use despite adverse consequences. It

is characterized by compulsive behavior and the active

pursuit of a lifestyle that centers around searching for,

obtaining, and using the drug.

Supplemental Security Income (SSI) program: A

Federal income support program for low-income

disabled, aged, and blind persons, which was established by Title XVI of the Social Security Act.

Eligibility for the program is based on income and

resources.

Third-party payment: Payment by a private insurer or

government program to a medical provider for care

given to a patient.

Title V of the Social Security Act: See maternal and

child health block grants.

Title X of the Public Health Service Act: 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.

Title XX of the Public Health Service Act: Established

by the Adolescent Family Life Act of 1981, provides

Federal funds for demonstration projects to encourage

adolescents to postpone sexual activity and demonstration projects to provide comprehensive services for

pregnant and parenting adolescents.

Title XX of the Social Security Act: Established by the

Omnibus Budget Reconciliation Act of 1981 (Public

Law 97-35), a program of block grants to States for the

provision of social services, for the purpose of

assisting individuals to: 1) achieve or maintain eco-
Appendix A-Glossary of Abbreviations and Terms . III-281

nomic self-support; 2) achieve or self-sufficiency;

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.

Administered by the Office of Human Development

Services in DHHS.

Tort: A private or civil wrong or injury, other than breach

of contract, for which the court will provide a remedy

in the form of an action for damages. A tort may be

either: 1) a direct invasion of some legal right of the

individual; 2) the infraction of some public duty by

which special damage accrues to the individual; or 3)

the violation of some private obligation by which

special damage accrues to the individual. Three

elements of every tort action are existence of legal duty

from defendant to plaintiff, breach of duty, and damage

as a proximate result.

Tort law: The branch of law pertaining to torts (see

above).

Treatment services: Services intended to cure or ameliorate the effects of a disease of other health problem

once the problem has occurred. Compare preventive

health services.

Underclass: Definitions of “underclass” vary. There is

considerable controversy concerning whether the definition should be restricted to residence in an area

characterized by a specific level of demographic

characteristics (e.g., low earned income, low educational attainment, and low labor market participation)

or be expanded to include attitudinal/behavioral dimensions (e.g., alienated, unmotivated).

Unprotected sexual intercourse: Sexual intercourse

without precautions taken to prevent pregnancy or the

transmission of AIDS or sexually transmitted diseases.

Venereal disease: See sexually transmitted disease.

Well-child care: Preventive health care for children,

including immunizations, health education, parental

guidance, physical examinations and other tests that

screen for illness or developmental problems.

Younger adolescents: As defined in most studies and

data analyses, adolescents ages 10 to 14.
Appendix B

BURDEN OF HEALTH PROBLEMS AMONG U.S. ADOLESCENTS

OTA’s analysis in Volume II, based on a broad range

of measures of adolescent health and a wide variety of

sources of data, suggests that the conventional wisdom

that American adolescents as a group are so healthy that

they do not require health and related services is not

justified. OTA’s findings regarding the burden of health

problems among U.S. adolescents are summarized in the

table below.

In considering the estimates in this appendix, it is

important to note several limitations of the available

data, in particular:

The data here on prevalence and incidence come

from widely varying sources. When national data

were not available, more limited sources are used

and such sources are noted. However, even national

data have their limitations.

A particular shortcoming of available data on

adolescents apparently “most at risk’ of specific

problems (see last column) is that, although disaggregations of health status information by gender,

race, ethnicity, and age are often difficult to obtain,

such data are more likely to be available than

crosstabulations of data providing valid information

about the causes of differences in health status. For

example, meaningful data on socioeconomic status

and health, and the interactions of socioeconomic

status with other factors, are particularly lacking in

the United States. But information on the relationships among a wide range of biological (e.g.,

genetic), psychological (e.g., perceptual), behavioral

(e.g., engagement in risk-taking behaviors such as

sports), and social (e.g., family income, community)

factors and particular health problems, and the

relationships of health problems with each other, is

scarce. Typically, special research studies are required (and have sometimes been conducted) to

determine the relationships of the broad range of

possibly explanatory factors to adolescent health

problems. The availability of such studies is discussed in specific chapters in Volume II of this

Report (also see ch. 18, “Issues in the Delivery of

Services to Selected Groups of Adolescents,’ in this

volume). Some of the information from special

research studies is reflected in the table below, but,

often, the only information available is by gender

and/or racial and ethnic background. In considering

the information shown below, it is important not to

confuse mere correlations of racial, ethnic, gender,

and other (e.g., income) factors with causality.

For a complete understanding of the sources and

limitations of each data point presented here, the interested reader is encouraged to consult the specified

chapters in Volume II of this Report, Background and the

Effectiveness of Selected Prevention and Treatment

Services. A synthesis of the crosscutting issues in data

collection and dissemination with respect to adolescent

health can be found in Appendix C, “Issues Related to the

Lack of Information about Adolescent Health and Health

and Related Services, ” in Volume I of this Report,

Summary and Policy Options.

Prevalence. incidence. or Adolescents most at risk

Problem other measure of burden according to available data1

Family problems2

Full scope unknown. In 1985, between 620,000

to 720,000 adolescents ages 1Oto17 were

maltreated. 3An estimated 120,000 adolescents between ages 13 and 18 were in

foster care in 1985. In 1984, about onethird of females and one-fifth of males using

runaway and homeless youth centers reported that physical or sexual abuse was a

problem that led to their running away.4

Many homeless adolescents report having

been abused (physically and sexually) prior

to becoming homeless. Females seem to

beat greater risk than males (especially for

sexual abuse). Adolescents in “authoritarian” or “overindulgent” families and adolescents in families with a stepparent are at

increased risk.

1 ~e ~veats a~ve rwa~ing available data, particularity on gender and r~ial factors.

z~e ~. 3, “Paren~F and Families’ Intluence on Adolescent HAth,” in VOI. II.

~ese data are basedon data fromtho U.S. Department of Health and Human Services’ (DHHS) National Center on Child Abuse and Neglect. Maltreatment

was defined by DHHS x instances vwhere “a child’s health or safety is seriously endangered.”

4Th=e ~ta are frm the fi~l y-r 19W annual reprt~r ~na~ay y~uth ~nters prepar~ by the Administration for children, youth, and Families in DHHS.

See ch. 14, “Hopelessness: PreventIon and Sedces,” in Vol. Il.

-111 -282-
Appendix B—Burden of Health Problems Among U.S. Adolescents . III-283

Prevalence, incidence, or Adolescents most at risk

Problem other measure of burden according to available data1

School problems5

In October 1988, the status dropout rate6 for

individuals ages 16 to 24 was 12.6 percent

(4 million individuals).

Injuries:

● Nonfatal injuries7 National survey data indicate about one-third

of children (ages 5 to 17) experienced an

accidental or intentional injury in 1988.8 In

1985, accidental and intentional injuries

(and poisonings) accounted for 8,177,000

visits to physician offices among adolescents ages 10 to 18. In 1987, accidental

and other injuries accounted for 25 percent

of hospitalizations for males ages 10 to 14

and 33 percent of hospitalizations for males

ages 15 to 18.9 Playing basketball, football,

or baseball and riding a bicycle accounted

for 772,000 emergency room visits by

adolescents in 1988.’0

. Accidental injury deaths Accidental injuries are the leading cause of

death among adolescents. In 1987, 12.9

percent of all deaths to adolescents ages

10 to 14 and 46.2 percent of all deaths to

adolescents ages 15 to 19 were due to

accidental injuries. In 1987, there were

10,658 accidental injury deaths among

10- to 19-year-olds.11 The vast majority (74

percent) of those accidental injury deaths

are due to vehicle-related injuries; others

are due to drowning (8 percent), accidental

firearms injuries (4 percent), and other

causes (15 percent).

. Suicide deaths13 In recent years, adolescent suicide rates have

apparently increased. There were a total of

2,152 officially reported suicides among

10- to 19-year-olds in 1987. In 1987, 1.5

percent of all deaths to adolescents ages

10 to 14 and 10.3 percent of all deaths to

adolescents ages 15 to 19 were due to

suicide.

Hispanic adolescents (status dropout rate of

33.0 percent); adolescents in central cities

(status dropout rate of 15.4 percent); black

adolescents (status dropout rate of 13.8

percent).

Adolescents who engage in risk-taking behavior (e.g., participation in contact sports).

Adolescents who are physically abused.

Adolescents who engage in risk-taking behavior (e. g., consumption of alcohol, unsafe

driving; failure to use automobile safety

belts). Adolescents ages 15 to 19 are at

greater risk than adolescents ages 10 to

14. Males, especially ages 15 to 19, are at

considerably greater risk than females.12

American Indian and Alaska Native adolescents experience death from accidental

injury at twice the rate of blacks or whites.

White male adolescents and American

Indian and Alaska Native adolescents (both

sexes combined) have the highest rates of

motor-vehicle-related accidental deaths.

Black male adolescents have higher rates

of drowning deaths than white adolescents

of either sex and black female adolescents.

Adolescents who have made a previous suicide attempt. White males ages 15 to 19

have higher suicide rates than either white

females or blacks. American Indian adolescents have much higher suicide rates than

white adolescents.

Ssee Ch, 4, ‘{sch~ls and Discretionary Time,” in Vol. Il.

6The ~tatu~ ~rowu( ~afe ,s the ~roportlon of individuals who ar e not enrolled in school and have not finished high school at any given point in time. These

Calculations are based on Current Population Survey (a household-based survey) data from the U.S. Department of Commerce, Bureau of the Census.

7See ch 5, “Accidental Injuries. Prevention and Services, ” in VOI. II

8From DHHS, National Health Interview survey, For ~doleS~ents under age 17, the data are reported by a proxy respondent, usuaily the mother.

9Utlllzat{on data on Physlclan V[slts from DHHS’ NationalAmbulatory Medical Care survey, and Utilization data on hospitalizations from DHHS’ Nationa l

Hospital Discharge Survey,

10From the U S Consumer Product Safety Cornrnlssion.

11 In 1987, there were 2,130 a~ldental ,njury deaths among 10. to 14.year.Oids (1 2.9 deaths per 100,000) and 8,528 accidental injury deaths among 15- to

19-year-olds (46 2 deaths per 100,000) Mortahty statistics are gathered by DHHS’ National Center for Health Statistics,

12The ~ale.to.female ratio differs by ~ausG of death For exam pie, from 1984.86 the differences in the male-to-female ratio ranged from 9 9:1 for deaths due

to drowning to 1,51 for hommde

13S@e ~h 11 Mental Health problems preven tlon and services,” In vol. fl, Mortality statistics are gathered by DHHS’ National Center for Health Statistics
///-284 ● Adolescent Health—-Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Prevalence, incidence, or Adolescents most at risk

Problem other measure of burden according to available data1

. Homicide deaths’ 4

Chronic Physical lllnesses15:

● Serious chronic physical illness

. Significant physical problem that

could interfere with development

● Acne

18

. Dysmenorrhea (difficult and painful menstruation)18

Nutrition and Fitness Problems20

Dental and Oral Health Problems=:

. Dental caries (cavities)

● Severe malocclusion

There were approximately 2,100 adolescent

homicide victims in 1987. In 1987, 1.6

percent of all deaths to adolescents ages

10 to 14 and 10.0 percent of all deaths to

adolescents ages 15 to 19 were due to

homicide.

An estimated 5 to 10 percent of adolescents

have a chronic condition (e.g., leukemia,

cerebral palsy, hearing or visual impairment) that limits their activities.16

Unknown. Latest available data (from 1970)

indicate 22 percent of adolescents have

such a problem.17

80 to 90 percent of adolescents experience

some degree of acne at some time.

National data not available, but local surveys

suggest that 25 to 45 percent of female

adolescents have missed some school or

work because of dysmenorrhea.le

Many adolescents suffer from some nutritional

or fitness problem.21

Full extent unknown, but declining. From 1980

to 1987, caries prevalence among adolescents in school declined 20 to 40 percent.23

According to a national school-based survey in 1987,44 percent of 10-year-oIds had

experienced caries, while 84 percent of

17-year-olds had experienced caries. However, 22 percent of 10-year-olds and 12

percent of 17-year-olds needed fillings (restorations) for their decayed teeth in 1987.

Unknown. Latest available data (from 1970)

In 1985,689 black males ages 10 to 19 died as

compared with 657 white males, but there

were almost 5.5 times as many white males

as blacks in the population. The races and

ages of those committing adolescent homicides are unknown.

Adolescents of low socioeconomic status (e.g.,

family incomes of less than $10,000) are

more likely to have a limitation in a major

activity as a result of a chronic condition

(9.8 percent have limitations) than adolescents of higher socioeconomic status (e.g.,

family income of more than $35,000) (5.1

percent have limitations).

Males, white adolescents tend to have more

serious problems.

Females only.

Nutritional deficiencies: Female adolescents,

adolescent athletes of both sexes, adolescents with chronic physical or mental illness

or disabilities, and homeless and runaway

adolescents.

Obesity Available information suggests problems with obesity for black female adolescents, Mexican Americans, Native Hawaiians, American Indians and Alaska Natives, Samoans, and Tongans of both

sexes.

Adolescents vvithout access to fluoridated water

or fluoride treatments are at increased risk

for dental caries. Nonwhite (especially American Indian) adolescents have a higher

percentage of untreated caries than white

adolescents. 24 Juveniles in juvenile justice

facilities have more decay, too. Small group

of adolescents with rampant caries. 25

indicate 13 to 16 percent of 12- to 17-yearolds have severe to very severe malocclusion.

14- ~l~o, ~h. 13, ti~linquenq: prellention and serv~~, in Vol. Ii, ad ch. 18, “lSues in the Delivery of Services to Selected Groups of Adolescents,” in

this volume. Mortality statisti& are gathered by DHHS’ National Center for Health Statistics.

15- A. 6, “chronic physical Illnesses: Prevention and services,” in VOI. Il.

16This ~timate is&@on information from DHHS’ National Health Interview Survey. See ch. 6, “chronic Physical Iltnesses: prevention and !%rViCOS,” in

Vol. Ii, for Information on how the estimate was derived.

17~~ on &ta from DHHS’ Nationai Health Examination Survey (cond~t~ in 1%7-70), which inciuded an examination by a physician.

18Acne and dys~nhorrea were ~i~:t~ ~ repr~~tative of health pmble~ of spedai concern to adolescents.

19~~ ~ &ta from Iwai surveys. in the m~t r~ent national survey (the National Health Examination Survey ~nductd in 1967-70), ~ per~nt Of

adolescents who had begun to menstruate experienced menstrual pain, and 14 percent reported frequent schooi absenteeism due to dysmenorrhea.

~~e &. 7, #lNutfltion and fitne~ problem: Preventhn and services,” in voi. ii.

21 Data on ~~le=n~r nutfitlon and fitne~ problems ~me from a numkr of sources, among them the U.S. Department of Agriculture’s Nationwide Food

Consumption Surveys and DHHS’ National Heaith and Nutrition Examination Surveys.

22- ~. 8, 4iDentai and ~ai Heaith pm~ems: Prmmrrtkn and SW/k=,” in VOi. il.

23Fmrn SurveW of ~WI-ti ~i~ren ~uct~ by DHHS’ National Institute of Dental Research.

24Availabie data do not separate t~ eff~ts of r~e from in~me level or other rOleVant faCtOrS.

25 RamPant ~ries is a rap~ly progressing form of dental ~ries Wflbh invoives extensive breakdown of enamel and dentin, and pulpai pathosis.
Appendix B-Burden of Health Problems Among U.S. Adolescents . III-285

Prevalence, incidence, or Adolescents most at risk

Problem other measure of burden according to available data1

. Periodontal disease In 1987, many adolescents in school ages 14

to 17 experienced some gingival inflammation, but few have more serious gingival

problems (e.g., 22 percent experienced

periodontal attachment loss of more than 2

mm); 0.1 percent to 2.3 percent of U.S.

adolescents have localized juvenile periodontitis.

AIDS and Other Sexually Transmitted Diseases (STDS)

26:

● STDs The national prevalence and incidence of

STDs other than gonorrhea and syphilis

are unknown.27 In 1989, 30 percent of

newly reported gonorrhea cases and 10

percent of newly reported syphilis cases in

the U.S. occurred among 10- to 19-yearolds.

● AIDS/HIV infection

Pregnancy and Parenting30:

. Sexual activity31

. Contraceptive use31

. Pregnancy32

● Abortion 32

AIDS: 568 cases among 13- to 19-year-olds as

of September 1990.28 HIV infenction: prevalence unknown, but estimates run as high

as 3.7 percent in a sample of runaway and

homeless adolescents in New York City

age 18 and under.=

In

In

1988, 53 percent of adolescent females

ages 15 to 19 had ever had sexual intercourse. In 1988, about 64 percent of adolescent males ages 15 to 18 had ever had

sexual intercourse.

1988, 20 percent of sexually active female

adolesents ages 15 to 19 reported current

condom use.

About one million U.S. adolescents become

In

pregnant each year. In 1988, there were

110 pregnancies per 1,000 females adolescents ages 15to 19. Pregnancy rates for

sexually active adolescents ages 15 to 19

declined between 1970 and 1985.

1984, over 400,000 adolescents obtained

abortions. In 1984,41 percent of all pregnancies to females ages 15 to 19 (44 per 1,000

females ages 15 to 19) and 56 percent of

pregnancies to adolescents under age 15

(8.3 per 1,000 females under age 15)

ended in abortion.

Adolescents who do not have good oral hygiene; adolescents who use smokeless

tobacco. Nonwhite adolescents (especially

American Indians) have worse periodontal

health than white. Disabled adolescents.

Periodontal problems increase by age

throughout adolescence and into adulthood.

Sexually active adolescents only, especially

those who do not use condoms or who

have multiple sexual partners. In 1988,

about 64 percent of adolescent males ages

15 to 18 had ever had sexual intercourse

and about 53 percent of adolescent females ages 15 to 19 had ever had sexual

intercourse. Only 20 percent of sexually

active female adolescents ages 15 to 19

reported current condom use.

Black, non-Hispanic adolescents ages 13 to 19

accounted for 36 percent of all adolescent

AIDS cases through August 1990; Hispanic

adolescents ages 13 to 19 accounted for 18

percent Sexually active adolescents, especially those who engage in unsafe sexual

practices (e.g., no condoms, multiple sexual partners). Also intravenous drug users

who share needles and their partners;

adolescents with hemophilia. Homeless

and runaway adolescents.

Higher rates of sexual activity among homeless and runaway adolescents, blacks,

Hispanics, adolescents of lower socioeconomic status.

Higher contraceptive use among non-Hispanic

white adolescents, adolescents of higher

socioeconomic status, older adolescents.

Sexually active females who do not use effective contraceptive methods. Higher pregnancy rates among black and Hispanic

adolescents of lower socioeconomic status;

American Indian, Native Hawaiian adolescents; homeless and runaway adolescents.

Pregnant females who both want and are able

to obtain an abortion. In 1983, abortion

rates as a percentage of pregnancies were

higher for white adolescents (40.5 percent

of white adolescent pregnancies) than black

adolescents (38.1 percent of black adolescent pregnancies).

26 See ~h 9, ‘(AIDS and mher Sexual& Transmitt~ Diseases: Prevention and %Wk9S,” in VOI. Il.

27DHHSI centerS for DiSeaSe control ~nly ~llwts data on fwo sexually trar-lsmitt~ diseases other than AIDS/1-ilV-gonorrhea and syphilis.

28These are AIDS data from DHHS’ Centers for Disease Control’s monthly “HIV/AIDS Surveillance” report.

~Among homelm~ and ~nWay ~olewents staying at Covenant House in NW Yofi, 3.7 per~nt test~ positive for HIV; S- ch. 14 “Hopelessness:

Prevention and Services,” in Vol. 11, for more information.

30sW ~h 10, “pregnanq and Parenting: Prevention and %M@S,” in VOI. Il.

31 These data are from DHHS’ National ~rvey of Family Growth ~nd~ted period ~ally by the National Center for Health statiSt&.

32B~ed on information from the AJan Guttmacher blStitute.
///-286 . Adolescent Health—Volume III: Crosscutting Issues in the Delivery of Healfh and Related Services

Prevalence, incidence, or Adolescents most at risk

Problem other measure of burden according to available data1

● Childbearing 33 In

● Out-of-wedlock childbearing33 In

1988, there were 488,941 births to females

under age 20. In 1984, 45.6 percent of all

pregnancies to 15-to 19-year-olds.

1988, about 65 percent of the 488,941

* Adoption34

babies born to adolescents under age 20

were born out of wedlock (322,406 births,

including 312,499 to females ages 15 to 19

and 9,907 to females under age 15 (92

percent of births to adolescent females

under 15)).

Less than 10 percent of all adolescents who

become pregnant choose adoption.

. Subjective distress38

Mental Health Problems35:

● Diagnosable mental disorders36 National data are not available. A series of

local studies show that an estimated 18 to

22 percent of adolescents have one or

more diagnosable mental disorders.37 The

most common disorders are attention deficit disorder, oppositional disorder, conduct

disorder, and separation anxiety disorder.

Prevalence varies by disorder.

Varies by measure: The National Adolescent

Student Health Survey of 8th and 10th

graders 3g found in 1987 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” (13.2 percent). The

University of Minnesota Adolescent Health

Survey40 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 one month before the survey.

Pregnant females who do not want or cannot

obtain an abortion. For adolescents ages

15 to 19 in 1984, birth rates were higher for

black adolescents (96 births per 1,000

black adolescent pregnancies) than for

white adolescents (44 per 1,000 white

adolescent pregnancies).

Adolescents of lower socioeconomic status

are more likely to have children out of

wedlock than adolescents of higher socioeconomic status. Black females are more

likely to bear children out of wedlock than

white females.

Adolescents of higher socioeconomic status

are more likely to choose adoption than

adolescents of lower socioeconomic status.

In 1982, 7.4 percent of white adolescents

and 1 percent of black adolescents put their

babies up for adoption.

Homeless and runaway adolescents. Males;

middle and older adolescents; low socioeconomic status adolescents.

Females, American Indians and Alaska Native

adolescents; on one measure, rural males.41

33Based on data gather~ by DHHS’ National Center for Health Statistks.

34From S.L. Hofferth, ‘Teenage Pregnancy and lts Resolution,” Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Volume 11: Wti”ng

Papem and StatiskalAgpendixes, S.1.. Hofferth and C.D. Hayes (eds.) (Washington, DC: National Academy Press, 1987).

35~e ~. 11, Mental Health Problems: Prevention and Services,” in VOI. Ii.

36 Diagnosable mental disorders (e.g., a~nduct disorder, separation anxiety diso~er, depression) are indu~ in the American psychiatric Assodation’s

Diagnostic and Statistical Manual of h!ental Disorders, 3rd cd., revised (DSM-R-111).

37s=ta~e11 -1 in ~, 11, ‘tMental He~lttj problems: Prevention ad ~rvi~s,” in Vol. It, forasample of studies on the prevalence of DSM-111 diagnoses among

adolescents.

38subj=.ive distress is not “~~Sa~ily, but is possiNy, relat~ to a mental health problem.

39The National Adolescent Health Surv{jy, ~nduct~ in 1987, sampled 8th and 1 oth graders and relies on self-reported information.

‘%he Adolescent Health Survey, conducted by the University of Minnesota, sampled 7th through 12th graders in the State of Minnesota and relies on

self-reported information.

41~ Minnesota adole~ents (mmtly ~hite, non-Hispanic) surveyed, mral males were most likely to report that “life is uninteresting.”
Appendix B-Burden of Health Problems Among US. Adolescents ● III-287

Prevalence, incidence, or Adolescents most at risk

Problem other measure of burden according to available data1

. Suicide attempts

Alcohol, Tobacco, and Drug Abuse43:

● Alcohol use

● Tobacco use

. Illicit drug use:

Delinquent behavior48:

● Serious violent offenses

● Serious property offenses

Full extent unknown. In 1987, however, 13

percent of 8th and 15 percent of 10th

graders surveyed reported having made a

suicide attempt.42

Extent of abuse unknown. In 1989,4.2 percent

of high school seniors reported daily use of

alcohol. In 1987-89, 15.8 percent of 10th

graders and 11.1 percent of high school

seniors reported recent heavy drinking .44

In 1989, 18.9 percent of high school seniors

reported daily cigarette smoking.45 In 1987,

4.4 percent of 10th grade males used

smokeless tobacco.46

Full extent of abuse unknown. In 1989, 2.9

percent of high school seniors reported

daily use of marijuana or hashish; 0.3

percent reported daily use of cocaine; 0.3

percent reported daily use of hallucinogens; 0.3 percent reported daily use of

inhalants.

Estimates vary, depending in part on whether

they are based on official arrest records or

on data from self-reports or reports of

victims. 49 In 1988, there were 1.6 million

arrests of adolescents. In 1987, about

700,000 adolescents were confined to public or private juvenile justicefacilities.5051

Arrest data and victims’ reports show an

overall decline since the mid-1970s. However, in 1987, the number of adolescents

held in public facilities for serious violent

offenses increased for the first time since

1983. For aggravated assault, murder, and

nonnegligent manslaughter, arrest data

show an increase in recent years; for

robbery and forcible rape, they show a

decrease.

Arrest data show a major overall decline since

the mid-1970s.

Adolescents who have experienced family

disruption (divorce, death, abandonment);

abused adolescents; homeless and runaway adolescents; gay and lesbian adolescents; adolescents with substance abuse

problems. White females; American lndians and Alaska Natives.

Adolescents whose parents, siblings, or peers

use alcohol; homeless and runaway adolescents; American Indian adolescents.

Adolescents whose parents, siblings, or peers

smoke. Adolescents in families of lower

socioeconomic status.

White, non-Hispanic adolescents, then Hispanic adolescents, then black adolescents.47

Availability of income positively related to

use of illicit drugs among students. Some

evidence that adolescents with mental

health problems more likely to be problem

users of drugs. American Indian adolescents. Homeless and runaway adolescents.

In comprehensive self-report surveys, almost

all adolescents report having committed

some delinquent act (typically not a serious

delinquent act). Homeless and runaway

adolescents (prostitution, panhanding, drug

dealing).

15- to 17-year-old males, black males, males

living in urban areas. The gender gap for

arrest rates is narrowing-from 11.4

(males):1 (females) in 1965 to 7.5:1 in 1987

for serious violent offenses.

15- to 17-year-old males, black males, males

living in urban areas, though the gender

gap in arrest rates is narrowing--from 6.7

(males):1 (females) in 1965 to 3.6:1

in 1987 for serious property offenses.

42From the National Adolescent Student Health Survey, a one-time self-report survey of 6th and IOth 9raders in 1987.

~We ch. 12, “fllcohol, Tobacca, and Drug Abuse: Prevention and Services,” in VOI. Il.

44 Heavy drin~ng is defined ~ hating h~ 5 or more drinks “on one occasion” (National Adolescent Student Health Survey wording) or “in a row” (Monitoring

the Future/High School Seniors Survey wording) in the 2-week period prior to the survey.

fiAmong high ~hool seniors, 77 percent smoked 1 to 5 ~garettes daily; 4.4 per~nt smoked one pack of cigarettes dtily, and 11,2 permntrepOrtd SfTIOkhg

half a pack of cigarettes or more per day (Monitoring the Future/High School Seniors Survey).

46From the National A~les~nt Student Health Survey, a one-time self+epod survey of 6th and IOth graders in 1987.

47From DHHSI National Institute on Drug Abuse national household survey data.

@s~ A. 13, “Delinquency: Prevention and Services,” in VOI. Il.

@S~table 131 in ~, 13, ‘iDeli~quenqr: ~evention and Services,” in VOI. it, for information about the four principal sources of nationat data on the prevalence,

incidence, and demographic correlates of adolescent delinquency: 1 ) the Uniform Crime Reports, 2) the National Crime Survey, 3) the National Youth

Survey, 4) the Monitoring the Future/High School Seniors Survey.

5oFrom the U.=j. Department of Justi~’s CMf]ce of Juvenile Justice and Delinquency Prevention statist~.

51 For Purp=os of ~unting arre~t~ and detentions, “Juvenile” is a legal term. A juvenile is a person subject to JIJVenile couft jurisdiction for PuWoses of

adjudication and treatment based on age and offense limitations defined by State law. The upper age of original juvenile court jurisdiction ranges from 16

to 19, but for most States is 17 or 18.
III-288 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Prevalence, incidence, or Adolescents most at risk

Problem other measure of burden according to available data1

Homelessness52 Unknown, although DHHS estimated in 1984

(on the basis of 1976 data) that there areas

many as 1 million homeless and runaway

adolescents each year.53

Poverty

Multiple problems

17 percent (5.3 million) of adolescents live

‘below the Federal poverty level; another 10

percent (3.0 million) are “near poor” (family

incomes between 100 and 149 percent of

the Federal poverty level).

Full extent unknown. In 1987, using problem

behavior theory as a guide, Dryfoos estimated that 10 percent of adolescents ages

11 to 17 are at very high risk of multiple

behaviorally based problems; another 40

percent are at medium risk.54 Research on

covariation is limited.55

Adolescents who leave home because of

physical, sexual or emotional abuse; adolescents with substance-abusing parents; adolescents in foster care; formerly institutionalized (e.g., juvenile justice, mental health

system) adolescents; adolescents in homeless families; gay adolescents.

Adolescent mothers; adolescents living in single parent female-headed households;

black, Hispanic, Asianr American Indian

and Alaska Native adolescents; Native

Hawaiian adolescents; rural adolescents.

Homeless and runaway adolescents.

~The lg~ census made efforts to count homeless persons, but it is unlikety that it will produce an amurate COUrlt.

~~~ on ~ta from J. DryfoOS, ArMescwfs at Risk (New York, NY: Oxford University preSS, 1990).

~COW~a~n is the tendency of health problems to ~ur in the same individual at about the same time. Most Of the Wkknce on ~variatiOn of adolescent

problems is based on cross-sectional studies, so it is still unclear for many problems whether one problem leads to another or the problems occur together,

due to a single cause of set of causes (see D.W. Osgood and J.K. Wilson, “Covariation of Adolescent Health Problems,” paper prepared under contract

to Carnegie Council on Adolescent [development and Carnegie Corporation of New Yom for the Of fim of Technology Assessment, U.S. Congress,

Washington, DC, 1990 (Springfield, VA: National Technical Information Service, NTIS No. PB 91-154 377/AS)). Another limitation of the evidence on

covanation is that most of the evidence is limited to ccwanation in adolescent behaviors and does not consider emotional or physical problems.

SOURCE: Office of Technology Assessment, 1991, based on data presented in various chapters in Vol. II of this Report, and inch. 18, “Issues in the Delivery

of Health and Related Services,” in this volume.
Appendix C

HCFA’S METHOD FOR ESTIMATING NATIONAL MEDICAID ENROLLMENT

AND EXPENDITURES FOR ADOLESCENTS AGES 10 THROUGH 18

To develop estimates of national Medicaid enrollment

and expenditures for adolescents ages 10 through 18, the

Health Care Financing Administration (HCFA) within the

U.S. Department of Health and Human Services used the

method outlined below.

1.

2.

3.

4.

To Develop National Estimates for

Ages 6 to 14 and 15 to 20 Combined

Thirty-five States (Alabama, Arkansas, Arizona, Colorado, District of Columbia, Florida, Georgia, Idaho,

Illinois, Iowa, Kansas, Louisiana, Maine, Maryland,

Massachusetts, Mississippi, Montana, Nebraska, New

Hampshire, New Jersey, New Mexico, New York

North Carolina, North Dakota, Ohio, Oklahoma,

Oregon, Rhode Island, South Carolina, South Dakota,

Tennessee, Texas, Utah, Virginia, West Virginia)

reported data in fiscal year 1988 on Medicaid enrollees

(ever-enrolled), Medicaid recipients (those who used

at least one covered service during the year), and

Medicaid expenditures for age groups 6 to 14 and 15

to 20 (new form HCFA-2082),

The remaining States, Puerto Rico, and the Virgin

Islands reported Medicaid recipients and expenditures

only (no enrollees) and only for the age group 6 to 20

(old form HCFA-2082).

The Medicaid enrollee and expenditures totals for age

groups 6 to 14 and 15 to 20 for the 35 States listed in

step 1 were blown up to national totals using ratios

developed from the recipient and expenditure data for

age group 6 to 20 (available in all States). The blowup

factors for expenditures were calculated on a serviceby-service basis. (On average, the 35 States in step 1

accounted for about 58 percent of Medicaid recipients

and 63 percent of aggregate expenditures for the age

group in question).

To Develop Separate Estimates for

Ages 10 to 14 and 15 to 18

The number of Medicaid enrollees in the 10 to 14 and

15 to 18 age groups was derived from the above counts

for ages 6 to 14 and 15 to 20, respectively, by applying

ratios calculated from data on Medicaid-covered

persons from the March 1989 Current Population

Survey. The age distributions from the Current Population were first smoothed to eliminate some fluctuation

5

●

●

●

●

in the counts from age to age (primarily in the teen

years).

Average costs per enrollee by service category for age

groups 6 to 14 and 15 to 20 were calculated using the

results of steps 1 through 3. Averages for age groups

10 to 14 and 15 to 18 were estimated by interpolation

using an exponential cost function whose parameters

were calculated to reproduce average costs for the age

group 6 to 14 and 15 to 20.

Limitations

Medicaid expenditure data are on a date-of-vendorpayment basis rather than a date-of-service basis, as

one would normally like to have. This means that,

because of payment lags, the fiscal year 1988 expenditures in the numerators of the per-enrollee costs relate

to a slightly different population from the enrollee

counts in the denominators.

Medicaid enrollee counts are of individuals everenrolled during the fiscal year rather than the more

desirable person-year counts. Data from other sections

of form HCFA-2082 can be used to develop personyear counts, but not by age group. The closest HCFA

can come to the population of interest here is Aid to

Families With Dependent Children, who show averages of about 9 months of enrollment during a fiscal

year. Thus, for children, per capitas based on personyears would be about one-third higher ( 12/9) than those

based on ever-enrollment counts.

Age-unknown cells were ignored in the calculations.

This fact plus internal inconsistencies within form

HCFA-2082 mean that aggregate (all-age) expenditure

totals derived from our tables will fall somewhat short

(perhaps about 0.5 percent) of published totals.

In general, the data HCFA used for these estimates

come from infrequently used sections of form HCFA2082 and have not, to HCFA’s knowledge, been subject

to a great deal of analysis. HCFA adjusted for some

obvious reporting problems discovered, but other data

problems may remain. Consequently, the estimates

should be considered provisional.

SOURCE: U.S. Department of Health and Human Services, Health Care

Financing Administration Office of the Actuary, unpublished HCFA-2082 data on Medicaid expenditures and

enrollment in fiscal year 1988, Baltimore, MD, June 1990.

-111 -289-
INDEX
Index

Note: This is the index for Volume III of Adolescent Health only. An index incorporating key terms from all three volumes of

Adolescent Health will be included with the publication of Volume II in fall 1991, and will also be published as a separate document,

available from OTA, in fall 1991.

Abortion, 263, 285

alternatives to, 177, 243

consent and confidentiality, 128-129, 132, 135, 137, 140, 141,

142, 143, 144-145, 150-151

funding, 92-93, 174, 243

insurance, 92-93, 174

minorities, 185

Absenteeism from school, 54, 168

Access to services, 3, 65-66, 159-210

consent and parental notification and, 134-135, 136, 138, 151,

152

financial barriers, 1, 30, 63, 77-120, 188, 189, 198-199

hospital-based, 32,34

legal barriers, 134-135, 136, 138, 151, 152

minorities, 187-196

poverty and, 169-171

rural areas, 198-199

school-linked health centers, 3, 41-56

see also Outreach services; Referral to services; Utilization of

services

Accidents and injuries, 59, 216,244, 245, 246, 262,283

Federal programs, 233-235, 244-246, 252-253

minorities, 183, 184, 186

motor vehicle, 183, 186, 197, 217-218, 235, 244, 245, 246,

252-253, 262

prevention, 235,244,245,246,262

research, 252, 253-254

rural areas, 197

safety equipment, 252-253

school-linked health centers, 44

whites, 183

Accreditation Council for Graduate Education, 26

Acne, 10, 20,47, 61, 63

ACTION, 172-173,216, 244

Acute diseases and disorders, see Emergency services; Schoollinked health centers

Administration for Children, Youth, and Families, 176, 192

Administration for Native Americans, 192-193

Administration on Developmental Disabilities, 176

Adolescent health care clinics, 31-34

Adolescent Health Youth Advisory Panel, 60

Adolescent medicine, 23-29

Adoption, 177, 286

Adults, nonfamily

mentor influence, 173, 191

support from, 188, 190

Advisory bodies

community, 42, 51, 200

multidisciplinary, 57

youth panels, 59, 60

African Americans, see Black Americans

Age factors

age of majority, 123, 134-135, 138, 141-148, 150

competence v., 123, 134-135, 138, 141-148, 150

consent requirements, 123, 124-125, 126, 128, 130, 136,

141-146, 150

.

definitional, 213, 219-224

elderly persons, 172, 244, 95, 289

physician utilization, 9-10

see also Developmental processes

Agricultural workers, 176, 177

AIDS, 11,89,93-94, 243, 254, 255, 262,285

consent and confidentiality, 127-128, 132, 138

education, 235

Federal programs, 233-235, 239-241

minorities, 185, 195, 196, 241

screening, 132

Aid to Families With Dependent Children, 79,95-98, 100, 116,

152, 162, 173, 174, 175, 225,229

Alabama, 29,41-42, 82,97, 103, 105, 107, 111, 124

Alaska, 82,97, 103, 105, 107, 111, 124, 129

Alaska Natives, 162, 186, 250

Alcohol abuse, 229-230,253, 254, 287

clinical services, 35-39 (passim)

consent and confidentiality in treatment, 129-130, 131, 133,

135, 137, 153

counseling, 17-18, 47

driving while intoxicated, 18, 137

Federal programs, 229-230

insurance for treatment, 88-89

minority groups, 183, 185, 186, 193, 196, 229

physician diagnosis and counseling, 17-19

school-linked health centers, 47, 54

Alcohol, Drug Abuse, and Mental Health Administration, 17,

193-194, 214, 229-233,253

American Academy of Child and Adolescent Psychiatry, 26

American Academy of Family Physicians, 26,52, 136

American Academy of Pediatrics

consent and confidentiality, 136

financial access to services by adolescents, 102, 109

primary and comprehensive services delivery, 12-13, 14, 25,

28,52, 62

American College of Obstetricians and Gynecologists, 52,

136-137

American College of Physicians, 26

American Indians, 180, 186, 192-193, 194, 195,229,250,252,

254

accidents, 162, 186, 250

dropouts, 186-187, 188, 191

poverty, 162, 174, 175, 192

see also Indian Health Service

American Medical Association, 17-18, 25-26,52

American Psychological Association, 25

American Society for Adolescent Psychiatry, 63

Anemia, 20, 185

Anticipatory guidance, 14

Anti-Drug Abuse Acts of 1986 and 1988, 231-232

Apprenticeships, 252

Arizona, 82, 97, 103, 105, 107, 111

Arkansas, 50, 82,97, 103, 105, 107, 111, 127, 129

Arts and humanities, 40

Asian Americans, 180, 182, 183, 185-186, 188, 190

-111 -293-
III-294 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Associations, see Professional associations

Athletics, see Sports and recreation

Attitudes of adolescents toward

drug abuse, 19

health professionals, 8, 14-15,20-23,32-33,52, 109, 190

others/selves, by minority adolescents, 181, 191, 262

school influences and services, 43, 52

Attitudes of nonadolescents, 58

health professionals, 7, 12-13, 15, 17, 22-23, 24, 28-29, 30,

51-52,62-63, 109

parents, 50-51,55

racial prejudice, 181, 183, 184, 190

see also Public opinion

Automobiles, see Motor vehicles

Barriers, see Access to services

Bicycles, 252, 255

Black Americans, 180, 182, 183-185, 190, 191

preventive health interventions, 188

role models, 171

school-linked health centers, 46

uninsured, 79-80

utilization of services, 11-12, 46, 179, 188

Block grants, 174, 175, 229, 251

drug abuse and mental health, 153

maternal and child health services, 153, 177, 194, 235-236

social services, 229

Bureau of Health Care Delivery and Assistance, 176-177,200

Bureau of Indian Affairs, 193,217

Bureau of Maternal and Child Health, 29,48, 177, 263

California, 21,29,34-36,82,97, 103, 105, 107, 111, 171

Canada, 14-15

Casey v. Population Services International, 128

Center for Population Options, 41-47

Centers for Disease Control, 214-215,221,233-235, 253

Child abuse and neglect, 61, 125, 126, 130, 175, 196,250

sexual abuse, 37

Child Abuse Prevention and Treatment Act, 176

Children’s Bureau, 257-258

Chinese Exclusion Act, 180

Chronic physical diseases and disorders, 13, 284

insurance, 93-94

minorities, 186

poverty, 168

see also Diseases and disorders

Civil Rights Act of 1964, 90

Cognitive factors

age v. competence, 123, 134-135, 138, 141-148, 150

developmental, 123, 134-135, 138, 141-148, 150

emancipated and mature minors. 125, 126-127, 136, 140,

149-150, 151

intelligence, 125, 128, 140, 147

see also Decisionmaking

Colorado, 50, 82,97, 103, 105, 107, 111

Commitment (involuntary), 130, 140, 144

Communicable diseases, see AIDS; Sexually transmitted diseases

Community-based programs and activities

advisory bodies, 42, 51, 200

comprehensive health care, 1, 29-32, 34-41, 170-171, 176-

177, 213, 225

cost factors, 36

financial factors, 33,39

models, 35-41, 56-57

staffing, 45, 55, 56, 64

Comprehensive health care, 1, 5-73, 104, 106, 170-171,

176-177, 12-13, 14,25,28,52,62

clinical services, 31-41

demonstration projects, 30, 31

evaluation, 30, 32, 33, 36, 38, 51, 52-57, 64, 171

funding, 30-31,33,38, 39,47-48,50

integrated services, 56, 57-59, 66

models, 35-41, 56-57

school-linked, 41-57, 64-65, 104, 106, 171

staffing, 45, 55, 56, 64

Conference on Health Futures of Adolescents, 57,58

Congressional committees, 259-261

Connecticut, 49,82,97, 103, 105, 107, 111

Consent and confidentiality, 1, 8, 121-155, 195,254

abortion, 128-129, 132, 135, 137, 140, 141, 142, 143,

144-145, 150-151

abused and neglected minors, 126

access to services, 134-135, 136, 138, 151, 152

age factors, 123, 124-125, 126, 128, 130, 136, 141-146, 150,

127-128, 132, 138

alcohol abuse treatment, 129-130, 131, 133, 135, 137, 153

commitment (involuntary), 130, 140, 144

competency of minors, 123, 134-135, 138-150, 151

contraceptive services, 128-129, 132, 135, 140, 150-151, 153

drug abuse treatment, 129-130, 131, 133, 135, 137, 138, 153

emancipated, independent, and mature minors, 126-127, 131

emergency services, 127, 131

family planning services, 128-129, 132-133, 135

financial aspects, 125, 135, 137, 138

hospital-based clinics, 32

infectious disease services, 127-128, 132

insurance reimbursement, 117, 136, 170, 152, 153, 175

Legislation, general, 123-134, 150, 152

litigation, 123, 125-133 (passim), 139-140, 149-151

mental health services, 130, 131, 133-134, 140, 144, 145-146,

147, 153

peer influence, 143, 147-148

physician attitudes, 15,62-63

pregnancy-related services, 129, 133, 137, 141, 142, 143,

144-145

primary care, 62-63

professional associations, position, 136-138

professional ethics, 134-138, 140-141, 151-152

regulations, 132, 137, 152

school-linked health centers, 50-51, 52

sexually transmitted disease services, 127-128, 132, 135, 137

standards of competency, 125, 126-127, 131, 136, 140,

149-150

State law, 123-135, 138, 139-140, 150, 151-152, 153

Consumer Product Safety Commission, 216, 244,245, 246

Contraception and contraceptives, 177,240, 285

consent and confidentiality, 128-129, 132, 135, 140, 150-151,

153

counseling, 21, 44, 51, 53-54, 56

Federal programs, 177,243

insurance, 93, 101

physician competence, 21

school-linked health centers, 44, 51, 53-54, 56
Index ● III-295

utilization of by poor adolescents, 169

Coordination

Federal, 3, 193, 194,250,252,253-256, 257-258

health care providers, 57-59

local, 57-59, 250

State-level, 263

Correctional programs, 167,255

evaluation, 250

Counseling

abortion, 177, 243

alcohol and drug abuse, 17-18,47

at clinics, 36, 37, 39-40

contraception, 21, 44, 51, 53-54, 56

by physicians, 10, 14-15, 17-18, 20-21,62

school-linked health centers, 43-44, 47, 53, 56

see also Psychological and psychiatric services

Cost factors

access to services, 1, 30, 63, 77-120, 188, 189, 198-199

free clinics, 34, 37-41,60

health insurance, 83, 84-85, 87, 88,93,94, 114

school-linked health centers, 47-48, 50, 56

transportation, 170

Court cases, see Juvenile courts; Litigation; specific court cases

Crimes and criminals, 169, 250, 255,287

minorities, 183, 184-185

police, 146, 184

victims, 169, 183, 197-198

see also Child abuse and neglect; Delinquency; Juvenile

courts

cultural factors, 55, 160, 188, 189, 190, 229

language issues, 189, 192

minorities, 179-181, 182, 183, 184, 186-192 (passim), 194,

196, 201, 202

religious influences and organizations, 51, 56, 190, 191, 192

rural areas, 198, 199

Current Population Survey, 77, 161, 162

Databases, lack of, 58

Deaths, see Homicides; Morbidity and mortality; Suicide

Decisionmaking

commitment (involuntary), 130, 140, 144

competency of minors, 123, 134-135, 138, 141-148, 150

empowerment approaches, 36, 58, 59, 60

skills, 230

training in, 148

see also Advisory bodies; Consent and confidentiality

Definitional issues

adolescence, 213, 219, 224

competence, 139-141

consent, 123

emancipated and mature minors, 126, 136

family autonomy, 125, 110

minorities, 180

parental authority, 125

poverty, 159

primary health care, 7,62

Delaware, 82, 99, 103, 105, 107, 111

Delinquency, 217,253, 255,287

minorities, 171, 184-185, 187, 196, 250

poverty and, 169, 171

prevention, 250,251,258

rural areas, 197

schools and, 255, 250

see also Correctional programs; Juvenile courts

Demography

uninsured, 77-81

workforce, 165, 178-179

see also Age factors; Gender differences; Minorities; Morbidity and mortality; Socioeconomic status

Demonstration projects, 172-173, 177, 194,200,244,246,247,

252, 253,254-255, 262

comprehensive health centers, 30, 31

educational, 33

evaluation, 33-34, 52, 252

health insurance, 77-81, 100,99, 100

Dental health, 61, 177, 186, 284-285

fluoridation, 235

insurance, 91, 93

school-linked health centers, 44, 47

Department of Agriculture, 177-178, 196, 216, 219, 245, 246

Department of Commerce, 216, 219

Department of Defense, 216, 219, 245,246-247

Department of Education, 196,217,219-220,245, 247-250,258

Department of Health and Human Services, 173-177, 214-216,

220-223,253,256, 258

minority programs, 190, 192-196

spending, 225-244

see also specific constituent agencies

Department of the Interior, 217, 223

Department of Justice, 196,217, 223, 245, 250, 251, 253, 258

Department of Labor, 178, 217,223, 245,251-252

Department of Transportation, 217-218, 223, 245, 252-253

Dermatologists, 19-20

Developmental Disabilities Act, 176

Developmental processes, 183

cognitive, 123, 134-135, 138, 141-148, 150

disabilities, 176, 186,229

minorities, 181

puberty, 61

Diabetes, 91, 235

Diagnosis, 10

drug and alcohol abuse, 17-19,63, 102

insurance, 85-86, 1, 48, 99, 100, 101-104, 116, 117, 174

mental health problems, 16-17, 31, 63

physician skills, 15-22,23, 29,63

sexually transmitted diseases, 127-128

skin diseases, 19-20

Diet, see Nutrition

Disabilities, 93-94, 168, 176, 186, 229

Disadvantaged Minority Health Improvement Act of 1990, 196,

243

Discretionary time, 61

see also Sports and recreation

Diseases and disorders, 282-288

acne, 10, 20, 61, 63

anemia, 20, 185

diabetes, 91, 235

obesity, 185

see also Accidents and injuries; Chronic physical diseases and

disorders; Disabilities; Drug abuse; Mental health and

illness; Morbidity and mortality; Sexually transmitted

diseases; Screening

District of Columbia, 50, 82, 97, 103, 105, 107, 111, 129, 189

Door, The, 36-41
///-296 ● Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Dropouts, 55, 61

minorities, 185

poverty, 55, 168

rural areas, 198

urban areas, 55

Drug abuse, 214,230-231,233, 237, 253, 254,287-288

access to services, 19

attitudes of adolescents, 19

block grants, 153

clinical services, 35-39 (passim)

consent and confidentiality, 129-130, 131, 133, 135, 137, 138,

153

counseling, 17-18, 47

diagnosis, 17-19,63, 102

Federal programs, 193-194, 229-232

historical perspectives, 19

insurance, 83, 88-89, 102, 108, 115, 117, 170

minority groups, 193, 194, 196, 229

physician competence, 17-19,22, 23,29

poverty and, 169

prevention, 173,254

professional education, 19

school-linked health centers, 44, 47, 54

socioeconomic factors, 169

see also Alcohol abuse; Tobacco use

Drug Abuse Education and Prevention Act, 229

Early and Periodic Screening, Diagnosis, and Treatment program, 1,44,48,99, 100, 101-104, 116, 117, 174

Economic factors

independent minors, 126

rural areas, 198

see also Cost factors; Financial factors; Funding; Income;

Poverty; Socioeconomic status

Education and Human Services Consortium, 57

Educational factors, 235,235

Federal role, 196, 217, 219-220, 245, 247-250

job training and aiding, 178, 217,225,251-252,255

minorities, 187, 196

sex education, 243

see also Counseling; Dropouts; Preventive health measures

and health education; Professional education; School

influences and services; Universities and colleges

Education of the Handicapped Act, 262

Eisenstadt v. Baird, 128

Elderly persons, 172,244, 109-110

Emancipated and mature minors, 125, 126-127, 131, 136, 140,

149-150, 151

Emergency services, 51,54, 174

consent and confidentiality, 126, 127, 131, 137

Employee Retirement and income Security Act, 83

Employer mandate, 110, 113

Employment and Training Administration, 178, 251, 252

Employment and unemployment

Federal programs, 29, 178,217, 251-252,251-252,255

health insurance benefits, 80,83-94 (passim), 110, 112, 113,

117

job training and aiding, 178, 217,225,251-252,255

minorities, 181

poverty and, 165, 169, 170, 178

research, 252

school-linked health centers, 44, 49

self-employed, 80, 110, 113

workforce demography, 165, 178-179

see also Staffing

Empowerment approaches, 36,58, 59,60

youth panels, 59,60

Epidemiology, see Morbidity and mortality

Ethics of confidentiality, 134-138, 140-141, 151-152

Ethnicity, see Cultural factors; Minorities; specific groups

Evaluation issues

community-based comprehensive service centers, 30, 32, 33,

36, 38,51,52-57,64, 171

consent and confidentiality, 123, 134-135, 138, 141-150, 151

correctional programs, 250

demonstration projects, 33-34,52,252

Federal policies, 65-66

integrated services, 57-58, 66

juvenile justice, 250

local services, 255

minority-oriented services, 189, 191

professional education, 28-29,33,57

school-linked health centers, 51, 52-57, 64

sex education, 243

Exercise, see Physical fitness

Families, 34,61, 125,230, 282

adoption, 177, 286, 79, 95-98, 100, 116, 152, 162, 173, 174,

175,225, 229

counseling, 44

Federal programs, 173

insurance costs, 83

legal issues, 123, 125, 131

minority, 179, 187, 188, 190

poor, 159-161, 162, 169-170, 173-174,243

single-parent, 162, 173-174, 190

support by, 159-160, 184, 188, 190

support for, 190, 196

see also Child abuse and neglect; Foster care; Parents and

parenting

Family planning services

consent and confidentiality, 128-129, 132-133, 135

insurance, 93, 96, 100, 101, 103

school-linked health centers, 45

Family Support Act, 173

Family Support Admini . .stration, 173-175, 192, 214, 220, 225

Federal Government, 2-3, 171-178, 191-196, 199-200,213-263

community-based comprehensive service centers, 259-261

consent and confidentiality, 123, 128-129, 152-153

education, 196, 217, 219-220, 245, 247-250

employment programs, 29, 178, 217, 251-252, 251-252, 255

evaluation issues, 65-66

funding, 29,48, 55, 64, 65, 92-93, 117, 174-178, 193, 194,

196,200

health insurance, 114-115, 117

interagency coordination, 3, 193, 194, 250, 252, 253-256,

257-258

local governments, cooperation with, 176, 192,232-233,235,

243,250,252,255,262

mental health, 190, 191-196, 232-233, 235, 241, 243

military service, 126, 255

minorities, 190, 191-196, 241, 243

poverty, 171-178

preventive health measures, 258
Index ● III-297

professional education, 29

research, 250, 262

rural areas, 199-200

States, cooperation with, 65, 110, 173, 176, 192, 232-233,

235, 236, 250,252, 263

States, funding conditions, 65, 250

see also Block grants; legislation (specific Federal); Medicaid; specific Federal agencies,” specific health problems

Females, 79,95-98, 100, 116, 152, 162, 173, 174, 175,225,229

anemia, 185

single parents, 162, 173-174, 190

see also Pregnancy

Financial factors

access to services, 1, 30, 63, 77-120, 188, 189, 198-199

child support, absent parents, 173-174

community-based comprehensive service centers, 33, 39

consent and confidentiality, 125, 135, 137, 138

school-linked health centers, 45, 47-50

see also Cost factors; Funding; Health insurance; Staffing

Fitness, see Physical fitness

Florida, 49, 50, 82, 97, 103, 105, 107, 111

Fluoridation, 235

Food assistance, 178, 246,255

Foster care, 172

Foster Grandparent Program, 172

Foundations, see Nonprofit organizations

4-H clubs, 200, 246

Free clinics, 34, 37-41, 60

Funding

abortion, 92-93, 177, 243

comprehensive service centers, 30-31, 33, 35, 38, 39, 47-48,

50

Federal, 29,48, 64, 65, 92-93, 117, 171-178, 193, 194, 196,

200

Federal funding conditions for States, 65, 250

local, 47-48, 52,54, 55

school-linked health centers, 47-48, 50

training, 29

see also Block grants

Gender differences

clinic utilization, 35

competency of minors, 146

diagnosis, 11

utilization of services, 9-10, 35, 46, 146

see also Females; Males

Geographic factors, see Regional programs and trends; Rural

areas; Suburban areas; Urban areas; specific States and

other geographic areas

Georgia, 82, 97, 103, 105, 107, 111

Government role, see Federal Government; State-level programs and activities

Griswold v. Connecticut, 128

Hawaii, 82,97, 103, 105, 107, 111, 191

Hawaiian Natives, 186-187, 188, 191

Head Start program, 176

Health Care Financing Administration, 174-175, 192,214,220,

225, 229, 289

see also Medicaid; Medicare

Health care professionals, 147-148

attitudes of, 7, 12, 15, 17, 20-22, 23, 51-52, 62-63, 109

attitudes toward, 7, 12-15, 17, 20-23, 24, 28-29, 30, 32-33,

51-52,62-63

availability of, 23-26

education of, 190, 202

ethics of confidentiality, 134-138, 140-141, 151-152

Federal programs, 29, 196

health educators, 25

insurance, nonphysicians, 94, 115, 117

liability, 130, 104

minority, 190, 196

nurses and nursing, 31, 35 55 99, 104, 115, 117, 145, 240 ,--,

nutritionists, 22-23

psychologists, 23-24

social workers, 23-24, 25

student aid, 190, 195

training of, 26-29

see also Physicians; Professional associations;

Staffing

Health education, 44

Health insurance, 77-94, 115, 117, 170, 190

abortion, 92-93

alcohol abuse treatment, 88-89

chronic diseases, 93-94

consent and confidentiality, 117, 136, 170

contraceptives, 93

cost, 83, 84-85, 87, 88, 93, 94, 114

demonstration project, 77-81, 100

dental health, 91,93

diagnostic services, 85-86

disabled persons, 93-94

drug abuse treatment, 83, 88-89, 115, 117

Specialists;

as employee benefit, 80, 83-94 (passim), 110, 112, 113, 117

families, costs, 83

Federal action, 114-115, 117

health maintenance organizations, 17, 31, 34, 35-36, 83, 84,

85, 87-88,89,93,99

historic perspectives, 109-110,99, 110, 112-113

mental health services, 83, 86-88, 115, 117

minorities, 79-80

nonphysicians, payment for services, 94, 115, 117

physicians and, 50, 84, 99, 104, 105, 108-110, 111, 115,

116-117, 175

pregnancy and, 84,90-93,98

preventive services, 85-86

psychological and psychiatric services, 86,87

regional trends, 80-81

regulation of, 83, 87, 90-91, 92, 110, 112, 115

school-linked health centers, 50

screening services, 85-86, 88

socioeconomic factors, 77-81

underinsured/uninsured, 46, 52, 77-81, 82, 83, 94, 110,

111-114, 169-170, 175

see also Medicaid

Health maintenance organizations, 17, 31, 34, 35-36, 83, 84,

87-88,89,93,99

Health Resources and Services Administration, 29, 176, 194-

195, 215,222,235-237

Healthy People 2000,241

Hispanic Health and Nutrition Examination Survey, 185, 188

Hispanics, 179, 180, 185, 191, 195, 185, 195, 196,241

cultural factors, 188, 189, 190

poverty, 162
///-298 . Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

,

school influences, 46

uninsured, 79

Historical perspectives

civil rights, 180

clinics, 35, 37, 39

drug abuse, 19

health insurance, 79,83-84

interagency coordination, 79, 254-256, 257-258

minorities, 188, 201

physicians, 62

professional associations, 25-26

rural areas, 198

school-linked health centers, 41.

utilization of services, 182

Hodgson v. Minnesota, 132-133

Hopelessness, 61, 167, 174, 176, 192, 193,213,229,237,249,

254,287

see also Runaways

Homicides, 59, 284

minorities, 184

Hospitals and hospitalization, 11-12, 199

access to services, 32, 34

clinics, 17, 31, 32-34, 35-36

drug abuse, 108

mental health, 34, 86-87, 106-108, 130, 134, 145

minorities, 11-12

physicians’ screening of hospitalized adolescents, 20

utilization, general, 11-12, 32, 34, 87

see also Commitment (involuntary)

Idaho, 82,97, 103, 105, 107, 111, 127

Illinois, 49,82,97, 103, 105, 107, 111, 171, 191

Immigration and immigrants, 181, 182, 192

Immigration Reform and Control Act, 192

Immunizations, see Vaccines

Income, 167-169

insurance status and, 78

see also Poverty

Indian Education Act, 249

Indian Health Service, 193, 195, ‘215, 222,237

Indiana, 82,97, 103, 105, 107, 111

Indians, see American Indians; Alaska Natives

Individual benefits management, 94

Individual differences

emancipated and mature minors, 125, 126-127, 131, 136, 140,

149-150, 151

experience, 147

intelligence, 125, 128, 140, 147

resilient children, 166-167

Infants of adolescents, care of, 44

Injuries, see Accidents and injuries

Inpatient care, see Hospitals and hospitalization; Residential

treatment programs

Institute of Medicine, 30,255

Insurance, see Health insurance; Medicaid; Medicare

Integrated health services, 57-59

Intelligence, 125, 128, 140, 147

Interdisciplinary approach, see Multidisciplinary approach

International Center for Integrative Studies, 41

Iowa, 49,82, 97, 103, 105, 107, 111

Job Corps, 252

JOBS program, 173

Job training and aiding, 40,44,49, 178,217,225,251-252, 255

Job Training Partnership Act, 178,217,251-252

Juvenile courts, 125, 126, 171, 183, 196,250,253

evaluation, 250

Juvenile delinquency, see Correctional programs; Delinquency

Juvenile Justice and Delinquency Prevention Act, 250,253

Kaiser Permanence, 34-36

Kansas, 82,97, 103, 105, 107, 111, 124

Kentucky, 49,82,97, 103, 105, 107, 111

Language issues, 189, 192

Legal issues

child support, absent parents, 173

commitment of minors, 130, 140, 144

consent and confidentiality, 123-135, 138, 139-140, 150,

151-152, 153

families, 123, 125, 131

financial liability, 124, 125, 130

professional legal services, 38, 39

see also Consent and confidentiality; Correctional programs;

Crimes and criminals; Delinquency; Juvenile courts;

Litigation

Legislation

access to services (model State statute), 47, 59-60

consent and parental notification, 123-135, 138, 150, 152

health insurance, 83

Legislation (specific Federal)

Anti-Drug Abuse Acts, 231-232

Child Abuse Prevention and Treatment Act, 176

Chinese Exclusion Act, 180

Civil Rights Act, 90

Developmental Disabilities Act, 176

Disadvantaged Minority Health Improvement Act, 196, 243

Drug Abuse Education and Prevention Act, 229

Education of the Handicapped Act, 262

Employee Retirement and Income Security Act, 83

Family Support Act, 173

Immigration Reform and Control Act, 192

Indian Education Act, 249

Job Training Partnership Act, 178,217,251-252

Juvenile Justice and Delinquency Prevention Act, 250,253

National and Community Service Act, 173,262

National Apprenticeship Act, 252

National Consumer Health Information and Health Promotion

Act, 241

National Youth Runaway Act, 37

Native Hawaiian Health Care Act, 191

Omnibus Budget Reconciliation Acts, 79, 98, 99-100, 101,

103, 110, 115, 116, 117, 175

Pregnancy Discrumination Act, 90-91,82, 115, 117

Public Health Service Act, 43,50,99,132,153,177, 243-244

Runaway and Homeless Youth Act, 176,229,254

Social Security Act, 100, 153, 173-177, 194,229,235

Stewart B. McKinney Homeless Assistance Act, 249,262

Leisure time, see Discretionary time; Sports and recreation

Litigation

consent and confidentiality, 123, 125-133 (passim), 139-140,

149-151

torts, 124, 125, 139

Longitudinal studies, 169, 171,254
Index . III-299

Long-term care, 93-94

Louisiana, 82,97, 103, 105, 107, 111

Maine, 82,97, 103, 105, 107, 111

Males

minority, 196, 243

school-linked services, 46, 56

sex education, 243

see also Gender differences

Marriage, 126, 198

Maryland, 29,53, 82,97, 103, 105, 107, 111

Mass media, 56

Massachusetts, 27, 82, 97, 103, 105, 107, 111

Medicaid, 79-82,94-110, 111, 112-113, 115-117, 174-175,229

abortion, 174

age factors, 95, 289

consent and confidentiality, 152, 153, 175

cost factors, 4, 95, 96, 116

demonstration programs, 99, 100

drug abuse treatment, 102, 108, 1,48,99, 100, 101-104, 116,

117, 174

eligibility, 65, 94, 95-100, 105, 107, 108, 116-117, 170, 175,

229

enrollment and expenditures, 4, 95, 96, 116, 175, 289

family planning services, 93, 96

medically needy programs, 96-97

mental health services, 106, 108

nonphysicians, payment for services, 104

outpatient services, 106, 107, 108

pediatricians, 99, 109, 115

physicians’ participation, 50,99,104,105,108-110, 111,115,

116-117, 175

private health insurance, relation to, 99, 110, 112-113

regional differences, 98, 108, 116-117

school-linked health centers, 46, 48, 50, 52

screening, 1, 48, 99, 100, 101-104, 116, 117, 174

specialists, 111

State-level issues, 94-117 (passim), 152, 170, 174, 175, 199,

229

utilization of services, 4, 95, 96, 116, 175, 289

see also Early and Periodic Screening and Treatment Program

Medical services and treatments, 61-64

consent and confidentiality, 123-153

nontraditional, 188, 195-196

school-linked health centers, 43, 44

vaccines, 145, 188, 235, 240

see also Diagnosis; Health care professionals; Hospitals and

hospitalization; Outpatient care; Screening

Medicare, 109-110

Mental health and illness, 61, 254, 255,286

block grants, 153

commitment of minors, 130, 140, 144

consent and confidentiality, 130, 131, 133-134, 140, 144,

145-146, 147, 153

depression, 186

Federal programs, 153, 190, 191-196,232-233,235, 241,243

hospital-based services, 34, 86-87, 106-108, 130, 134, 145

insurance, 83, 86-88, 115, 117, 106, 108, 170

minorities, 183, 185, 186, 188, 193-194

multiple problems, 61

outpatient care, 87, 106-108, 134, 145

rural areas, 198

school-linked health centers, 44, 46-47

utilization of services, 87

see also Alcohol abuse; Counseling; Drug abuse; Psychological and psychiatric services; Suicide

Mentor influence, 173, 191

Methodological issues, evaluation, 4, 95,289

Michigan, 49, 82,97, 103, 105, 107, 111, 191

Migrant and seasonal workers, 176, 177,213, 237

Military service, 126, 255

Minnesota, 29,41,51,82,97, 103, 105, 107,111, 133, 181, 198,

199

Minorities, 1-2, 178-196, 199, 201,241, 243

abortion, 185

access to services, 187-196

accidents and injuries, 183, 184, 186

acute diseases, 185, 195, 196, 241

alcohol abuse, 183, 185, 186, 193, 196,229

attitudes, 181, 191, 262

competency of minors, 147

crime, delinquency, and correctional programs, 171, 183,

184-185, 187, 196, 250

cultural factors, 179-181, 182, 183, 184, 186-192 (passim),

194, 196,201, 202

developmental processes, 181

dropouts, 185

drug abuse, 193, 194, 196, 229

education, 187, 196

employment, 181

evaluation of services, 189, 191

families, 179, 187, 188, 190

Federal programs, 190, 191-196,241, 243

health problems, 183-187

historic perspectives, 188, 201

homicides, 184

hospitalization, 11-12

insurance, uninsured, 79-80

males, 196, 243

mental health and illness, 183, 185, 186, 188, 193-194

physician utilization, 10

poverty, 161, 162, 164, 165, 179, 188, 191

pregnancy, 183, 185, 186187

prejudice toward, 181, 183, 184, 190

preventive health interventions, 188, 254

professionals, 190

regional trends, 184, 199

risk factors, general, 179, 182-187

school influences and programs, 46, 196

sexual activity, 183, 185

urban areas, 182, 184, 185

utilization of services, 10-12, 46, 179, 182-183, 188

workforce, 178-179

see also Cultural factors; specific groups

Mississippi, 82, 97, 103, 105, 107, 111, 127

Missouri, 82,97, 103, 105, 107, 111

Models

community-based comprehensive service centers, 35-41,

56-57

health insurance, 117

integrated delivery, 57, 58

school-linked health centers, 41-57

see also Demonstration projects; Role models

Montana, 82, 97, 103, 105, 107, 111
111-300. Adolescent Health—Volume Ill: Crosscutting Issues in the Delivery of Health and Related Services

Morbidity and mortality, 4,57,282-288

blacks, 183-185

minorities, 183-187

rural adolescents, 197-198

Motor vehicles

accidents, 183, 186, 197, 217-218, 235, 244, 245, 246,

252-253, 262

intoxicated drivers, 18, 137

Multidisciplinary approach, 57-59(

professional education, 29,57,64

see also Comprehensive health care

National Academy of Sciences, 250

National Adolescent Student Health Survey, 254

National Ambulatory Medical Care Survey, 8-11, 13, 182

National and Community Service Act, 173,262

National Apprenticeship Act, 252

National Center for Health Statistics, 8, 165, 182

National Conference of Catholic Bishops, 51

National Consumer Health Information and Health Promotion

Act, 241

National Health Examination Survey, 165

National Health Interview Study, 8-12, 165, 167-168, 197,235,

254

National Highway Traffic Safety Administration, 252-253

National Institutes of Health, 200,215-216, 222-223,237-241

National Institute of Justice, 250,253

National Institute of Mental Health, 193-194,232-233

National Institute on Child Health and Human Development,

240

National Institute on Drug Abuse,, 230-232

National Science Foundation, 216

National Youth Runaway Act, 37

Native Americans, see Alaska Natives; American Indians;

Native Hawaiians

Native Hawaiian Health Care Act, 191

Native Hawaiians, 186-187, 188, 191

Nebraska, 82,97, 103, 105, 107, 111, 124

Nevada, 82,97, 103, 105, 107, 111, 127

New Hampshire, 82,97, 103, 105, 107, 111, 127

New Jersey, 43,49,82,97, 103, 105, 107, 111

New Mexico, 82, 97, 103, 105, 107, 111

New York, 34-35,39-41,43,49,82, 97, 103,105, 107,111, 191

Nonprofit organizations, 65,252,256

National Science Foundation, 216

Robert Wood Johnson Foundation, 33, 41, 42, 46, 47, 56,

170-171

school-linked health centers funding, 47

North Carolina, 82,97, 103, 105, 107, 111

North Dakota, 82,97, 103, 105, 107, 111

Nurses and nursing, 31, 35,55,99, 104, 115, 117, 145,240

Nutrition, 47, 61, 176, 178, 185- 186, 188, 193, 225, 235, 246,

254, 255,284

food assistance, 178,246, 255

professionals, 22-23

Obesity, 185

Office of Child Support Enforcement, 173-174

Office of Community Services, 174

Office of Disease Prevention and Health Promotion, 241,253

Office of Family Assistance, 173

Office of Human Development Services, 175-177, 192-193,

220,229

Office of Minority Health, 185-196,241,243

Office of Population Affairs, 177,243-244

Office of Refugee Resettlement, 192

Ohio, 29,37-38,82,97, 103, 105, 107, 111

Ohio v. Akron Center for Reproductive Health, 133

Oklahoma, 82,97, 103, 105, 107, 111

Omnibus Budget Reconciliation Acts, 79,98,99-100, 101,103,

110, 115, 116, 117, 175

Oregon, 49,82,97, 103, 105, 107, 111, 124, 129

Outpatient care

drug abuse, 108, 106, 107, 108

mental health, 87, 106-108, 134, 145

Outreach services

clinics, 39

school-linked health centers, 54, 56

State Medicaid programs, 99

Parental notification, see Consent and confidentiality

Parents and parenting by adolescents, 39,254,255,285,286

block grants for services, 153, 177, 194,235-236

see also Pregnancy

Parents and parenting of adolescents, 124-138, 147-148, 230,

254

attitudes, 50-51,55, 79, 95-98, 100, 116, 152, 162, 173, 174,

175,225,229

child support payments, absent parents, 173

conflicts, 173, 250

consent and confidentiality, 129

school involvement, 50-51, 55, 56

single parents, 162, 173-174, 190

uninsured, 78-80

see also Adoption; Child abuse and neglect; Consent and

confidentiality; Foster care

Parham v. J.R., 130

Participatory approaches, see Empowermmt approaches

Pediatricians, 12-14,62

attitudes, 21, 51-52,62-63, 109

diagnostic skills, 15-20

education, 26-29, 99, 109, 115

Peer influence, 36, 187, 230

assertiveness training, 144

consent and confidentiality, 143, 147-148

Pennsylvania, 82,97, 103, 105, 107, 111

Physical fitness, 188,283

Physical illness, 61, 284

Physicians, 13-14,62, 199

attitudes of, 7, 12, 15, 17, 20-22, 23, 51-52, 62-63, 109

consent and confidentiality, 15, 62-63

contraceptive services, competence in delivering to adolescents, 21

counseling, 10, 14-15, 17-18, 20-21, 62

diagnostic skills, 15-22,23, 29,63

ethics of confidentiality, 134-138, 140-141, 151-152

health insurance issues, 50,99, 104, 105, 108-110, 111, 115,

116-117, 175

utilization of, 8-11, 169, 188, 199

see also Pediatricians

Police, 146, 184

Poverty, 1-2, 159-178, 198, 199, 200-201, 202-203, 237, 243,

247, 287
Index .111-301

access to services, 79, 95-98, 100, 116, 152, 162, 169-171,

173, 174, 175, 192, 225,229,

chronic diseases, 168

clinical services, 31, 33

contraceptives, 169, 243

delinquency, 169, 171

disabled, 168

dropouts, 55, 168

drug abuse, 169

employment, 165, 169, 170, 178

families, 159-161, 162, 169-170, 173-174,243

Federal programs, 171-178

job training, 251

minorities, 161, 162, 164, 179, 184, 185, 188, 189, 191

physician utilization, 11

pregnancy, 169, 176, 177, 243

regional trends, 162-163, 165

risk factors, general, 159-160, 162, 167-169, 170

schools in poor areas, 46, 55

sexual activity, 169, 177

uninsured, 78-81, 83, 94

urban areas, 165, 169, 170-171, 182, 185

see also Medicaid

Preferred provider organizations, 84,88

Pregnancy, 177, 183,214, 237,254-255,285

block grants for services, 153, 177, 194

consent and confidentiality, 129, 133, 137, 141, 142, 143,

144-145

Federal programs, 153, 177, 178, 194, 235-236

health insurance, 84,90-93,98

minorities, 183, 185, 186187

physician utilization, 9-10

poverty and, 169, 176, 177, 243

school-linked health centers, 44, 53-54, 55, 56

see also Abortion; Contraception and contraceptives; Family

planning services

Pregnancy Discrimination Act of 1978,90-91,92, 115, 117

Preventive health and education measures

accidents, 235, 244, 245, 246, 262

delinquency, 250, 251, 258

drug abuse, 173,254

insurance, 85-86

minorities, 188, 254

safety equipment, 252-253

sex education, 44, 243

see also Counseling; Diagnosis; Screening; Safety equipment; Well child care

Primary health care, 5-73, 176, 12-13, 14, 25,28, 52,62

defined, 7,62

school-linked health centers, 44

see also Physicians; Screening

Professional associations, 17-18,25-27,52,76, 136-137

adolescent-specific, 25-26, 27,28, 52,62-63

consent and confidentiality guidelines, 136-138

pediatrics, 12-13, 14, 25, 28,52, 62, 102, 109, 136, 197

see also specific associations

Professional education, 29,57

drug abuse, 19

evaluation, 28-29, 33, 57

Federal role, 29

health care personnel, 190, 202

multidisciplinary, 29, 57, 64

Psychological and psychiatric services

commitment for, 130, 140, 144

comprehensive clinics, 39

diagnostic, 16-17

insurance, 86, 87

screening, 31

specialists, 23, 25, 26, 63

Public Health Service, 176-177, 193-196, 214-215, 220-221,

229-244

Public Health Service Act, 32, 50,99, 132, 153, 177, 243-244

Public opinion

attitudes toward adolescents, 58

school-linked health centers, 50-51, 55

Racial and ethnic factors, see Minorities

Recreation, see Sports and recreation

Referral to services, 10, 31-32,44,52,55-56, 175

see also Outreach services

Refugees, 186, 192

Regional programs and trends, 255,98, 108, 116-117

minorities, 184, 199

poverty, 162-163, 165

rural residence, 196, 199

uninsured, 80-81

Regulations

consent and confidentiality, 123, 137, 152

private insurance, 83,87,90-91,92, 110, 112, 115

Relatives, see Families; Parents and parenting

Religious influences and organizations, 51,56, 190, 191, 192

Research

accidents, 252, 253-254

age v. competence, 123, 134-135, 138, 141-148, 150

employment, 252

family planning, 153

longitudinal studies, 169, 171, 254

see also Demonstration projects; Evaluation

Residential treatment programs, 175,252

Retired Senior Volunteer Program, 172

Rhode Island, 43, 82,97, 103, 105, 107, 111, 124

Risk factors, 34, 55-56,64, 235, 254,282-288

minorities and, 179, 182-187

multiple problems, 61, 287

poverty-associated, 159-160, 162, 167-169, 170

see also Alcohol abuse; Drug abuse; Morbidity and mortality;

Tobacco use

Robert Wood Johnson Foundation, 33, 41, 42, 46, 47, 56,

170-171

Roe v. Wade, 128-129

Role models, 148, 171, 203

see also Mentor influence; Peer influence

Runaway and Homeless Youth Act, 176,229,254

Runaways, 37, 176, 193,229, 254

Rural areas, 1, 165, 182, 196-200,201-202

accidents, 197

Safety equipment, 252-253

School influences and services, 61, 230,283

absenteeism, 54, 168

alcohol abuse treatment, 47,54

apprenticeships, 252

attitudes of adolescents, 43, 52

consent and confidentiality, 50-51, 52
//1-302 . Adolescent Health–-Volume III: Crosscutting Issues in the Delivery of Health and Related Services

contraceptives, 44, 51, 53-54, 56

cost factors, 47-48, 50, 56

counseling, 43-44, 47, 53, 56

delinquency, 255

driver education, 252-253

drug abuse, 47,54

evaluation, 51, 52-57, 64

financing, 45,47-50

food programs, 178, 246

funding, 47-48, 50

insurance reimbursement, 50

male-oriented, 46, 56, 46, 48, 50, 52

mental health, 46-47

minorities, 46, 196

outreach, 54, 56

parent involvement, 50-51,55, 56

poor areas, 168-169

pregnancy, 53-54,55,56

screening, 52, 55-56

sex education, 44, 243

sexual activity interventions, 51, 53-54, 55, 56, 235

teachers, 27, 86-87

see also Dropouts; School-linked health centers

School-linked health centers

adolescent perspectives on, 43

evaluation of, 52-55

funding of, 47-50

limitations of, 55-57

parental and community attitudes toward, 50-51

physician attitudes toward, 51-52

quality of care in, 55

services in, 43-44

State initiatives, 49

utilization of, 45-47

Screening, 12, 235, 132

insurance, 85-86, 88, 1, 48, 99, 100, 101-104, 116, 117, 174

mental illness, 31

school-linked health centers, 52, 55-56

sexually transmitted diseases, 127-129, 132

see also Well child care

Sex differences, see Gender differences

Sexual activity, 61,235, 243, 262, 263, 285

attitudes of nonadolescents, 23

consent and confidentiality, 127-129, 131, 132-134, 135, 137,

138

educational interventions, 44

homosexual, 138

minorities, 183, 185

physician competence in discussing, 21-22

poverty and, 169, 177

school-linked health centers, 44, 51, 53-54 55 56, 235 ,. -,.

see u/so Contraception and contraceptives; Pregnancy

Sexually transmitted diseases, 61, 285

clinical services, 35, 37

consent and confidentiality, 127-128, 132, 135, 137

diagnosis, 127-128

Federal programs, 233-235, 239-241

minorities, 185

physician competence in diagnosing, 21, 23, 29

school-linked health centers, 44

screening, 127-129, 132

see also AIDS

Skin diseases

acne, 10, 20, 61, 63

diagnosis, 19-20

Smoking, see Tobacco use

Social Security Act, 100, 153, 173-177, 194,229,235

Society for Adolescent Medicine, The, 25,27,28,52,62-63

Socioeconomic status, 167-169

clinic utilization, 32

competency of minors, 144-145, 146-147

drug abuse, 169

health insurance coverage, 77-81

minorities, 183

physician utilization, 10-11

utilization of services, 10-12, 32, 46

see also Income; Poverty

South Carolina, 82,97, 103, 105, 107, 111, 124

South Dakota, 82,97, 103, 105, 107, 111

Special education, 262

developmental disabilities, 176, 186, 229

Specialists, 10,23, 25-29,63

adolescent-specific, 25-26, 27, 28, 52,62-63

dermatologists, 19-20, 111

nutritionists, 22-23

psychologists and psychiatrists, 23, 25,26, 63

see also Pediatricians

Sports and recreation, 40,56, 225

Staffiig

clinics, 37, 39

community-based comprehensive service centers, 45, 55, 56,

64

rural areas, 199

school-linked health centers, 45, 55, 56, 64

Standards

correctional facilities, 250

ethics of confidentiality, 134-138, 140-141, 151-152, 65, 94,

95-100, 105, 107, 108, 116-117, 170, 175,229

State-level programs and activities, 79, 95-98, 100, 116, 152,

162, 173, 174, 175, 225,229

coordination, 263

Federal funding conditions, 65, 250

health insurance regulation, 83,87,90-91,92, 110, 112, 115,

50, 65,94-117 (passim), 152, 170, 174, 175, 199,229

minorities, 191, 192

school-linked health centers, 47, 49, 50

see also Block grants; specific State names

Stewart B. McKinney Homeless Assistance Act, 249, 262

Student aid, 190, 195

Student Community Service Program, 172

Substance abuse, see Alcohol abuse; Drug abuse

Suburban areas, 35, 165, 169

Suicide, 59, 138, 183, 184, 198,283, 287

Summer programs, 251-252, 262

Supplemental Security Income, 100

Support Center for School-Based Clinics, of Center for Population Options, 41

Supreme Court, 123, 125, 128-134, 140, 150, 177,243

Task Force on Pediatric Education, 29

Teachers, 27, 86-87

Technical assistance, 41, 192,217

Tennessee, 82,97, 103, 105, 107, 111

Texas, 41,82, 97, 103, 105, 107, 111
Index .111-303

Third-party payers, see Health insurance; Medicaid; Medicare

Tobacco use, 54, 169, 240,255, 287

Torts, 124, 125, 139

Unintentional injuries, see Accidents and injuries

Universities and colleges, 171, 193, 195, 198,230

student aid, 190

urban areas

clinics, 170-171

dropouts, 55

minority groups, 182, 184, 185

poverty, 165, 169, 170-171, 182, 185

Utah, 50, 82,97, 103, 105, 107, 111, 129

Utilization of services

gender differences, 9-10,35, 146

hospital-based, 11-12, 32, 34, 87,4, 95,96, 116, 175, 289

minorities, 10-12, 46, 179, 182-183, 188

physicians, 8-11, 169, 188, 199

poor adolescents, 169

rural areas, 198-199

school-linked health centers, 45-46, 54, 56

socioeconomic status, 10-12

see also Access to services

Vaccines, 44, 145, 188,235,240

Vermont, 82,97, 103, 105, 107, 111

Violence, 169, 184-185,250, 287

Virginia, 82,97, 103, 105, 107, 111

Vocational issues, see Employment and unemployment; Job

training and aiding

Volunteers and volunteering, 36, 37, 38, 39, 172-173, 191,

172-173, 216,244

Volunteers in Service to America, 172, 244

Washington, 29,82,97, 103, 105, 107, 111

Webster v. Reproductive Health Services, 129, 133

Well child care, 12

West Virginia, 82,97, 103, 105, 107, 111

Wisconsin, 50, 82,97, 103, 105, 107, 111

W.T. Grant Foundation, 256

Wyoming, 82,97, 103, 105, 107, 111, 124, 129