Adolescent Risk
Behaviors
Elyse Olshen Kharbanda, MD, MPH
Assistant Clinical Professor of Pediatrics and Public Health
Columbia University
Adolescent risk
behaviors
Why adolescents take
risks
• Developing one’s own moral code and
establishing an identity, separate from parents
is a major task of adolescence
– Early adolescence (ages 11-14) – first stages of
separation from parents, desire to look and act like
peers, difficulty with impulse control
– Middle adolescence (ages 15-17) – further distancing
from parents and allying with peers, feelings of
omnipotence and immortality can lead to dangerous
behaviors
– Late adolescence (ages 18-21) - fully identify one’s
own moral code, more confident and better able to
delay gratification, can be protective factors
Why do we care?
• Testing limits is part of normal adolescent
emotional and psychological development
• Adolescent risk behaviors can lead to
significant morbidity and mortality
• Risk behaviors are often interrelated
• Adolescents who participate in multiple
risky behaviors are often depressed or
have other mental illness
Mortality statistics
•
Adults
1. Heart disease
2. Cancer
3. Stroke
•
Adolescents
1. Accidents
2. Homicide
3. Suicide
Morbidity statistics
• Nearly 1 million US teens become
pregnant every year
• Nearly 4 million teens contract a STI
each year
• Alcohol consumption is associated
with motor vehicle injuries and
fatalities, unwanted sexual activity,
unprotected sexual activity, violence
perpetration and violence
victimization
Plan for presentation
• Unintentional
Injuries
• Violence
• Suicide
• Smoking/drinking/
drugs
• Cutting
• Teen Pregnancy
• Obesity
• Epidemiology
(National and NYC
data)
• Implications
• How to
screen/counsel
patients related to
these issues
Definition of injury
• Unintentional or intentional damage to
the body resulting from acute exposure
to thermal, mechanical, electrical, or
chemical energy or from the absence of
such essentials as heat or oxygen
Unintentional injuries –
National data
• Leading cause of mortality among
adolescents 10-19 years
• Approximately 8000 deaths due to
unintentional injury in 2005
• 71% mortality due to MVAs
• Approximately 2/3 of MVA related
mortality is alcohol-related
More about injuries
• Injuries are not accidents. They can be
prevented by changing the environment,
individual behavior, products, social
norms, legislation, and governmental
and institutional policy
Accidents/Unintentional
injuries
• Data from NYC YRBS
– % students reported they never or rarely
wore a seat belt 16%
– % students who in past 30 days rode in car
with driver who had been drinking 18%
– % students who in past 30 days drove a car
after drinking 4%
– % students who rode a bicycle reported they
never or rarely wore a helmet 90%
Accidents/Unintentional
injuries
• Screening regarding safety at
medical visits
• Seat belts
• Bicycle helmets
• Drinking and driving
Violence
• “Threatened or actual use of
physical force or power against
another person, against oneself,
or against a group or community
that either results in or has a
high likelihood of resulting in
injury, death, or deprivation”
Violence – National data
• Homicide is the second leading
cause of death in adolescents
• 2000 deaths annually among 15-19
year olds
• Homicide rates (ages 15-19) by
race
– White males 3.6 per 100,000
– Hispanic males 26.6 per 100,000
– Black males 60.6 per 100,000
Violence – National data
• Approximately 9% of US high school
students report lifetime history of sexual
assault
• Up to 40% of adolescents report history
of dating violence
• Victimization associated with future
victimization, depressive
symptomatology, increased risk
behaviors and future suicide attempts
Violence – NYC data
• From 2005 NYC YRBS
– % students who carried a weapon at
least once in past 30 days 17%
– % students who did not go to school
at least once in past 30 days because
they felt unsafe 9%
– % students in past year who were in a
physical fight 36%
Violence
• Screening
–
–
–
–
–
access to firearms
carrying a weapon
fighting with peers
gang membership
dating violence/sexual assault
• Intervention
– For youth with violence related behaviors,
evaluate readiness to change
– Evaluate youth with histories of aggression
for psychiatric comorbidity – consider psych
referral
Suicide – National data
• Third leading cause of death among
adolescents
• Approximately 1600 suicides per year
among 10-19 year olds
• Suicide rates by gender (ages 14-19)
–
–
–
–
–
–
Females 2.5 per 100,000
10.3 per 100,000
Males
Suicide rates by race (ages 14-19)
Whites
7.4 per 100,000
Hispanic 5.4 per 100,000
3.5 per 100,000
Blacks
Suicide – NYC data
• 2005 NYC YRBS
– % students who felt sad or hopeless
daily for 2 weeks in past 12 months
32%
– % students who seriously
considered attempting suicide in the
past 12 months 15%
– % students who attempted suicide in
the past 12 months 10%
Suicide – risk factors
•
•
•
•
Prior suicide attempts
Depression
Alcohol or substance abuse
Associated with multiple other risky
behaviors
–
–
–
–
Smoking
Early sexual activity
Violence victimization
Disordered eating
Suicide
• Screening
– Depression
• Mood, affect, sleep, appetite, boredom,
restlessness, social isolation, school/work
performance
– Impulsiveness
– Mania
– Suicidal ideation/suicide attempts
• Interventions
– Mental health referral – if actively
suicidal, refer to C-CPEP
– Involve parents/legal guardian
SSRIs and suicidality
• SSRIs are an effective treatment for
depression (TADS)
• Increasing SSRI use in 1990s associated
decreased rates of suicide
• Concern regarding reports of suicides
following starting on SSRIS
• Meta-analysis of published and unpublished
data found increased suicidal
thoughts/behaviors (no completed suicides
in trials)
• 2004 FDA Black Box warning on SSRIs for
depressed children and adolescents
Smoking/drinking/drugs
- NYC data
• NYC 2005 YRBS
– % students who smoked in past 30 days (was
24% in 1999) 11%
– % students who drank in past 30 days 36%
– % students who reported binge drinking in
past 30 days 14%
– % students who used marijuana in past 30
days 12%
– % students who sniffed glue, inhaled
paints/aerosols, etc… 9%
– % students offered, sold or given an illegal
drug on school property in past year 26%
Smoking/drinking/drugs
• While many consider this to be a rite of
passage, these behaviors are associated with
significant morbidity and mortality
• 2/3 MVA mortality is alcohol-related
• Early smoking risk for use of other drugs
• Drinking and drugs associated with
–
–
–
–
–
–
unwanted sexual activity
unprotected sexual activity
violence perpetration and victimization
problems with the law
school failure
Psychiatric co-morbidity
Smoking/drinking/drugs
• Interventions
– CRAFFT screening tool
1. Have you ever ridden in a Car driven by someone
(including yourself) who was high or had been using
alcohol or drugs?
2. Do you ever use alcohol or drugs to Relax, feel better
about yourself, or fit in?
3. Do you ever use alcohol or drugs while you are by
yourself Alone?
4. Do you ever Forget things you did while using alcohol
or drugs?
5. Do your Family or Friends ever tell you that you
should cut down on your drinking or drug use?
6. Have you ever gotten into Trouble while you were
using alcohol or drugs?
– Scoring: 2 or more positive items indicate the need
for further assessment.
–From: Knight JR; Sherritt L; Shrier LA//Harris SK//Chang G. Validity of the CRAFFT
substance abuse screening test among adolescent clinic patients. Archives of
Pediatrics & Adolescent 156(6) 607-614, 2002.
Cutting
• Form of intentional self-injury without
the intent of suicide
• May involve any sharp objects –
razors, glass, pins, etc…
• Most common sites are arms, wrists,
ankles
• Most common among adolescent
girls (up to 14% in one survey)
Why do adolescents
cut?
• Means to cope with painful
emotion
• Relief of agitation or anxiety
• Addictive quality – may result in
release of endorphins
• May be “contagious”
• Associated with other
psychopathology
Cutting
• Screening
– Ask about self injury
– Look for scars
• Intervention
– Refer to ER if injured or thought to be
suicide attempt
– Refer for mental health services
•
•
•
•
Individual therapy
Group therapy
Family therapy
Medications
Sexual risk behaviors
– National data
• Approximately half of high school students
are sexually active
• Adolescents have the highest rates of
STDs of all age groups
• Young adults represent half of all new HIV
cases in the US
• Risky sexual practices can be sign of
mental health issues or prior trauma history
Sexual risk behaviors
– NYC data
• 2005 NYC YRBS
– % students who ever had sexual
intercourse 48%
– % students with lifetime history of
4 or more partners 18%
– % sexually active students who
used a condom with last
intercourse 69%
Sexual risk behaviors
• Screening
– Need to talk to teens alone – teens of
any age can access reproductive health
care without parents
– Sexual activity
– Condom use
– Partners
– Prior STIs, pregnancy
• Intervention
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–
–
–
Annual GC/CT testing
Pap
HIV, RPR
HPV vaccine
Teen pregnancy
• While teen pregnancy rates
were on a 10-year decline, they
have increased in the past two
years
• Wide state-level variation exists
Teen Pregnancy’s Link to
Poverty and Other Social Issues
• What are the chances of a child growing up in poverty if
his/her mother: (1) gave birth as a teen, (2) was
unmarried when the child was born, and (3) did not
receive a high school diploma or GED?
– 27% if one of these things happen.
– 42% if two of these things happen.
– 64% if three of these things happen.
• If none of these things happen, a child’s chance of
growing up in poverty is 7%.
• A child born to a teen mother who has not finished high
school and is not married is nine times more likely to be
poor than a child born to an adult who has finished high
It Matters, National Campaign
schoolSource:
and is Why
married.
Consequences of Teen
Pregnancy
• Only 40% of young teen mothers graduate from
high school.
• Teen fathers earn less than older fathers (20-21).
• Compared to children born to older mothers (20-21
years old), children born to teen moms are more
likely to:
–
–
–
–
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to drop out of high school.
to use Medicaid and SCHIP.
to experience abuse/neglect.
to enter the foster care system.
to end up in prison (sons).
The Costs of Teen
Childbearing
An Overview
By The Numbers: The Public Costs of
Teen Childbearing
• Project goal: Measure the costs that could be
averted if teen mothers, 19 and younger, delay
their first birth to 20-21 years old.
– What is the impact on the young mother and
her child’s subsequent life outcomes and
what does this cost taxpayers?
• Both national and state-specific cost estimates
have been measured.
Costs Included in the
Analysis
• Costs linked to teen moms
– Public assistance
– Lost tax revenue
• Costs linked to the children of teen parents
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–
–
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Lost tax revenue
Public Health Care
Incarceration of sons
Child welfare
• Costs linked to teen fathers
– Lost tax revenue
National Findings
• Teen childbearing costs taxpayers at least $9.1
billion annually.
– Total cost breakdown is $8.6 billion for 17
and younger and $0.5 billion for 18-19 year
olds.
• Average annual public sector cost associated
with a child born to a mother aged 17 and
younger is $4,080.
National Findings
• Most of the costs of teen childbearing are
associated with negative consequences for the
children of teen mothers and include:
– $1.9 billion for increased public sector health care
costs
– $2.3 billion for increased child welfare costs
– $2.1 billion for increased costs for state prison
systems
(among adult sons of teen mothers)
– $2.9 billion in lost tax revenue due to lower taxes
paid by the children of teen mothers over their own
adult lifetimes.
Costs for the Children of
Teen Mothers
Children of teen mothers are more likely to:
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Have decreased educational attainment
Earn less money
Suffer high rates of child abuse and neglect
Grow up poor
Live in single-parent households
Enter the child-welfare system
Become teen mothers themselves
Youth Development
• Not all teens are behaving badly
• Programs to address single risk
behavior not successful
• Helping teens attain a sense of
competency, usefulness,
empowerment, and resilience
• Protective factors: family
connectedness, spirituality, school
connectedness, positive self-identity,
self-efficacy
Transtheoretical
model
• Developed by DiClemente and
Prochaska
• Integrates current behavior, intention to
change, decisional balance, and
strategies
• Behavior is an incremental, continuous,
and dynamic process
• New behavior results from decision
making processes that occur through
series of stages
• Each stage of change contains specific
tasks
Stages of change
•
•
•
•
•
•
•
Precontemplation
Contemplation
Preparation
Action
Maintenance
Termination
Relapse
Precontemplation
• Stage in which there is no intention
to change in the foreseeable future
(aprox 6 months)
• May be uninformed or underinformed
about consequences
• May have tried to change and
become demoralized
Contemplation
• Intend to change in the next 6
months
• Are aware of the pros and cons
• Profound ambivalence may keep
someone stuck here for a long time
Preparation
• Self awareness of need to change and
intent to do so within a month
• May have taken some significant action
in past year such as a class or seeing a
health or mental health provider
• Possible results of change considered
• Empowerment, recognizing possible
substitutes, and how to reward self
• “How could we make a plan?” Clinician
provides helping relationship
Action
• Has made overt changes in lifestyle
in the last 6 months
• For this stage must attain the criteria
that professionals agree reduces risk
i.e. with smoking total abstinence is
required
Maintenance
• Estimate that this stage lasts from 6
months to 5 years
• Are not working as hard to prevent
relapse as in action stage.
• Less temptation and more
confidence
Relapse
• Treat as re-entry into another cycle
• Recognize that stages from
precontemplation or contemplation
need to be relived
Termination
• Applies to some behaviors
• No temptation and 100% self –
efficacy
• It is as if one never acquired the
habit/risk in the first place.