RISK BEHAVIORS

drug use among teens
christopher l. ringwalt

hiv/aids and its impact on adolescents
denise dion hallforscarolyn tucker halpernbonita iritani

sexual activity among teens and teen pregnancy trends
sheila peters

TABLE 1

sexually transmitted diseases
angela huang

smoking and its effect on children's health
christopher s. greeley

suicide
peter l. sheras

teen pregnancydouglas b. kirby

DRUG USE AMONG TEENS

Substance abuse is an international problem of epidemic proportions that has particularly devastating effects on youth because the early initiation of alcohol, tobacco, or other drug (ATOD) use within this population is linked to abuse and related problem behaviors among adults. The cost of alcohol abuse to society is estimated to be $250 billion per year in health care, public safety, and social welfare expenditures. Key trends in substance use by twelfth graders are displayed in Table 1.

Causes

A number of models and theories address the causes of adolescent ATOD use. The most salient of these is the "Risk and Protective Factor" framework, which has identified a variety of psychosocial factors associated with ATOD use. In the individual domain, substance use has been linked to values and beliefs about and attitudes toward substances, genetic susceptibility, early ATOD use, sensation seeking, and various psychological disorders including anti-social, aggressive, and other problem behaviors. In the family domain, ATOD use has been associated with familial substance use, poor parenting practices including harsh or inconsistent discipline, poor intrafamilial communication, and inadequate supervision and monitoring of children's behaviors and peer associations. In the peer domain, substance use has been linked to social isolation and association with ATOD-using and otherwise deviant peer networks. In the school domain, ATOD use has been linked to poor academic performance and truancy, as well as a disorderly and unsafe school climate and lax school policies concerning substance use. In the community and environmental domains, ready social and physical access to ATODs has been associated with use, as has lack of recreational resources (especially during the after-school hours).

Protective Factors

Protective factors, or factors that promote resiliency, have also been identified in these various domains. Among those most frequently cited are religiosity or spirituality, commitment to academic achievement, strong life skills, social competencies, and belief in self-efficacy. Protective factors in the family and school domains include strong intrafamilial bonds, positive family dynamics, and positive attachment to school. In the community and environmental domains, strongly held adult values antithetical to substance use constitute protective factors, as do clearly communicated and consistently enforced regulations concerning use.

Prevention Strategies

A variety of strategies have demonstrated effectiveness in preventing or reducing ATOD use. Project Alert, described by Phyllis Ellickson and colleagues in a 1993 article, and Life Skills Training Program, described by Gill Botvin and colleagues in 1995, are the two most-prevalent effective classroom-based-curricula. The "Reconnecting Youth" Program, described by Leona Eggert and colleagues in 1994, is designed for high school students who manifest poor academic achievement or who are at high risk for dropping out and other problem behaviors. In the family domain, the Iowa Strengthening Families Program, described by Richard Spoth and colleagues in 1999, has received considerable attention. In the community and environmental domains, strategies have been developed to increase the enforcement of public policies and ordinances that inhibit adolescent substance use. These include efforts targeting tobacco and alcohol outlets, including restrictions on their location and density and on alcohol and tobacco advertising. Also effective is the vigorous enforcement of laws governing sales to minors, including using underage youth to buy alcohol and tobacco products in "sting" operations. Increasing excise taxes on alcohol and tobacco products has also been associated with reductions in use, as has linking apprehension for infractions of laws related to purchasing and consuming ATODs to suspension or revocation of driver's licenses. Other preventive measures that target youth drivers include "zero tolerance" laws linking evidence of alcohol on the breath with suspension or revocation of driving privileges.

The results of two decades of evaluative research have yielded considerable information suggesting that a number of approaches to adolescent ATOD use prevention do not work. Scare tactics, designed to frighten adolescents into avoiding drugs, are often recognized as such by their target audiences and can even be counterproductive. Efforts to raise self-esteem as a drug prevention strategy have long been discredited given the lack of association between self-esteem and ATOD use. Strategies designed to increase knowledge and convey information about the risks and dangers of drug use are generally recognized to be failures, in part because of the lack of association between knowledge and use. Indeed, all largely didactic approaches to prevention education, such as Project "Drug Abuse Resistance Education" (Project DARE), are widely understood to be ineffective, especially if they concentrate on long-term risks. Mass media campaigns are of dubious value, especially if they are brief, aired in contexts that are unlikely to reach their target audience, and uncoordinated with a comprehensive, community-wide strategy.

Unfortunately, relatively little is also known about prevention on college campuses. Many college campuses have cultures that are at least covertly supportive of alcohol consumption, and many administrators treat the issue with benign neglect. While most drinking on college campuses occurs in neighborhood bars and residential contexts such as fraternities, relatively little has been done to develop and implement demonstration programs that increase enforcement of, and penalties for, selling or otherwise supplying liquor to underage students.

It is known that even the most effective and comprehensive school-based strategies, and even those that reinforce their messages across multiple grade levels, are only slightly more effective than school-based programs that are generally discredited in the early twenty-first century. There has evolved a consensus among both practitioners and researchers that school-based programs, by themselves, are insufficient. Such efforts should be part of a broad and comprehensive array of prevention approaches that integrate both supply and demand reduction strategies in the family and community, as well as the individual, domains.

See also: Drug and Alcohol Abuse; Guidance and Counseling, School; Family Composition and Circumstance, subentry on Alcohol, Tobacco, and Other Drugs; Out-of-School Influences and Academic Success; Risk Behaviors, subentry on Smoking and Its Effect on Children's Health.

bibliography

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Center for Substance Abuse Prevention. National Center for the Advancement of Prevention. 2000. 2000 Annual Summary: Effective Prevention Principles and Programs. Rockville, MD: Center for Substance Abuse Prevention.

Dusenbury, Linda. 2000. "Implementing a Comprehensive Drug Abuse Prevention Strategy." In Increasing Prevention Effectiveness, ed. William B. Hansen, Steve M. Giles, and Melodia Fear-now-Kenney. Greensboro, NC: Tanglewood Research.

Eggert, Leona L.; Thompson, Elaine A.; Herting, Jerald R.; Nicholas, Liela J.; and Dicker, Barbara G. 1994. "Preventing Adolescent Drug Abuse and High School Dropout through an Intensive School-Based Social Network Development Program." American Journal of Health Promotion 8:202–215.

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Ennett, Susan; Tobler, Nancy S.; Ringwalt, Christopher L.; and Flewelling, Robert L.1994. "How Effective Is Drug Abuse Resistance Education? A Meta-Analysis of Project DARE Outcome Evaluations." American Journal of Public Health 84:1394–1401.

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internet resource

Join Together OnLine. 1999. "Alcohol Abuse Costs Society $250 Billion Per Year." <www.jointogether.org/sa/news/features/reader/0,1854,261313,00.html>.

Christopher L. Ringwalt

HIV/AIDS AND ITS IMPACT ON ADOLESCENTS

Acquired immunodeficiency syndrome (AIDS) is a significant threat to youth and young adults. It is the seventh leading cause of death among U.S. youth aged fifteen to twenty-four. More than 126,000 cases of AIDS among individuals ages twenty to twenty-nine had been diagnosed in the U.S. through June 2000. Given the long latency period between infection and symptoms, most of these individuals were infected as adolescents. Estimates of human immunodeficiency virus (HIV) among adolescents range from 112,000 to 250,000 in the United States, although actual prevalence is not known because representative data are not available. Estimates of HIV incidence in the early twenty-first century suggest that at least 50 percent of the 40,000 new infections in the United States each year are among individuals under twenty-five years old, and 25 percent are among persons aged twenty-one or younger.

HIV Transmission

The majority of HIV infections among adolescents are contracted through sexual activity. Among HIV positive thirteen to nineteen year-old females who had not developed AIDS, 49 percent of the cases were associated with exposure through sexual contact, 7 percent through injection drug use, 1 percent through blood exposure, and 43 percent through a risk not reported or identified. Among males in the same age group, 50 percent were associated with male to male sex, 5 percent with injection drug use, 5 percent with both male to male sex and injection drug use, 5 percent with hemophilia or coagulation disorder, 7 percent with heterosexual exposure, 1 percent with blood exposure, and 28 percent with an unreported or unidentified risk.

Many adolescents are sexually experienced, but the extent of experience and risk varies for different groups of adolescents. Youth Risk Behavior Survey (YRBS) data indicate that about half of all high school students report having engaged in intercourse at least once. Almost 10 percent of youth were younger than age thirteen at first sexual intercourse, and by twelfth grade, 65 percent of students have become sexually active. Sexual risk increases with the number of partners and the failure to use condoms. In the YRBS data, about 16 percent of high school students report having had sex with four or more partners; 48 percent of adolescent African-American males report four or more sexual partners. Forty-two percent of sexually active respondents did not use a condom at last intercourse.

The presence of other sexually transmitted infections (STIs) can also facilitate HIV transmission. Adolescents and young adults are physiologically and behaviorally at higher risk for acquiring STIs. An estimated three million cases of STIs other than HIV are acquired each year among persons between ten and nineteen years old. Youth under the age of twenty-five account for two-thirds of the total number of cases of STIs diagnosed annually. Rates of chlamydia, gonorrhea, and human papillomavirus are particularly high among sexually active female teens. An individual's risk is affected by STI prevalence among the pool of potential sex partners. African-American and Hispanic teens, for example, are disproportionately overrepresented among AIDS cases and cases of other STIs. Given that sexual networks tend to be homogeneous by race, these youth are more likely to face greater prevalence of HIV among their sex partners.

Drug use also places young people at risk for HIV. The most direct route is through sharing needles. Addicts may engage in sex with multiple partners to obtain drugs or money to buy drugs, and may thus increase the spread of infection to otherwise low-risk individuals. Non-injected drugs may also reduce inhibitions, influencing the individual to engage in risky sexual activity. Studies show that there are positive relationships between substance use and various facets of sexual behavior, such as timing of initiation, frequency, persistence, and risk taking, for both adolescents and young adults. However, findings regarding this pathway are mixed and may vary by race/ethnicity. For example, the link between substance use and sexual activity may be less strong among African Americans. Alcohol consumption has been linked to sexual risk taking among white adolescents, but a more recent study found that young women's condom use patterns were not linked to pre-coital substance use.

Pathways to HIV Prevention

Longitudinal studies that follow high-risk youth into adulthood provide a way for researchers to understand the developmental pathways of problem behavior. Greater involvement with problem behavior as a youth is predictive of greater involvement in young adulthood. However, problem behavior in the teen years does not necessarily lead to poor adult outcomes. For most adolescents, drug use and sexual activity reflect behavior that is experimental and socially normative. Longitudinal studies have shown that a "maturing out" process typically occurs, particularly if the individual is embedded in conventional institutions such as marriage.

Although most adolescents will grow out of many risk behaviors, prevention efforts are needed to reduce the risk of HIV infection during adolescence. As has been found with other risk behaviors, studies have demonstrated that knowledge about risk is not sufficient for the prevention of HIV risk behavior. This is not really surprising, given the variety of individual and contextual factors that contribute to motivation and the persistence of risk behaviors into young adulthood. For example, substance abuse, suicidality, and depression in adolescence are strong predictors of increasing or maintaining HIV high risk behaviors in young adulthood. Other contributing factors are problems in relationships with parents, friends' misbehaviors, stressful events, and neighborhood violence and unemployment.

Given the complexity of factors that contribute to risk behavior, prevention efforts that focus exclusively on knowledge are unlikely to be successful. However, there are effective school-based HIV prevention programs, which typically rely on principles of Social Cognitive (Learning) Theory. These principles include the use of experiential activities that allow for the modeling and practicing of skills, and the reinforcement of group norms against unprotected sex. A focus on reducing sexual risk behaviors and the use of trained motivated teachers enhance program effectiveness. However, adolescents live and learn in a variety of social contexts, and it is important to expand the scope of HIV prevention to include contextual interventions. For example, consistent adult monitoring can reduce opportunities for risky behaviors, and religious involvement protects adolescents from premature sex and drug use behaviors. Although they are currently very limited, school-based or school-linked clinic services, such as condom distribution and STI diagnosis and treatment, can be another important strategy for prevention.

See also: Guidance and Counseling, School; Health Services; Out-of-School Influences and Academic Success; Risk Behaviors, subentries on Sexual Activity Among Teens and Teen Pregnancy Trends, Sexually Transmitted Diseases; Sexuality Education.

bibliography

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internet resource

Centers for Disease Control and Prevention. 2001. "Young People at Risk: HIV/AIDS Among America's Youth." <www.cdc.gov/hiv/pubs/facts/youth.htm>.

Denise Dion Hallfors

Carolyn Tucker Halpern

Bonita Iritani

SEXUAL ACTIVITY AMONG TEENS AND TEEN PREGNANCY TRENDS

Adolescent sexuality is often viewed from a negative perspective that focuses primarily on sexual behavior and its association with other high-risk behaviors. Youth are sometimes negatively viewed as sex-crazed, hormone-driven individuals who want the perceived independence of adulthood without the responsibility of adulthood. On the other hand, psychosexual development is a critical developmental process during adolescence. P. B. Koch has identified the need for research identifying healthy psychosexual development in adolescents. As children emerge into adolescence, their developing gender identity shapes whom they interact and associate with, especially peers. Negative media images that appear to promote lustful, irresponsible sexual behavior are often associated with early sexual activity among adolescents. However, it is crucial to identify what protective factors can shape positive psychosexual development, including delaying the onset of sexual activity. Research has yet to identify gender-specific strategies that can promote positive psychosexual development in boys and girls.

Early Sexual Activity

Early sexual activity is a growing issue in adolescent development. According to both the National Survey of Family Growth and the Youth Risk Behavior Survey, adolescents are engaging in sexual activity at earlier ages. In general, older adolescents (age fifteen and older) demonstrate a reduction in early sexual activity, whereas adolescents younger than thirteen demonstrate an increase in sexual activity. In addition, two-thirds of high school students report having sex before graduating from high school. These findings persist in the face of an apparent leveling off of sexual activity in adolescents.

Peer pressure to engage in adult-like activities can encourage adolescents to engage in various levels of sexual experimentation. Adolescents who engage in sexual experimentation are at increased risk for sexually transmitted diseases, including HIV/AIDs, and pregnancy. Moreover, risk for early sexual experimentation is associated with other high-risk behaviors in adolescence, including sexual abuse and drug and alcohol use, and emotional adjustment.

In regard to puberty, early-maturing adolescents are more likely to engage in early sexual experimentation than are later-maturing adolescents. They confront their emerging sexuality at younger ages than their peers do, and are more likely to be pursued by older peers in social settings because they appear physically older than their chronological age.

For both male and female adolescents, adolescence represents, in part, a time for pressure to engage in sexual intimacy. As girls enter adolescence (typically a few years before boys), they begin to grow into womanhood and become sexualized objects. Within the media, images of sexuality and overly thin body images can socialize girls into seeing themselves as sexual objects. On the other hand, boys are pressured to exhibit their manhood through sexual conquests.

Much of the research on early sexual activity in adolescents does not address early patterns of noncoital sexuality. Noncoital sexuality is defined as involvement in sexual contact that does not include the exchange of body fluids. Research suggests that by middle adolescence most youths have begun to engage in sexual experimentation, including kissing, with 97 percent of adolescents experiencing their first kiss by age fifteen. Understanding the onset of noncoital sexuality and factors influencing its timing is vital to delineating patterns of early sexual activity in teenagers.

Adolescent condom use has increased for both males and females. The decline in teenage pregnancy is, in part, attributable to an increase in contraceptive use. However, since psychosexual development is a new challenge faced during adolescence, some youths are ill informed, and even though they may choose to use contraceptives, they may use these methods incorrectly.

Teenage Pregnancy

The association of early sexual activity with teenage pregnancy has been a societal concern for decades. For females, teenage pregnancy can complicate adolescent development and contribute to a troublesome transition to young adulthood, which involves a potential future as a single parent with limited educational and economic opportunities. Since the 1990s the overall teenage pregnancy rate has declined, though, according to the National Campaign to Prevent Teen Pregnancy, four out of ten girls still get pregnant before their twentieth birthday. The United States has the highest teen pregnancy, birth, and abortion rates of any industrialized nation.

Teenage mothers are at risk for poverty and school failure, while their offspring are at risk for low birth-weight, poor access to health care, poverty, and early childhood developmental problems. Programs such as Aid to Families with Dependent Children (AFDC), which were created to support single parent mothers, have been criticized as being an incentive for the birth of children out of wedlock in poor communities. Consequently, poor teen mothers have sometimes been blamed for their circumstances and negatively portrayed within the media and the public arena. Yet the overall decline in teenage pregnancy has occurred across all ethnic groups, including the poor ethnic minority groups that are most likely to be demonized in the media as having excessive teenage pregnancy rates.

A significant risk factor for early sexual experimentation is a history of sexual trauma. This is true for both males and females, though the level of risk is increased for females. Adolescent girls who have a history of sexual trauma during childhood and/or adolescence may try to cope during their adolescent years by being sexually provocative. This coping mechanism is negative; however, victims of sexual abuse may try to control future sexual encounters by initiating sexual contact. This may influence the likelihood of their involvement in prostitution and other sexually exploitative illegal activities.

Girls with a history of sexual trauma are also at great risk for involvement in the juvenile justice system, particularly if they do not have supportive home environments that allow them the opportunity to heal from their traumas. Girls within the juvenile justice system are likely to exhibit runaway behaviors in an effort to get out of abusive home environments. Through these runaway patterns, some girls are introduced to sexual exploitation in their effort to survive on the street. Boys who are victims of sexual abuse are at risk for offending behaviors if they lack supportive home environments, and they are also at risk for involvement in the juvenile justice system.

The use of alcohol and drugs reduces inhibitions, and can therefore influence participation in unprotected sexual activity. Boys and girls with a history of smoking and alcohol use have an increased risk for early sexual activity, in part because the use of these substances can influence the decision making of adolescents in social contexts.

Efforts to conduct sexuality education within the home environment have been found to be insufficient. Parents need to provide supportive learning environments in which children can develop a healthy understanding of their sexuality, particularly during their adolescent years. Adolescence represents a time of fundamental change, as adolescents are introduced to new reproductive capacities that have to be understood cognitively, socially, and emotionally.

Pregnancy Prevention

Adolescents receive most of their information about sexuality from peers, which often leads to misinformation. Adolescents need structured formal and informal learning environments with age-appropriate peers to address issues of sexuality. These programmatic models may be available within school and community-based settings. Most pregnancy prevention programs fall within three categories: knowledge interventions, access to contraception, and programs to enhance life options. Lisa Crockett and Joanne Chopack suggest three categories of programs: programs that focus on sexual antecedents, programs that focus on nonsexual antecedents, and programs that focus on a combination of both sexual and nonsexual antecedents. Programs that focus on sexual antecedents directly target sexual behavior and often focus on reducing sexual activity, minimizing the number of sexual partners, and contraceptive use. Programs that focus on nonsexual antecedents indirectly target sexual activity by focusing on other outcomes, such as academic achievement, youth development (including leadership skills), and service-learning models.

Joy Dryfoss has proposed the need for comprehensive health-promotion models as the best practice within sexuality education. This practice not only seeks to minimize risk, but to provide leadership and prosocial skills development to shape the changing lives of young people. Scholars and activists continue to debate the usefulness of abstinence versus education, including birth control strategies. Abstinence-based models show mixed results when rigorously researched, with a limited demonstrated effect on sexual behavior. Many abstinence-only proponents believe that birth control education increases the likelihood of teen sexual activity; however, the evaluations do not support this notion. Sex education models designed to support the psycho-sexual development of adolescents have been extensively debated, based on religious, moral, family, and community values and attitudes. Educational systems have been permitted to provide abstinence-based education to combat historically high teenage pregnancy rates. Those that propose that birth control education should include life-skills development assert that interventions need to be grounded in the realities of those who are at greatest risk for premature sexual activity and associated negative consequences.

Young people from poor, underserved, innercity communities are at risk for poor access to health care, including health education, which increases their risk of negative developmental outcomes related to early sexuality activity. Programmatic efforts need to take into account the social context of these communities. Young people living in such an environment particularly need increased life options rooted in effective decision making, which may lead to a delay in early sexual activity in the adolescent years. According to Saul Hoffman, author of "Teenage Childbearing Is Not So Bad After All … Or Is It? A Review of the New Literature," teenage pregnancy prevention programs targeting teen mothers in poor, underserved communities may yield indirect effects in addition to reducing teen pregnancy. These programs may represent pathways out of poverty for these poor populations of teen mothers.

Within inner-city communities of color, program models such as the I Have a Future program founded by Dr. Henry Foster provide a supportive learning community for youths residing in economically deprived communities with high rates of multi-generational teen pregnancy and sexually transmitted diseases. Such families often remain trapped in poverty, poor health care systems, and economic deprivation. The I Have a Future model provides comprehensive adolescent health services, prosocial skills development, leadership development, alcohol and drug education, gender and ethnic identity development, and academic support. In addition, participants gain exposure to positive role models within the supportive staff and through community linkages to colleges and universities. This program represents a mixed-gender context in which both males and females adolescents can develop positive decision-making skills regarding delayed sexual activity, and it provides a promising framework for effective interventions for high-risk youth.

Positive psychosexual development is important in making a successful transition through adolescence. Adolescents need safe opportunities to relate to peers and develop meaningful attachments without bringing harm to themselves. Psychosexual development is shaped by media, family, community, and peer contexts, and comprehensive strategies that address these contexts are needed to fully support adolescent development. Media literacy can be incorporated into intervention models in order to increase understanding of gender stereotypes. Girls must confront the overwhelming stereotypes of thin, sexually provocative body images of females, whereas males must confront macho images reinforcing masculine control.

The Role of Parents

Parents need resources to support their vital role in shaping the lives of adolescents. Families, and parents in particular, need help in learning effective ways of supporting their adolescent's psychosexual development. In the face of declining teenage pregnancy rates, it is imperative that research focus on targeted evaluations of promising practices that can influence positive developmental outcomes. Some communities and individual programs are strapped for funds to establish and maintain programming, while evaluation goals are deferred because of limited funding. Academic communities can partner with local communities and health promotion agencies to assist in the development of rigorous research paradigms that can increase knowledge of effective interventions that can be potentially replicated in other communities.

In the face of community efforts to address teenage pregnancy, some parents may be apprehensive about other adults influencing their children regarding personal, sensitive issues. For parents who feel comfortable and equipped in addressing these issues with their children, the National Campaign to Prevent Teen Pregnancy offers several tips for parents, including being aware of their own personal values and attitudes regarding sexuality and how they want their children to be introduced to the sensitive topic of sexuality. Effective parent–child communication regarding love and intimacy, as well as family rules and standards about teenage dating, can provide needed support for adolescents who are confronting the social and emotional challenges related to puberty. Parents are encouraged to introduce the topic of sexuality and sex education early in a child's development. How early this occurs is again influenced by the personal values and attitudes of the parents. Parents can also assist as interpreters of negative media images that foster inconsistent and controversial attitudes toward early sexual activity and promiscuity.

In addition, parents are encouraged to become knowledgeable about their children's social contexts. Monitoring children's activities includes not only knowing where one's children are, but also who are the friends and peer associates of one's children. It is also important to provide life options that provide children with constructive, safe opportunities for personal growth.

Other effective models of service include gender-specific interventions that assist adolescents in understanding positive manhood and womanhood development. Through the development of positive gender identity, adolescents can fully consider their role in relationships with family, peers, and community.

There has been some debate regarding gender-specific versus mixed-gender programs to address the issue of teenage pregnancy. Programs are encouraged to be intentional in their efforts to maximize opportunities for education and life-skills development, whether in same-gender or mixed-gender environments. Same-gender programs can provide safe learning environments in which groups can fully consider the challenges facing adolescents to engage in early sexual activity. In particular, for girls who may have been traumatized by males, it is critical that they have opportunities to voice their concerns and experiences without any perceived threat by male counterparts. On the other hand, in the absence of trauma-related experiences, adolescents may benefit from healthy, mixed-gender programs that focus on the shared responsibility of both sexes in family planning. Otherwise, the burden for safe sex, including contraceptive use, is often perceived as the responsibility of the female. Even though females are more likely to experience pubertal changes earlier than their male counterparts, these females are not necessarily advanced in their emotional maturity to the point that they can assume sole responsibility for sexual behavior.

In order to address premature sexual activity among teenagers effectively, comprehensive community strategies are needed to address the myriad of issues involved and the diversity in social and community contexts. In 2002, thirteen community partnerships within eleven states were implementing comprehensive youth preventive interventions to combat teenage pregnancy. These partnerships distribute the responsibility for sexuality education across the family, community, and school.

See also: Guidance and Counseling, School; Health Services; Parenting; Out-of-School Influences and Academic Success; Risk Behaviors, subentry on Sexually Transmitted Diseases; Sexuality Education.

bibliography

Crockett, Lisa, and Chopak, Joanne S. 1993. "Pregnancy Prevention in Early Adolescence: A Developmental Perspective." In Early Adolescence: Perspectives on Research, Policy, and Intervention, ed. Richard Lerner. Hillsdale, NJ: Erlbaum.

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Hoffman, Saul D. 1998. "Teenage Childbearing Is Not So Bad After All … Or Is It? A Review of New Literature." Family Planning Perspectives 30 (5):236–239, 243.

Kirby, Douglas. 2001. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy.

Koch, P. B. 1993. "Promoting Healthy Sexual Development During Early Adolescence" In Early Adolescence: Perspectives on Research, Policy, and Intervention, ed. Richard Lerner. Hillsdale, NJ: Erlbaum.

internet resources

Advocates for Youth. 2002. "Adolescent Pregnancy and Childbearing." <www.advocatesforyouth.org/publications/factsheet/fsprechd.htm>.

National Campaign to Prevent Teen Pregnancy. 2002. "Ten Tips for Parents to Help Their Children Avoid Teen Pregnancy." <www.teenpregnancy.org/resources/reading/tips/tips.asp>.

National Center for Chronic Disease and Health Promotion. 2002. "Preventing Teen Pregnancy." <www.cdc.gov/nccdphp/teen.htm>.

Wertheimer, Richard, and Moore, Kristin. 2002. "Childbearing by Teens: Links to Welfare Reform." Urban Institute. <http://newfederalism.urban.org/html/anf24.html>.

Sheila Peters

SEXUALLY TRANSMITTED DISEASES

Sexually transmitted diseases (STDs) are viral and bacterial infections passed from one person to another through sexual contact. In 1960 there were two common STDs; by the beginning of the twenty-first century, there were more than twenty-five. In 1980 alone, eight new STD pathogens were recognized in the United States. In 1995 STDs accounted for 87 percent of cases reported among the top ten diseases in the United States.

The Institute of Medicine coined the phrase "the hidden epidemic" to describe the problem of STDs in the United States. STDs disproportionately affect women and young people. In 1996 an estimated 15 million new cases of STDs occurred in the United States, of which at least one-quarter were among adolescents between the ages of fifteen and nineteen. Adolescents are at a higher risk for contracting sexually transmitted disease because of biological and behavioral factors.

Biological Factors

During each sexual encounter, women are at an inherently greater risk of acquiring an STD than men are. Young women are especially vulnerable to infection because of the increased amount of immature ectopic tissue on the endocervix, which increases the likelihood of acquiring certain STDs such as chlamydia, gonorrhea, and HIV. Adolescent women also have "immature" or unchallenged local immune systems that make them more vulnerable to STD infections. Most sexually transmitted diseases are asymptomatic and go undiagnosed, further promoting the spread of infection.

Behavioral Risk

Behavioral risk factors that predispose individuals to STDs include age at initiation of sexual activity, having multiple sexual partners or a partner with multiple partners, use of barrier protection, and use of diagnostic and treatment services. Furthermore, risk of STDs may be compounded by additional socioeconomic factors, though this relationship is unclear. Many markers of STD risk (e.g., age, gender, race/ethnicity) are associated with fundamental determinants of risk status (e.g., access to health care, residing in communities with high prevalence of STDs) to influence adolescents' risk for STDs. Since the early 1980s the age of initiation of sexual activity has steadily decreased and age at first marriage has increased, resulting in increases in premarital sexual experience among adolescent women and an increasing number of women at risk. Multiple (sequential or concurrent) sexual partners rather than a single, long-term relationship increases the likelihood that a person may become infected. The Centers for Disease Control and Prevention (CDC) showed that almost 45 percent of women who initiated sexual activity before the age of sixteen had more than five lifetime sexual partners. Among women who delayed first sex until after the age of twenty, however, only 15 percent had more than five lifetime sexual partners. Of women who delayed their first sexual activity until after the age of twenty, close to 52 percent had only one lifetime sexual partner, compared with about 19 percent of women who had initiated sex before the age of sixteen. The risk of STDs increases with the total number of lifetime sexual partners, whether over a short time period or spread over a life course.

In addition to having more than one sexual partner, adolescents may be more likely to engage in unprotected intercourse or engage in high-risk sexual activities such as anal sex. They may also select partners at higher risk. For example, young women are more likely than women in other age groups to choose a partner who is older than themselves. Additionally, oral sex and mutual masturbation may also lead to the spread of infection and should be considered risky activities.

Studies have shown that adolescents who are involved in one risky behavior are more likely to be involved in others. Adolescent boys and girls who have had sex are also more likely to drink alcohol, take drugs, and smoke cigarettes than adolescents who have not had sex. A quarter of adolescents interviewed reported that they were under the influence of drugs or alcohol when they last engaged in sexual intercourse. There is evidence that young people who avoided risky behavior had positive influences in their lives, such as a strong relationship with their parents.

The high prevalence of STDs among adolescents may also reflect multiple barriers to quality STD prevention services. Adolescents may lack insurance or the ability to pay for such services. They may lack transportation to reach an adequate facility. Additionally, they may feel uncomfortable in facilities and with services designed for adults. Adolescents may also be concerned about the confidentiality of their visits. Most studies following adolescents who have been diagnosed and treated for STDs by health care providers show a high incidence of reinfection at follow-up visits.

Prevalent Bacterial STDs

The most prevalent bacterial STDs are gonorrhea and chlamydia. Ongoing surveys of women in clinic settings has shown that adolescent women consistently have higher rates of chlamydia infection when compared to other age groups. In 2000 women aged fifteen to nineteen years old had the highest rates of chlamydia infection among all women even when overall prevalence declined. Chlamydia rates are low among men. Though the rates of gonorrhea decreased among adolescent women ages ten to nineteen years between 1996 and 2000, in 2000 the highest age-specific gonorrhea rates were among women in the fifteen-to nineteen-year-old age group. Adolescent men ages fifteen to nineteen years had the third-highest rates of gonorrhea when compared to other age groups of men.

Prevalent Viral STDs

Genital herpes simplex virus (HSV-2) and human papillomavirus (HPV) are prevalent among sexually experienced adolescents. Furthermore, infection with HSV-2, HPV, or HIV may result in negative reproductive morbidity, including neonatal transmission of these infections, cervical and genital cancer, and even premature death. As of yet, there are no effective cures for these viral infections.

Studies indicate that one in six Americans is infected with HSV-2, reflecting a ninefold increase since the early 1970s. An estimated 4 percent of Caucasians and 17 percent of African Americans are infected with HSV-2 by the end of their teenage years. One study of low-income pregnant women found an HSV-2 infection rate as high as 11 percent in women fifteen to nineteen years of age and 22 percent in women twenty-five to twenty-nine years of age.

Based on data from twenty-five states with integrated HIV and AIDS reporting systems, the CDC reported that for the period from January 1996 to June 1999 young people (aged thirteen to twenty-four) accounted for a much greater proportion of HIV (13%) than AIDS cases (3%). Though the number of new AIDS cases diagnosed during the period declined, no decline was observed in the number of newly diagnosed HIV cases among youth. Because progression from HIV infection to AIDS may be on the order of years, the reported number of AIDS cases may not reflect the actual rate of HIV infection among adolescents. At least half of all new HIV infections in the United States are among people under age twenty-five, and the majority of young people are infected sexually. In 1999 there were 29,629 cumulative cases of AIDS among those aged thirteen to twenty-four years. The CDC further reported that in 1999, of the cases of AIDS in young men aged thirteen to twenty-four years, 50 percent were among men who have sex with men; 8 percent were among injection drug users; and 8 percent were among young men infected heterosexually. Among young women aged thirteen to twenty-four years, 47 percent of cases reported were acquired heterosexually and 11 percent were acquired through injection drug use.

Impact

STDs prevent adolescents from leading healthy lives. They lead to declines in school performance, increased poverty, and higher crime rates. The financial cost of STDs runs in the billions each year. As a consequence of STDs, many adolescents experience serious health problems that often alter the course of their adult lives, including infertility, difficult pregnancy, genital and cervical cancer, neonatal transmission of infections, and AIDS.

See also: Guidance and Counseling, School; Health Services; Out-of-School Influences and Academic Success; Risk Behaviors, subentries on HIV/AIDS and its Impact on Adolescents, Sexual Activity Among Teens and Teen Pregnancy Trends; Sexuality Education.

bibliography

Kagan, Jerome, and Gall, Susan B., eds. 1998. The Gale Encyclopedia of Childhood and Adolescence. Detroit: Gale.

McIlhaney, J. S., Jr. 2000. "Sexually Transmitted Infection and Teenage Sexuality." American Journal of Obstetrics and Gynecology 183:334–339.

internet resources

Centers for Disease Control and Prevention. National Center for HIV, STD and TB Prevention. Division of Sexually Transmitted Diseases. 2002. "STDs in Adolescents and Young Adults: STD Surveillance, Special Focus Profiles." <www.cdc.gov/std/stats/PDF/SFAdoles2000.pdf>.

Centers for Disease Control and Prevention. National Center for HIV, STD and TB Prevention. Division of Sexually Transmitted Diseases. 2002. "STD Surveillance 2000." <www.cdc.gov/std/stats/TOC2000.htm>.

Angela Huang

SMOKING AND ITS EFFECT ON CHILDREN'S HEALTH

The impact of tobacco use in the United States and worldwide is staggering. According to the World Health Organization, 1.1 billion people worldwide regularly smoke tobacco products, and smoking accounts for 10,000 deaths per day. In 1990 there were 418,000 deaths in the United States alone attributed to smoking and its effects. Smoking kills two and one-half times more people than alcohol and drug use combined. In the United States 25 percent of the population regularly uses tobacco, with 6,000 new adolescent smokers each day–half of whom will go on to be regular smokers. Every day more than 15 million children are exposed to smoke in their homes. Environmental tobacco smoke (ETS), also known as "second hand smoke," poses significant risks to children. The United States Environmental Protection Agency (EPA) has classified ETS as a class A carcinogen, which means that ETS is known to cause cancer in humans. Exposure to ETS before the age of ten will increase a child's chances of developing lymphoma and leukemia (i.e., cancers of the blood) as an adult. The effects of ETS are actually worse than those acquired from smoking cigarettes directly.

Pregnancy/Perinatal/SIDS

It has been estimated that 19 percent to 27 percent of pregnant women smoke during their pregnancy. The pregnant woman who smokes not only affects her own health, but she harms the baby she is carrying as well. A major risk of smoking during pregnancy is the increased rate of premature delivery of the baby. Infants who are born prematurely can have many severe medical problems, including lung immaturity and brain injury. Maternal smoking contributes to 5 percent of all perinatal deaths (i.e., 2,800 deaths per year). Pregnant women who smoke are at a greater risk of miscarriage and low-birth-weight infants, as well as higher rates of long-term behavioral and mental problems in her child. Infants born to mothers who smoked during pregnancy have a much higher rate of Sudden Infant Death Syndrome (SIDS) than infants born to mothers who did not smoke during pregnancy. There is a dose-dependent relationship between ETS exposure during pregnancy and the rate of SIDS: The greater the exposure of cigarette smoke to an unborn baby, the higher their risk of SIDS. Cigarette smoke exposure is one of the few preventable risk factors for SIDS.

Newborn infants are in a unique situation when it comes to exposure to their mothers' smoke. Cotinine, a metabolite of nicotine, is found in newborn babies' blood at levels almost equivalent to their mothers'. There are significant levels of cotinine in a newborn's blood even if the mother herself does not smoke, but simply lives in a household where there is ETS exposure. There is a direct relationship between the maternal and newborn infant's blood levels of cigarette smoke products. The mother who smokes during pregnancy transfers the products in cigarette smoke to the fetus through the placenta, as well as to the newborn infant though breast-feeding. In fact, breast-fed infants have the same urinary cotinine levels as active adult smokers.

Childhood Diseases

The risks of ETS are not simply restricted to the newborn infant. There are many childhood illnesses that are dramatically worsened by exposure to smoke. A 1994 study by Joan Cunningham and colleagues showed that there was an increased risk of colds, wheezing, shortness-of-breath, and emergency room visits by children living in households where there is a smoker. There is also a significant increase is the risk of ear infections in children who live in households where there are smokers. Children born to mothers who smoke have a higher risk of developing asthma. Along with an increased risk of asthma, children of mothers who smoked during pregnancy will be at a greater risk of have problems with environmental allergies (e.g., hay fever). These effects can be seen in newborn infants as well as school-aged children.

Adolescence

Between 4 million and 5 million adolescents in the United States smoke daily. Each year more than 1 million people under eighteen years of age become daily smokers. Ninety percent of adults who regularly smoke began smoking before they were nineteen years of age. Throughout the 1990s the age at which children began smoking became increasingly younger. In 1990, 31 percent of all twelfth graders reported recent (within the last month) tobacco use while 21 percent were daily smokers. Shockingly, 8 percent of all eighth graders reported daily tobacco use. By the end of the 1990s the percentages of twelfth and eighth graders who recently used cigarettes was up to 36 percent and 21 percent, respectively. The younger and younger beginning smoker is reflected in the higher percentage of adolescent smokers as compared to the adult population. Besides the negative health effects of smoking itself, adolescents who smoke are fifteen times more likely to use drugs than their peers who do not smoke.

There are many reasons why a child or adolescent will begin to smoke. The most common influence is family and peer pressures, but the most potent factor is the media portrayal of "glamorous" smoking. The top three most popular brands of cigarettes amongst adolescents were the top three companies that spent the most on advertising. In 1993 these companies collectively spent $153 million dollars on advertising. Many popular sporting events are still sponsored by tobacco companies, and there is some evidence that advertising had been directed toward recruiting new child or adolescent smokers. To combat the draw of the media for adolescents to begin smoking, the Centers for Diseases Control and Prevention (CDC) began, in the fall of 2000, the Surgeon General's Report for Kids on Smoking. This was an attempt to enlist celebrities and sports figures to promote an antismoking message to young people. It involves posters and media advertisements directed toward children and adolescents, informing them of the health damages caused by cigarette smoking.

Costs

The true cost of smoking is incalculable, but there are some very practical measures that can be seen. In 1997 American children made more than 500,000 doctor visits for asthma, and 1.3 million visits for cough that were directly attributed to smoke exposure. This does not include the 115,000 cases of pneumonia, 260,000 cases of bronchitis, and more than two million ear infections. The annual cost of ear infections in children in the United States caused by smoke exposure is $1.5 billion. The actual total financial costs, directly related to the exposure of American children to ETS, are broken into direct medical costs and the loss of life costs. In 1997 the total medical cost of the complications of cigarette smoke on American children was $4.6 billion. The loss of life cost (calculated based upon loss of earnings and costs needed to prevent disease) was $8.2 billion. The true cost of cigarette smoking, however, is in the impact smoking has on the health of infants and children.

See also: Guidance and Counseling, School; Health Education; Health Services; Out-of-School Influences and Academic Success; Risk Behaviors, subentry on Sexual Activity Among Teens and Teen Pregnancy Trends.

bibliography

Aligne, C. Andrew, and Stoddard, Jeffrey J. 1997. "Tobacco and Children: An Economic Evaluation of the Medical Effects of Parental Smoking" Archives of Pediatrics and Adolescent Medicine 171 (7):648–653.

American Academy of Pediatrics Committee on Substance Abuse. 2001. "Tobacco's Toll: Implications for the Pediatrician." Pediatrics 107:794–798.

Centers for Disease Control and Prevention. 1997. "State-Specific Prevalence of Cigarette Smoking among Adults, and Children's and Adolescents' Exposure to Environmental Tobacco Smoke–United States, 1996." Morbidity and Mortality Weekly Reports 46:1038–1043.

Cunningham, Joan, et al. 1994. "Environmental Tobacco Smoke, Wheezing, and Asthma in Children in Twenty-Four Mothers." American Journal of Respiratory and Critical Care Medicine 86:1398–1402.

DiFranza, Joseph R., and Lew, Robert A. 1997. "Morbidity and Mortality in Children Associated with the Use of Tobacco Products by Other People." Pediatrics 97:560–568.

Joad, Jesse. 2000. "Smoking and Pediatric Respiratory Health." Clinics in Chest Medicine 21 (1):37–46.

Christopher S. Greeley

SUICIDE

School-age children can engage in many behaviors of concern to adults as a function of their development as well as the changing culture and environments in which they live. Perhaps the most concerning and baffling of these risk behaviors are the tendencies in some to consider ending their own lives at so young an age. Why children and adolescents consider these self-destructive actions is a complicated puzzle to understand and solve. Such behaviors must be considered in light of young people's vulnerability to external models, their increased anxiety related to issues of social acceptance, their desire to develop a unique identity, and the existence of unstable and abusive families.

In 1999 the surgeon general of the United States, David Satcher, issued a call to action to prevent suicide. Satcher noted the continuing increase in suicide rates among the young, with the rate tripling from 1952 to 1996. He stated that Americans under the age of twenty-five accounted for 15 percent of all completed suicides and that risk factors for suicide attempts among the young included depression, alcohol or drug use disorders, and aggressive and disruptive behaviors. Suicide was not just a mental health problem but a public health problem as well.

Occurrence

Suicide rates for children and adolescents are regularly reported by the National Center for Health Statistics in the U.S. Department of Health and Human Services. These reports count only those for whom suicide is listed as the cause of death. For this reason it is believed that suicides may be underreported. Those who sign death certificates (family physicians, emergency room staff, and medical examiners) may not always list the cause of death as intentional in order to avoid stigma for the family or because evidence of suicide may not be immediately present. It is suspected that vehicular accidents and deaths related to substance abuse, for instance, may in some cases be suicides, but they may not be recorded as such.

A review of statistics regarding rates of suicide reveal a number of facts. For those aged fifteen to twenty-four, suicide stands as the third-leading cause of death behind accidents and homicides. As of 1996, the rate of suicide deaths for Americans aged ten to fourteen was 1.6 deaths per 100,000 population (2.3 per 100,000 for males and 0.8 per 100,000 for females). For fifteen-to nineteen-year-olds the rate was 9.7 deaths per 100,000 (15.6 per 100,000 for males and 3.5 per 100,000 for females), and for those aged twenty to twenty-four the rate was 14.5 deaths per 100,000 (24.8 per 100,000 for males and 3.7 per 100,000 for females). Young males (aged fifteen to nineteen) are more likely to succeed at killing themselves than females by a ratio of at least five to one. Reports from the surgeon general also suggest that gay and lesbian youth may be two to three times more likely to commit suicide. Although accomplished suicide rates were highest for white males, young African American males showed the greatest increase during the 1980s and 1990s. White females had the next highest rates, followed by African-American females. Research on Hispanic populations indicated that rates of suicide in young men and women may be higher than for whites.

Suicides can be completed using a variety of means. Nearly 63 percent of suicides occur using firearms. Most other deaths are a result of more passive means such as drug poisonings or hangings. Suicide attempts are less likely to involve firearms and may, therefore, provide opportunities for discovery and rescue.

In addition to completed or accomplished suicides, many young people attempt suicide. Accurate rates for this group of attempted suicides, often called parasuicides, are even more difficult to obtain. Hospitals and emergency rooms may identify attempters, but many parasuicides go completely undetected or are confided only to the closest of friends. Possible ratios of attempts to completions may range from 10:1 to 150:1, depending upon the research and the definition of attempts. The continuum of suicidal behaviors, which includes actual suicide on one end and attempted suicides in the middle, includes on the other end the least severe form of self-destructiveness, usually identified as suicidal ideation or intent. The idea of killing oneself may occur quite frequently in young people, but it becomes serious only when there is intent to actually act. Such suicidal intent often includes a plan and a timetable in the person's mind.

Risk Factors

Many factors have been examined as contributors to the likelihood that a school-age child will become suicidal. Some factors appear to be historical or situational whereas others are psychological. A large percentage (perhaps as high as 90 percent) of those who are victims of suicide have diagnosable psychiatric disorders at the time of death. Many suffer from mood disorders, and a large percentage have made previous suicide attempts. Risk factors may include: psychiatric disorder, previous suicide attempt, co-occurring drug use and mental disorder, family history of suicide, impulsive or aggressive tendencies, feelings of hopelessness, loss of significant relationship, loss of job, physical illness, stress, lack of access to mental health treatment, availability of lethal means (e.g., guns or drugs), feelings of isolation and alienation, influence of peers or family members, unwillingness to seek help, cultural or religious beliefs or traditions, influence of the media, current epidemics of suicidal behaviors, and being a victim of bullying.

In the case of children and adolescents, two major themes related to increased risk for suicide are fears of humiliation by others and feelings of invisibility. Additional themes may also include general levels of stress, breakdown of psychological defenses, self-deprecatory thoughts, and a negative personal history.

Protective Factors

Just as some factors seem to increase the incidence of self-destructive suicidal intent, so also there appear to be conditions that make these thoughts and behaviors less likely. Such circumstances or characteristics are considered to be protective. Among those cited by the surgeon general in 1999 were: effective and appropriate clinical care; access to treatment and support for seeking help; restricted access to lethal means; family and community support; ongoing medical and mental health care relationships; learned skills in problem solving, conflict resolution and nonviolent dispute management; and a belief system, either cultural or religious in nature, that discourages suicide. Skills in anger management, impulse control, and appropriate action in the face of victimization have been also cited as protective factors.

Warning Signs

The warning signs of imminent suicidal behaviors can appear in many forms. They can be verbal, spoken to others; written as poems, songs, diary entries, or suicide notes; or made as threats directly ("I am going to kill myself") or indirectly ("You won't have me to kick around anymore"). Other warning signs include social withdrawal, getting things in order, giving things away, constant crying, or an angry or hostile attitude. Some signs occur in the person's environment, such as the death of someone close, family problems, or failure in school or at work. Lastly, some signs are those characteristic of depression or general mental and emotional difficulties. These latter signs might include sleep disturbance, feelings of despair, appetite change, or radical and abrupt changes in behavior or personality.

Formulation of the Problem

According to Jerry Jacobs, writing in 1971, early research into suicide examined five major stages seen in suicidal children. These included a history of problems, an escalation of problems, the failure of coping, the experience of helplessness, and finally, a justification for taking a self-destructive action. Although these stages may be present, in many cases adults do not observe them, but rather they are shared with peers. Adults may merely see the final behaviors.

It is important to realize that suicidal behavior can best be seen not as a disease (although it may in some cases be the manifestation of one), but rather as a symptom with many different possible underlying causes. Just as a headache could be caused by many things, so the action to end one's own life can be a result of any number of causes: depression or other mental illness, stress, grief or loss, unresolved conflict, substance use, unexpressed anger or rage, social pressure, lack of problem-solving or conflict resolution skills, hopelessness or frustration, chronic victimization, a desire for visibility or respect, the need to avoid humiliation, or the desire to be noticed.

Prevention

The best strategies for the prevention of suicide are those that reduce the number of risk factors and increase protective factors. This means making resources available to families and schools to aid in this process. In some cases early intervention is needed. Prevention or primary interventions need to: develop strategies for detecting suicidal individuals, treat all threats seriously, educate those who work with kids about suicide, increase peer education about suicide, teach families and communities to look for warning signs, reduce the availability of lethal means, make twenty-four-hour hotlines available, and use the media to teach the public how to recognize those at risk.

Finally, it must be acknowledged that the problem of self-destructive behavior affects everyone. Parents, schools, and communities must make a commitment to work to end this behavior and its causes.

See also: Guidance and Counseling, School; Mental Health Services and Children; Parenting; Out-of-School Influences and Academic Success.

bibliography

Berman, Alan L., and Jobes, David A. 1991. Adolescent Suicide: Assessment and Intervention. Washington, DC: American Psychological Association.

Fremouw, William J.; de Perczel, Maria; and Ellis, Thomas E. 1990. Suicide Risk: Assessment and Response Guidelines. New York: Pergamon Press.

Group for the Advancement of Psychiatry. 1996. Adolescent Suicide. Washington, DC: American Psychiatric Press.

Jacobs, J. 1971. Adolescent Suicide. New York: Wiley.

Peters, Kimberly D.; Kochanek, Kenneth D.; and Murphy, Sherry L. 1998. "Deaths: Final Data for 1996." National Vital Statistics Reports 47 (9). Hyattsville, MD: National Center for Health Statistics.

Robbins, Paul R. 1998. Adolescent Suicide. Jefferson, NC: McFarland.

Shaffer, David, and Craft, Leslie. 1999. "Methods of Adolescent Suicide Prevention." Journal of Clinical Psychiatry 60 (suppl. 2):70–74.

Sheras, Peter L. 2001. "Depression and Suicide in Adolescence." In The Handbook of Clinical Child Psychology, 3rd edition, ed. Eugene Walker and Michael Roberts. New York: Wiley.

U.S. Department of Health and Human Services, National Center for Health Statistics. 1998. Vital Statistics of the United States. Hyattsville, MD: U.S. Public Health Service.

U.S. Public Health Service. 1999. The Surgeon General's Call to Action to Prevent Suicide. Washington, DC: U.S. Public Health Service.

Peter L. Sheras

TEEN PREGNANCY

In the United States, teen pregnancy is an important problem. In 1997, the last year for which accurate estimates are available, about 896,000 young women under the age of twenty became pregnant. Among women aged fifteen to nineteen, 94 per 1,000 (or about 9%) became pregnant. This rate is much higher than that in other Western industrialized countries. In addition, according to a 1997 publication of the National Campaign to Prevent Teen Pregnancy, more than 40 percent of young women in the United States become pregnant one or more times before they reach twenty years of age.

The U.S. pregnancy rate is higher for females aged eighteen and nineteen (142 per 1,000) than for females fifteen to seventeen (64 per 1000). It is also higher for African Americans (170 per 1,000) and Hispanics (149 per 1,000) than for non-Hispanic whites (65 per 1,000). Much of this ethnic variation, however, reflects differences in poverty and opportunity.

On the positive side, the 1997 teen pregnancy rate in the United States was the lowest pregnancy rate since it was first measured in the early 1970s. The rate fluctuated considerably over the course of the 1970s, 1980s, and 1990s, however, reflecting both changing percentages of youth who have sex and improved use of contraception among those having sex.

While the teenage pregnancy rate is, by definition, based upon female teenagers, this does not mean that all the males involved in these pregnancies are teenagers. Indeed, in 1994, whereas 11 percent of fifteen-to nineteen-year-old females became pregnant, only 5 percent of fifteen-to nineteen-year-old males caused a pregnancy.

About four-fifths of teen pregnancies are unintended. Accordingly, in 1997, 15 percent of all teen pregnancies ended in miscarriages, 29 percent ended in legal abortions, and 55 percent ended in births.

Among mothers under the age twenty, the percentage of births that occur out of wedlock has risen dramatically–from 15 percent in 1960 to 79 percent in 2000. This large increase in and high rate of non-marital childbearing has alarmed many people and motivated many efforts to reduce teenage pregnancy.

Consequences of Teen Childbearing

According to a 1996 report written by Rebecca A. Maynard, when teenagers, especially younger teenagers, give birth, their future prospects decline on a number of dimensions. Teenage mothers are less likely to complete school, more likely to have large families, and more likely to be single parents. They work as much as women who delay childbearing for several years, but their earnings must provide for a larger number of children.

It is the children of teenage mothers, however, who may bear the greatest brunt of their mothers' young age. In comparison with those born to mothers aged twenty or twenty-one, children born to mothers aged fifteen to seventeen tend to have less supportive and stimulating home environments, poorer health, lower cognitive development, worse educational outcomes, higher rates of behavior problems, and higher rates of adolescent childbearing themselves.

Although the greatest costs are to the families directly involved, adolescent childbearing leads to considerable cost to taxpayers and society more generally. Estimates of these costs are in the billions.

Adolescent Sexual and Contraceptive Behavior

Obviously, teens become pregnant because they have sex without effectively using contraception. In the United States, the proportion of teens who have ever had sexual intercourse increases steadily with age. In 1995, among girls, the percentage increased from 25 percent among fifteen-year-olds to 77 percent among nineteen-year-olds, while among males it increased from 27 percent among fifteen-year-olds to 85 percent among nineteen-year-olds. Among students in grades nine through twelve across the United States in 1999, 50 percent reported sexual experience.

Most sexually experienced teenagers use contraception at least part of the time. Condoms and oral contraceptives are the two most common methods, but small and increasing percentages of teens use long-lasting contraceptives such as Depo-Provera or Norplant. Like some adults, however, many sexually active teenagers do not use contraceptives consistently and properly, thereby exposing themselves to risks of pregnancy or sexually transmitted diseases (STDs).

Factors Associated with Sexual Risk-Taking and Pregnancy

While nearly all youth are at risk of engaging in sex and thus girls becoming pregnant, many risk and protective factors distinguish between youth who engage in unprotected sex and sometimes become pregnant and those who do not. For example, when teens have permissive attitudes toward premarital sex, lack confidence to avoid sex or to use contraception consistently, lack adequate knowledge about contraception, have negative attitudes toward contraception, and are ambivalent about pregnancy and childbearing, then they are more likely to engage in sex without contraception.

Other more indirect environmental factors, however, also affect teen sexual risk-taking, either by decreasing motivation to avoid sex or through other mechanisms. For example, teens are more likely to engage in unprotected sex and become pregnant (1) when they live in communities with lower levels of education, employment, and income and thereby have fewer opportunities and encouragement for advanced education and careers; (2) when their parents also have low levels of education and income;(3) when they live with only one or neither biological parent and believe they have little parental support; (4) when they feel disconnected from their parents or are inappropriately supervised or monitored by their parents; (5) when they have friends who obtain poor grades and engage in nonnormative behaviors; and (6) when they believe their peers are having sex and are failing to use contraceptives consistently.

Furthermore, teens are more likely to engage in sex when they, themselves, (1) do poorly in school and lack plans for higher education; (2) use alcohol and drugs, engage in other problem or risk-taking behaviors, and are depressed; (3) begin dating at an early age, go steady at an early age, have a large number of romantic partners, or have a romantic partner three or more years older (the latter being a particularly telling factor); or (4) were previously sexually abused. These individual and environmental, sexual and nonsexual, risk and protective factors are the factors that programs try to change when they attempt to reduce teen sexual risk-taking and pregnancy.

Family Planning Services

The efforts most directly involved with preventing pregnancy among sexually experienced teens are family planning services. The primary objectives of family planning clinics or family planning services within other health settings are to provide contraception and other reproductive health services and to provide patients with the knowledge and skills to use their selected methods of contraception.

Large numbers of sexually active female teenagers obtain family planning services each year. Many of these young women receive oral contraceptives and to a lesser extent other contraceptives that are more effective than condoms or other non-prescription contraceptives. Accordingly, these family planning services prevent large numbers of adolescent pregnancies.

In addition to those practicing at family planning clinics, some clinicians in health clinics also focus upon the adolescent's sexual behavior. Several studies have found that these visits can increase contraceptive use when clinicians spend more time focusing upon the teen patients' sexual behavior; give a clear message about always using protection against pregnancy and STDs; show videos or provide pamphlets and other materials; discuss patients' barriers to avoiding sex or using contraception; and model ways to avoid sex or use condoms or contraception.

Sex and HIV Education Programs

To reduce teen pregnancy and also STDs, including HIV, most schools have implemented sex and HIV education programs. Typically, these programs emphasize that abstinence is the safest method of avoiding pregnancy and STD, but they also encourage condom and contraceptive use if teens do have sex. Contrary to the fears of some people, a large number of studies have demonstrated that these programs do not have negative behavioral effects, such as increasing sexual behavior. To the contrary, many studies have demonstrated that some, but not all of these programs, delay the initiation of sex, decrease the frequency of sex, and increase the use of contraception once youth have sex. They thereby reduce risk of pregnancy, as well as STD. Some sex and HIV education programs have been found to be effective in multiple states in the country, and some have found positive behavioral effects for almost three years.

Programs that are short and that focus upon knowledge increase knowledge, but they tend not to change behavior. In contrast, programs that effectively reduce sexual risk-taking (1) focus on changing specific sexual or contraceptive behaviors; (2) are based on health theories that specify the risk and protective factors to be addressed by the program;(3) give a clear message about avoiding unprotected sex; (4) provide basic, accurate information about the risks of teen sexual activity and about methods of avoiding intercourse or using contraception; (5) address social pressures that influence sexual behavior; (6) provide modeling and practice of communication, negotiation, and refusal skills; (7) employ a variety of teaching methods designed to involve the participants and help them personalize the information; (8) are appropriate to the age, sexual experience, and culture of the participants; (9) last a sufficient length of time to complete important activities adequately; and (10) select teachers or peer leaders who believe in the program they are implementing and then provide them with training.

Many people have proposed abstinence-only programs as a solution to reducing teen pregnancy and STDs. Such programs emphasize that abstinence is the only acceptable method of avoiding pregnancy, and they either fail to discuss contraception or emphasis its limitations. Although some abstinence-only programs might delay sex, there is thus far simply too little research to know which abstinence-only programs are effective.

In an effort to reduce teen pregnancy and STDs, including HIV, hundreds of high schools have made condoms available or have opened school-based health centers that provide reproductive health services. Although studies have demonstrated that these services do not increase teen sexual behavior, they have also found inconsistent results on improved contraceptive use.

Service-Learning Programs

Whereas the programs summarized above focus primarily on changing the sexual risk factors of adolescent sexual behavior, some programs focus primarily on the nonsexual risk and protective factors. In 1997 researchers Joseph P. Allen and associates found the strongest evidence for teen pregnancy reduction for one type of program, service learning.

By definition, service-learning programs include voluntary or unpaid service in the community (e.g., tutoring, working in nursing homes, helping fix up recreation areas) and structured time for preparation and reflection before, during, and after service (e.g., group discussions, journal writing, composing short papers). Often the service is voluntary, but sometimes it is prearranged as part of a class.

Although service learning does have strong evidence for reducing teen pregnancy, other youth development programs have not reduced teen pregnancy or childbearing (e.g., the Conservation and Youth Service Corps, the Job Corps, JOBSTART). Thus, it remains unclear why some programs are effective and others are not.

Comprehensive and Intensive Programs

A few programs designed to reduce teen pregnancy have been designed for high-risk youth and are both intensive and comprehensive. One of them, the Children's Aid Society Carrera program, is an intensive program operating five days per week and lasting throughout high school. It includes family life and sex education, medical care including reproductive health services, individual academic assessment and tutoring, a job club, employment, arts, and sports. Research demonstrates that it reduced both pregnancy and birthrates over a three-year period.

Conclusion

Despite declines in the teen pregnancy rate in the United States in the 1990s, teen pregnancy remains an important problem and diminishes the well-being of both teen mothers and their children. Fortunately, by the beginning of the twenty-first century there were a diverse group of programs that were demonstrated to be effective in reducing teen sexual risk-taking or pregnancy. These include reproductive health services and clinic protocols focusing upon patient sexual behavior, sex and HIV education programs, service-learning programs, and intensive and comprehensive programs for higher risk youth. The diversity of these programs increases the choices for communities. To reduce teen pregnancy, communities can replicate much more broadly and with fidelity those programs with the greatest evidence for success with populations similar to their own; replicate more broadly programs incorporating the common qualities of programs effective with populations similar to their own; and design and implement programs that effectively address the important risk and protective factors associated with sexual risk-taking in their communities.

See also: Guidance and Counseling, School; Health Services; Out-of-School Influences and Academic Success; Risk Behaviors, subentries on HIV/AIDS, Sexual Activity Among Teens and Teen Pregnancy Trends, Sexually Transmitted Diseases; Sexuality Education.

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Douglas B. Kirby