3 Why adolescents take risks Developing one’s own moral code and establishing an identity, separate from parentsis a major task of adolescenceEarly adolescence (ages 11-14) – first stages of separation from parents, desire to look and act like peers, difficulty with impulse controlMiddle adolescence (ages 15-17) – further distancing from parents and allying with peers, feelings of omnipotence and immortality can lead to dangerous behaviorsLate adolescence (ages 18-21) - fully identify one’s own moral code, more confident and better able to delay gratification, can be protective factors
5 Why do we care?Testing limits is part of normal adolescent emotional and psychological developmentAdolescent risk behaviors can lead to significant morbidity and mortalityRisk behaviors are often interrelatedAdolescents who participate in multiple risky behaviors are often depressed or have other mental illness
6 Mortality statistics Adults Adolescents Heart disease Cancer Stroke AccidentsHomicideSuicide
7 Morbidity statisticsNearly 1 million US teens become pregnant every yearNearly 4 million teens contract a STI each yearAlcohol consumption is associated with motor vehicle injuries and fatalities, unwanted sexual activity, unprotected sexual activity, violence perpetration and violence victimization
8 Plan for presentation Unintentional Injuries Violence Suicide Smoking/drinking/ drugsCuttingTeen PregnancyObesityEpidemiology (National and NYC data)ImplicationsHow to screen/counsel patients related to these issues
9 Definition of injuryUnintentional 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
10 Unintentional injuries – National data Leading cause of mortality among adolescents yearsApproximately 8000 deaths due to unintentional injury in 200571% mortality due to MVAsApproximately 2/3 of MVA related mortality is alcohol-related
11 More about injuriesInjuries are not accidents. They can be prevented by changing the environment, individual behavior, products, social norms, legislation, and governmental and institutional policy
12 Accidents/Unintentional injuries Data from NYC YRBS% students reported they never or rarely wore a seat belt% students who in past 30 days rode in car with driver who had been drinking% students who in past 30 days drove a car after drinking% students who rode a bicycle reported they never or rarely wore a helmet16%18%4%90%
13 Accidents/Unintentional injuries Screening regarding safety at medical visitsSeat beltsBicycle helmetsDrinking and driving
14 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”
15 Violence – National data Homicide is the second leading cause of death in adolescents2000 deaths annually among year oldsHomicide rates (ages 15-19) by raceWhite malesHispanic malesBlack males3.6 per 100,00026.6 per 100,00060.6 per 100,000
16 Violence – National data Approximately 9% of US high school students report lifetime history of sexual assaultUp to 40% of adolescents report history of dating violenceVictimization associated with future victimization, depressive symptomatology, increased risk behaviors and future suicide attempts
17 Violence – NYC data From 2005 NYC YRBS % students who carried a weapon at least once in past 30 days% students who did not go to school at least once in past 30 days because they felt unsafe% students in past year who were in a physical fight17%9%36%
18 Violence Screening Intervention access to firearms carrying a weapon fighting with peersgang membershipdating violence/sexual assaultInterventionFor youth with violence related behaviors, evaluate readiness to changeEvaluate youth with histories of aggression for psychiatric comorbidity – consider psych referral
19 Suicide – National data Third leading cause of death among adolescentsApproximately 1600 suicides per year among year oldsSuicide rates by gender (ages 14-19)FemalesMalesSuicide rates by race (ages 14-19)WhitesHispanicBlacks2.5 per 100,00010.3 per 100,0007.4 per 100,0005.4 per 100,0003.5 per 100,000
21 Suicide – NYC data 2005 NYC YRBS % students who felt sad or hopeless daily for 2 weeks in past 12 months% students who seriously considered attempting suicide in the past 12 months% students who attempted suicide in the past 12 months32%15%10%
22 Suicide – risk factors Prior suicide attempts Depression Alcohol or substance abuseAssociated with multiple other risky behaviorsSmokingEarly sexual activityViolence victimizationDisordered eating
23 Suicide Screening Interventions Depression Impulsiveness Mania Mood, affect, sleep, appetite, boredom, restlessness, social isolation, school/work performanceImpulsivenessManiaSuicidal ideation/suicide attemptsInterventionsMental health referral – if actively suicidal, refer to C-CPEPInvolve parents/legal guardian
24 SSRIs and suicidalitySSRIs are an effective treatment for depression (TADS)Increasing SSRI use in 1990s associated decreased rates of suicideConcern regarding reports of suicides following starting on SSRISMeta-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
25 Smoking/drinking/drugs - NYC data NYC 2005 YRBS% students who smoked in past 30 days (was 24% in 1999)% students who drank in past 30 days% students who reported binge drinking in past 30 days% students who used marijuana in past 30 days% students who sniffed glue, inhaled paints/aerosols, etc…% students offered, sold or given an illegal drug on school property in past year11%36%14%12%9%26%
26 Smoking/drinking/drugs While many consider this to be a rite of passage, these behaviors are associated with significant morbidity and mortality2/3 MVA mortality is alcohol-relatedEarly smoking risk for use of other drugsDrinking and drugs associated withunwanted sexual activityunprotected sexual activityviolence perpetration and victimizationproblems with the lawschool failurePsychiatric co-morbidity
27 Smoking/drinking/drugs InterventionsCRAFFT screening toolHave you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs?Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?Do you ever use alcohol or drugs while you are by yourself Alone?Do you ever Forget things you did while using alcohol or drugs?Do your Family or Friends ever tell you that you should cut down on your drinking or drug use?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) , 2002.
28 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, anklesMost common among adolescent girls (up to 14% in one survey)
29 Why do adolescents cut? Means to cope with painful emotion Relief of agitation or anxietyAddictive quality – may result in release of endorphinsMay be “contagious”Associated with other psychopathology
30 Cutting Screening Intervention Ask about self injury Look for scars Refer to ER if injured or thought to be suicide attemptRefer for mental health servicesIndividual therapyGroup therapyFamily therapyMedications
31 Sexual risk behaviors – National data Approximately half of high school students are sexually activeAdolescents have the highest rates of STDs of all age groupsYoung adults represent half of all new HIV cases in the USRisky sexual practices can be sign of mental health issues or prior trauma history
32 Sexual risk behaviors – NYC data 2005 NYC YRBS% students who ever had sexual intercourse% students with lifetime history of 4 or more partners% sexually active students who used a condom with last intercourse48%18%69%
33 Sexual risk behaviors Screening Intervention Need to talk to teens alone – teens of any age can access reproductive health care without parentsSexual activityCondom usePartnersPrior STIs, pregnancyInterventionAnnual GC/CT testingPapHIV, RPRHPV vaccine
34 Teen pregnancyWhile teen pregnancy rates were on a 10-year decline, they have increased in the past two yearsWide state-level variation exists
36 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 school and is married.Source: Why It Matters, National Campaign
37 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: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).
39 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 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.With funding from the WT Grant Foundation, the National Campaign worked with Dr. Saul Hoffman and Dr. Rebecca Maynard to update the national cost of teen childbearing. This was last calculated in Kids Having Kids, a landmark study published by the Urban Institute in In that volume, Rebecca Maynard estimated that the annual cost to taxpayers of childbearing among teens aged 17 and younger was nearly $7 billion in the mid-1990s, and the cost to society as a whole was nearly twice that amount. In our update of the analysis, we decided to include year olds.In addition to updating the national cost estimate, we worked with Saul to produce state-level estimates of the public costs of teen childbearing. This is the first time we have consistent state-level cost estimates (some states have done their own estimates using a variety of methodologies). We worked with two pilot states – Delaware and Texas – to refine the methodology.Our main project goal was to measure the costs that could be averted if teen mothers, 19 and younger, delay their first birth to years old. We controlled for all background characteristics such as education, poverty, etc. The one thing that we’re changing is when the woman gave birth. We’re comparing two groups of women – one group of women that gave birth at 19 or younger and one group that gave birth at 20.5 years old. What’s the impact on her subsequent life outcomes – and her children’s – and what does that cost tax payers.
40 Costs Included in the Analysis Costs linked to teen momsPublic assistanceLost tax revenueCosts linked to the children of teen parentsPublic Health CareIncarceration of sonsChild welfareCosts linked to teen fathersCosts to teen moms--Public assistance includes TANF, food stamps, housing.--Lost tax revenue is the decreased earnings and spending due to lower education attainment.The overwhelming majority of the costs are those to the children of teen mothers.--These children as adults, have decreased earnings and spending due to lower education attainment.--Public Health Care – more likely use Medicaid and SCHIP. The public health care also includes CHAMPUS and a small share of Medicare for disabled children.--Incarceration - Although the numbers of young women in juvenile justice and prisons are growing, the numbers were still too small to determine whether having a teen mother is a risk factor.--Child welfare- mostly foster care costs.Teen fathersLost revenue – again due to decreased earnings and spending.
41 National FindingsTeen 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 year olds.Average annual public sector cost associated with a child born to a mother aged 17 and younger is $4,080.The average cost for a mother 19 and younger is $1430.
42 National FindingsMost 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.The average cost for a mother 19 and younger is $1430.
43 Costs for the Children of Teen MothersChildren of teen mothers are more likely to:Have decreased educational attainmentEarn less moneySuffer high rates of child abuse and neglectGrow up poorLive in single-parent householdsEnter the child-welfare systemBecome teen mothers themselvesAs you can see the greatest cost are for lost tax revenue, followed by health care, incarceration, and child welfare.
44 Youth Development Not all teens are behaving badly Programs to address single risk behavior not successfulHelping teens attain a sense of competency, usefulness, empowerment, and resilienceProtective factors: family connectedness, spirituality, school connectedness, positive self-identity, self-efficacy
46 Transtheoretical model Developed by DiClemente and ProchaskaIntegrates current behavior, intention to change, decisional balance, and strategiesBehavior is an incremental, continuous, and dynamic processNew behavior results from decision making processes that occur through series of stagesEach stage of change contains specific tasks
47 Stages of change Precontemplation Contemplation Preparation Action MaintenanceTerminationRelapse
48 PrecontemplationStage in which there is no intention to change in the foreseeable future (aprox 6 months)May be uninformed or underinformed about consequencesMay have tried to change and become demoralized
49 Contemplation Intend to change in the next 6 months Are aware of the pros and consProfound ambivalence may keep someone stuck here for a long time
50 PreparationSelf awareness of need to change and intent to do so within a monthMay have taken some significant action in past year such as a class or seeing a health or mental health providerPossible results of change consideredEmpowerment, recognizing possible substitutes, and how to reward self“How could we make a plan?” Clinician provides helping relationship
51 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
52 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
53 Relapse Treat as re-entry into another cycle Recognize that stages from precontemplation or contemplation need to be relived
54 Termination Applies to some behaviors No temptation and 100% self –efficacyIt is as if one never acquired the habit/risk in the first place.
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