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Adolescent Risk Behaviors

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Presentation on theme: "Adolescent Risk Behaviors"— Presentation transcript:

1 Adolescent Risk Behaviors
Elyse Olshen Kharbanda, MD, MPH Assistant Clinical Professor of Pediatrics and Public Health Columbia University

2 Adolescent risk behaviors

3 Why adolescents take risks
Developing one’s own moral code and establishing an identity, separate from parents is a major task of adolescence Early adolescence (ages 11-14) – first stages of separation from parents, desire to look and act like peers, difficulty with impulse control Middle adolescence (ages 15-17) – further distancing from parents and allying with peers, feelings of omnipotence and immortality can lead to dangerous behaviors Late adolescence (ages 18-21) - fully identify one’s own moral code, more confident and better able to delay gratification, can be protective factors


5 Why do we care? Testing limits is part of normal adolescent emotional and psychological development Adolescent risk behaviors can lead to significant morbidity and mortality Risk behaviors are often interrelated Adolescents who participate in multiple risky behaviors are often depressed or have other mental illness

6 Mortality statistics Adults Adolescents Heart disease Cancer Stroke
Accidents Homicide Suicide

7 Morbidity statistics Nearly 1 million US teens become pregnant every year Nearly 4 million teens contract a STI each year Alcohol consumption is associated with motor vehicle injuries and fatalities, unwanted sexual activity, unprotected sexual activity, violence perpetration and violence victimization

8 Plan for presentation Unintentional Injuries Violence Suicide
Smoking/drinking/ drugs Cutting Teen Pregnancy Obesity Epidemiology (National and NYC data) Implications How to screen/counsel patients related to these issues

9 Definition of injury Unintentional or intentional damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat or oxygen

10 Unintentional injuries – National data
Leading cause of mortality among adolescents years Approximately 8000 deaths due to unintentional injury in 2005 71% mortality due to MVAs Approximately 2/3 of MVA related mortality is alcohol-related

11 More about injuries Injuries are not accidents. They can be prevented by changing the environment, individual behavior, products, social norms, legislation, and governmental and institutional policy

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 helmet 16% 18% 4% 90%

13 Accidents/Unintentional injuries
Screening regarding safety at medical visits Seat belts Bicycle helmets Drinking 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 adolescents 2000 deaths annually among year olds Homicide rates (ages 15-19) by race White males Hispanic males Black males 3.6 per 100,000 26.6 per 100,000 60.6 per 100,000

16 Violence – National data
Approximately 9% of US high school students report lifetime history of sexual assault Up to 40% of adolescents report history of dating violence Victimization associated with future victimization, depressive symptomatology, increased risk behaviors and future suicide attempts

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 fight 17% 9% 36%

18 Violence Screening Intervention access to firearms carrying a weapon
fighting with peers gang membership dating violence/sexual assault Intervention For youth with violence related behaviors, evaluate readiness to change Evaluate youth with histories of aggression for psychiatric comorbidity – consider psych referral

19 Suicide – National data
Third leading cause of death among adolescents Approximately 1600 suicides per year among year olds Suicide rates by gender (ages 14-19) Females Males Suicide rates by race (ages 14-19) Whites Hispanic Blacks 2.5 per 100,000 10.3 per 100,000 7.4 per 100,000 5.4 per 100,000 3.5 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 months 32% 15% 10%

22 Suicide – risk factors Prior suicide attempts Depression
Alcohol or substance abuse Associated with multiple other risky behaviors Smoking Early sexual activity Violence victimization Disordered eating

23 Suicide Screening Interventions Depression Impulsiveness Mania
Mood, affect, sleep, appetite, boredom, restlessness, social isolation, school/work performance Impulsiveness Mania Suicidal ideation/suicide attempts Interventions Mental health referral – if actively suicidal, refer to C-CPEP Involve parents/legal guardian

24 SSRIs and suicidality SSRIs are an effective treatment for depression (TADS) Increasing SSRI use in 1990s associated decreased rates of suicide Concern regarding reports of suicides following starting on SSRIS Meta-analysis of published and unpublished data found increased suicidal thoughts/behaviors (no completed suicides in trials) 2004 FDA Black Box warning on SSRIs for depressed children and adolescents

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 year 11% 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 mortality 2/3 MVA mortality is alcohol-related Early smoking risk for use of other drugs Drinking and drugs associated with unwanted sexual activity unprotected sexual activity violence perpetration and victimization problems with the law school failure Psychiatric co-morbidity

27 Smoking/drinking/drugs
Interventions CRAFFT screening tool Have 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, ankles Most 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 anxiety Addictive quality – may result in release of endorphins May 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 attempt Refer for mental health services Individual therapy Group therapy Family therapy Medications

31 Sexual risk behaviors – National data
Approximately half of high school students are sexually active Adolescents have the highest rates of STDs of all age groups Young adults represent half of all new HIV cases in the US Risky sexual practices can be sign of mental health issues or prior trauma history

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 intercourse 48% 18% 69%

33 Sexual risk behaviors Screening Intervention
Need to talk to teens alone – teens of any age can access reproductive health care without parents Sexual activity Condom use Partners Prior STIs, pregnancy Intervention Annual GC/CT testing Pap HIV, RPR HPV vaccine

34 Teen pregnancy While teen pregnancy rates were on a 10-year decline, they have increased in the past two years Wide state-level variation exists


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).

38 The Costs of Teen Childbearing

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 moms Public assistance Lost tax revenue Costs linked to the children of teen parents Public Health Care Incarceration of sons Child welfare Costs linked to teen fathers Costs 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 fathers Lost revenue – again due to decreased earnings and spending.

41 National Findings Teen childbearing costs taxpayers at least $9.1 billion annually. Total cost breakdown is $8.6 billion for 17 and younger and $0.5 billion for 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 Findings Most of the costs of teen childbearing are associated with negative consequences for the children of teen mothers and include: $1.9 billion for increased public sector health care costs $2.3 billion for increased child welfare costs $2.1 billion for increased costs for state prison systems (among adult sons of teen mothers) $2.9 billion in lost tax revenue due to lower taxes paid by the children of teen mothers over their own adult lifetimes. The average cost for a mother 19 and younger is $1430.

43 Costs for the Children of
Teen Mothers Children of teen mothers are more likely to: Have decreased educational attainment Earn less money Suffer high rates of child abuse and neglect Grow up poor Live in single-parent households Enter the child-welfare system Become teen mothers themselves As 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 successful Helping teens attain a sense of competency, usefulness, empowerment, and resilience Protective factors: family connectedness, spirituality, school connectedness, positive self-identity, self-efficacy


46 Transtheoretical model
Developed by DiClemente and Prochaska Integrates current behavior, intention to change, decisional balance, and strategies Behavior is an incremental, continuous, and dynamic process New behavior results from decision making processes that occur through series of stages Each stage of change contains specific tasks

47 Stages of change Precontemplation Contemplation Preparation Action
Maintenance Termination Relapse

48 Precontemplation Stage in which there is no intention to change in the foreseeable future (aprox 6 months) May be uninformed or underinformed about consequences May have tried to change and become demoralized

49 Contemplation Intend to change in the next 6 months
Are aware of the pros and cons Profound ambivalence may keep someone stuck here for a long time

50 Preparation Self awareness of need to change and intent to do so within a month May have taken some significant action in past year such as a class or seeing a health or mental health provider Possible results of change considered Empowerment, recognizing possible substitutes, and how to reward self “How could we make a plan?” Clinician provides helping relationship

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 –efficacy It is as if one never acquired the habit/risk in the first place.

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