2
Adolescent Health Status

SUMMARY

  • Most adolescents are considered healthy as defined by traditional medical measures of current health status, such as mortality rates, incidence of disease, prevalence of chronic conditions, and use of health services.

  • Adolescence is a period of both risk and opportunity. Adolescents may take risks that can jeopardize their health during these early years, as well as contribute to the leading causes of death and disease in adulthood. During adolescence, a range of health conditions can be identified and addressed in ways that affect not only adolescents’ functioning and opportunities, but also the quality of their adult lives. Adolescence also provides many opportunities to develop habits that create a strong foundation for healthy lifestyles and behavior over the full life span.

  • Some specific subpopulations of adolescents defined by selected population characteristics and other circumstances—such as those who are poor or members of a racial or ethnic minority; in the foster care system; homeless; in a family that has recently immigrated to the United States; lesbian, gay, bisexual, or transgender; or in the juvenile justice system—have higher rates of chronic health problems and may engage in more risky behavior relative to the overall adolescent population.



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2 Adolescent Health Status Summary • Most adolescents are considered healthy as defined by traditional medical measures of current health status, such as mortality rates, incidence of disease, prevalence of chronic conditions, and use of health services. • Adolescence is a period of both risk and opportunity. Adolescents may take risks that can jeopardize their health during these early years, as well as contribute to the leading causes of death and disease in adulthood. During adolescence, a range of health conditions can be identified and addressed in ways that affect not only adolescents’ functioning and opportunities, but also the quality of their adult lives. Adolescence also provides many op- portunities to develop habits that create a strong foundation for healthy lifestyles and behavior over the full life span. • Some specific subpopulations of adolescents defined by selected population characteristics and other circumstances—such as those who are poor or members of a racial or ethnic minority; in the foster care system; homeless; in a family that has recently immigrated to the United States; lesbian, gay, bisexual, or trans- gender; or in the juvenile justice system—have higher rates of chronic health problems and may engage in more risky behavior relative to the overall adolescent population. 52

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5 ADOLESCENT HEALTH STATUS mortality and morbidity • Motor vehicle crashes, homicide, and suicide, rather than infec- tious or chronic diseases, are the leading causes of mortality among adolescents. • Injuries continue to be the leading cause of mortality among ado- lescents; the majority of these injuries are due to motor vehicle crashes. • The prevalence of asthma and diabetes, two common causes of chronic illness in adolescents, has increased in recent years. • Between 10 and 20 percent of adolescents are affected annually by mental disorders, and half of all cases of adult lifetime mental disorders start by age 14. The most common mental health dis- order in adolescence is anxiety. • Sexually transmitted infections are the most commonly reported infectious diseases in adolescents and continue to increase in this population. Non-Hispanic black adolescents have higher rates of chlamydia and gonorrhea than any other racial or ethnic group. • The most common oral health problem in adolescence is dental caries. Non-Hispanic black adolescents have a higher prevalence of untreated dental caries than non-Hispanic white adolescents. Behavior and Health • Behavior that is unhealthful and/or risky, rather than infectious or chronic diseases, is the leading cause of morbidity among adolescents. • Use of alcohol, tobacco, and illicit drugs and carrying a weapon are adolescent behaviors that pose serious risk. • Pregnancy rates among adolescents aged 13–19 have decreased since 1990; declines have been seen among all racial and eth- nic groups, although the rate of pregnancy among Hispanic adolescents has been decreasing less dramatically. Pregnancy rates among Hispanic and non-Hispanic black adolescents con- tinue to be twice as high as those among non-Hispanic white adolescents. • The percentage of overweight adolescents has more than tripled since 1980, with more than 17 percent of adolescents aged 12–19 being considered overweight. • Certain subpopulations of adolescents, especially those who are in the juvenile justice or foster care system, are at significantly increased risk of health and mental disorders.

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5 ADOLESCENT HEALTH SERVICES – Adolescents who enter the juvenile justice system gener- ally have preexisting health problems, particularly substance abuse, sexually transmitted infections, unplanned pregnancies, dental problems, and psychiatric disorders. – Adolescents in foster care face more health challenges and chronic health issues—such as asthma, anemia, neurologi- cal abnormalities, emotional and behavioral problems, chronic physical disabilities, birth defects, and developmental delays— than those not in foster care. These adolescents are also at increased risk of unprotected sex and pregnancy, and have higher rates of severe mental health problems and substance use. M ost adolescents are considered healthy as defined by the tradi- tional medical measures of health status, such as mortality rates, incidence of disease, prevalence of chronic conditions, and use of health services. According to the National Survey of Child Health, ap- proximately 83 percent of adolescents aged 12–17 are in either excellent or very good health as reported by their parents, regardless of whether they live in urban or rural areas (Maternal and Child Health Bureau, 2005a,b). According to data from the Behavioral Risk Factor Surveillance System, 91 percent of those aged 18–24 consider themselves to be in good, very good, or excellent health (McCracken, Jiles, and Michels Blanck, 2007). This chapter explores how timing matters—how adolescence is a criti- cal time for health promotion. Many adolescents behave in risky ways or live in environments that not only affect their immediate health, but also have a significant impact on their health as adults. For example, McGinnis and Foege (1993) and more recently Mokdad and colleagues (2004) have shown that half of deaths among adults are due to health-related behaviors that for many people have their onset during adolescence. For example, tobacco use is the leading actual cause of preventable death in the United States. Other health-related behaviors that are associated with the leading causes of death include poor diet and physical inactivity, drug and alcohol abuse, risky driving, risky sexual behavior, and use of drugs. The effects of such health-compromising behaviors—and the extent to which the health system attempts to prevent and respond to them—are also influenced by socioeconomic status, living circumstances, school environment and quality, and after-school care. This chapter also considers how context matters for adolescents and their health and looks at how the social context and such factors as income, race/ethnicity, geography, and community efficacy may affect the health of adolescents. (The importance of context in adolescents’

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55 ADOLESCENT HEALTH STATUS access to and utilization of health services is explored more fully in Chap- ter 3.) Moreover, this chapter addressed differences in how need matters, as some segments of the adolescent population, defined by biology as well as behavior, have health needs that require particular attention in health systems. A recent analysis of the 21 Critical Health Objectives for Adolescents and Young Adults, a subset of the objectives of the Centers for Disease Control and Prevention’s (CDC’s) Healthy People 2010, highlights how little progress has been made in the overall health status of adolescents (Park et al., 2008; U.S. Department of Health and Human Services, 2006a). Of these 21 objectives, the only ones that have shown improvement since 2000 are unintentional injury-related behavior, pregnancy and sexually related behavior, and tobacco use (see Table 2-1). Moreover, several areas have worsened, including deaths caused by motor vehicle crashes related to alcohol use, which have risen, and obesity/overweight, which has increased along with a decrease in reported physical activity (Park et al., 2006). With these and many other findings in mind, this chapter explores available evidence on the health status of adolescents as defined by tradi- tional measures (mortality rates, incidence of disease, prevalence of chronic conditions, and use of health services). The chapter also offers a more complex and complete picture of health status by reviewing behaviors that may adversely affect health status not only during adolescence, but also in adulthood. Finally, the chapter highlights the current health status of vari- ous subpopulations of adolescents who are especially likely to be affected by several co-occurring health challenges, including those who behave in more than one risky way at the same time. Data on adolescents’ use of health services are discussed in Chapter 3. As discussed in Chapter 1, the committee focused this study on health services and policies for adolescents between the ages of 10 and 19, and where appropriate and possible, broke this population down into the two subsets of early adolescence (ages 10–14) and adolescence (ages 15–19). Throughout this chapter, health status is described for the adolescent popu- lation, and where data are available, is distinguished for these two subsets, adhering as closely as possible to these specific age ranges. Moreover, at some points in the chapter, the health status of those transitioning from adolescence to adulthood (those aged approximately 20–24) is included in the discussion because (1) the data do not always break off at exactly age 19, and (2) health problems in adolescence can have implications for adult health, and the progression of these problems is important to note. Finding: Most adolescents are considered healthy as defined by tra- ditional medical measures of current health status, such as mortality

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5 ADOLESCENT HEALTH SERVICES TABLE 2-1 21 Critical Health Objectives for Adolescents and Young Adults and Progress from Healthy People 2010, Ages 10–24 Baselinea Objective MORTALITY 1998 Reduce deaths of adolescents and young adults 10- to 14-year-olds (per 100,000) 21.5 15- to 19-year-olds (per 100,000) 69.5 20- to 24-year-olds (per 100,000) 92.7 1999 Reduce suicide rate 10- to 14-year-olds (per 100,000) 1.2 15- to 19-year-olds (per 100,000) 8.0 1999 Reduce deaths caused by motor vehicle crashes 15- to 24-year-olds (per 100,000) 25.6 1998 Reduce deaths caused by alcohol- and drug-related motor vehicle crashes Alcohol-related deaths 15- to 24-year-olds (per 100,000) 11.8 1999 Reduce homicides 10- to 14-year-olds (per 100,000) 1.2 15- to 19-year-olds (per 100,000) 10.4 MORBIDITY Sexually Transmitted Infections (STIs) 1998 (Developmental) Reduce the number of new cases of HIV/AIDS diagnosed among adolescents and young adults 16,479d 13- to 24-year-olds 1999 Reduce the proportion of adolescents and young adults with Chlamydia trachomatis infections 15- to 24-year-olds (percent) Females attending family planning clinics 5.0 Females attending STI clinics 12.2 Males attending STI clinics 15.7

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57 ADOLESCENT HEALTH STATUS Midcourse Reviewb Targeta Progress to Targetc 1999 2000 2001 2002 2003 2004 2005 2010 20.4 20.3 19.1 — — 18.7 — 16.8 Toward 68.6 67.4 67.1 — — 66.4 — 39.8 Toward 90.8 93.6 94.9 — — 96.4 — 49.0 Away — 1.5 1.3 — — 1.3 — TNP TNP — 8.0 7.9 — — 8.2 — TNP TNP — 26.3 26.3 — — 25.8 — TNP TNP 11.7 12.2 12.2 12.4 — — — TNP TNP — 1.1 — — — 1.0 — TNP TNP — NA — — — 9.3 — TNP TNP — — — — — — — TNP TNP — 5.9 5.9 6.0 — 6.9 — 3.0 Away — 13.5 13.3 13.5 — 15.3 — 3.0 Away — 17.0 17.0 17.0 — 20.2 — 3.0 Away Continued

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5 ADOLESCENT HEALTH SERVICES TABLE 2-1 Continued Baselinea Objective MENTAL HEALTH 2001 Increase the proportion of children and adolescents with mental health problems who receive treatment 4- to 17-year-olds (percent) 59.0 1997 Reduce the proportion of children and adolescents with disabilities who are reported to be sad, unhappy, or depressed 4- to 17-year-olds (percent) 31.0 1999 Reduce the rate of suicide attempts by adolescents that require medical attention 9th- to 12th-grade students (percent) 2.6 BEHAVIOR AND HEALTH Injuries 1999 Reduce the proportion of adolescents who report that they rode during the past 30 days with a driver who had been drinking alcohol 9th- to 12th-grade students (percent) 33.0 1999 Increase use of safety belts 9th- to 12th-grade students (percent) 84.0 1998 Reduce injuries caused by alcohol- and drug-related motor vehicle crashes Alcohol-related injuries 15- to 24-year-olds (per 100,000) 374.0 Violence 1999 Reduce physical fighting among adolescents 9th- to 12th-grade students (percent) 36.0 1999 Reduce weapon carrying by adolescents on school property 9th- to 12th-grade students (percent) 6.9 Binge Drinking 1998 Reduce the proportion of adolescents engaging in binge drinking of alcoholic beverages 12- to 17-year-olds (percent) 8.3

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5 ADOLESCENT HEALTH STATUS Midcourse Reviewb Targeta Progress to Targetc 1999 2000 2001 2002 2003 2004 2005 2010 — — — — — — 64.0 66.0 Toward — — — — — — 27.0 17.0 Toward — — 2.6 — — — 2.3 1.0 Toward — — 31.0 — 30.0 — 28.5 30.0 Met target — — 86.0 — — — 89.8 92.0 Toward 403.0 391.0 359.0 301.0 — — — TNP TNP — — 33.0 — — — 35.9 32.0 Toward — — 6.4 — — — 6.5 4.9 Toward 10.1 10.4 10.6 10.7 10.6 — 9.9 2.0 Away Continued

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0 ADOLESCENT HEALTH SERVICES TABLE 2-1 Continued Baselinea Objective Substance Use 1998 Reduce past-month use of illicit substances (marijuana) 12- to 17-year-olds (percent) 8.3 1999 Reduce tobacco use by adolescents 9th- to 12th-grade students (percent) 40.0 Pregnancy 1996 Reduce pregnancies among adolescent females 15- to 17-year-olds (per 1,000 families) 67.0 1999 Increase the proportion of adolescents who participate in responsible sexual behavior 9th- to 12th-grade students (percent) 85.0 Disordered Eating 1988–1994 Reduce the proportion of adolescents who are overweight or obese 12- to 19-year-olds (percent) 11.0 Physical Activity 1999 Increase the proportion of adolescents who engage in vigorous physical activity that promotes cardiovascular fitness 3 or more days per week for 20 or more minutes per occasion 9th- to 12th-grade students (percent) 65.0 NOTES: — = data not available; TNP = target not provided. aU.S. Department of Health and Human Services (2000). bU.S. Department of Health and Human Services (2006a, 2007a). rates, incidence of disease, prevalence of chronic conditions, and use of health services. Finding: Adolescence is a period of both risk and opportunity. Adoles- cents may take risks that can jeopardize their health during these early years, as well as contribute to the leading causes of death and disease in adulthood. During adolescence, a range of health conditions can

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 ADOLESCENT HEALTH STATUS Midcourse Reviewb Targeta Progress to Targetc 1999 2000 2001 2002 2003 2004 2005 2010 8.2 8.0 8.2 7.9 — — 6.8 0.7 Toward — — 34.0 — — — 28.4 21.0 Toward 56.0 54.0 — 44.4 — — — 43.0 Toward — — 86.0 — 88.0 — — 95.0 Toward 1999– 2003– 2000 2004 — — 16.0 — — 17.0 — 5.0 Away — — 65.0 — — — 64.1 85.0 Away cProgress to target = toward, away from, or met target compared with baseline data. Objec- tives without a projected target were not assessed. dIncludes ages 13 years and older. be identified and addressed in ways that affect not only adolescents’ functioning and opportunities, but also the quality of their adult lives. Adolescence also provides many opportunities to develop habits that create a strong foundation for healthy lifestyles and behavior over the full life span.

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2 ADOLESCENT HEALTH SERVICES MORTALITY AND MORBIDITY Mortality More than 17,500 adolescents aged 10–19 die annually according to the National Vital Statistics System Mortality File collected by CDC’s National Center for Health Statistics in 2004. In general, mortality rates in- crease with age even within this narrow age range. For example, those aged 15–19 have a mortality rate more than three times higher than that of those aged 10–14 (see Figure 2-1). This higher rate is attributable largely to mor- tality among males—more than twice that among females in this age group. American Indian/Alaskan Native non-Hispanic and black non-Hispanic adolescents generally have the highest mortality rates, while Asian/Pacific Islander non-Hispanics have the lowest (see Table 2-2). Deaths among adolescents are caused by injuries (unintentional, such as those due to motor vehicle crashes, and intentional, such as those due to suicide or homicide) and by natural causes (such as disease or a chronic health condition). Unintentional injury (the leading cause of mortality among adolescents), homicide, and suicide accounted for almost three- quarters of all deaths among adolescents aged 10–19 in 2004 (National Center for Injury Prevention and Control, 2007; see Figure 2-2). Uninten- tional injury was also one of the three leading causes of death among adults aged 35–54 in 2004; in contrast with adolescents, however, malignant neo- 70 60 Rates per 100,000 50 Overall 40 Motor vehicle accidents Homicide 30 Suicide 20 10 0 10–14 years 15–19 years Age Group FIGURE 2-1 Adolescent mortality rates (per 100,000) in 2004 by age group. SOURCE: National Center for Injury Prevention and Control (2007). Figure 2-1

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