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AIDS and Adolescents The committee finds no credible evidence that the threat of HIV infection or AIDS will cease in the near future in the United States, as noted in Chapter 1. Therefore, the committee believes it important to sustain effective HIV prevention programs for young people at or before the age at which they begin practicing behaviors that risk transmission of this deadly virus. Serological studies of HIV infection, surveys of sexual and drug use behaviors, and reports from clinics for the treatment of Hug use and sexually transmitted diseases (STDs) all indicate that some young people begin practicing behaviors that risk HIV transmission during and in some cases before their early teens. By the end of the teenage years, the majority of young persons in America report having begun sexual intercourse, and one-half report some experience with illicit drugs.) Evidence from HIV seroprevalence studies conducted among patients admitted to 37 metropolitan hospitals during 1988-1989 suggests that the HIV prevalence rate is vanishingly small among 11-year-olds but begins rising at age 12 and continues to rise throughout the teenage years.2 These behavioral and epidemiological facts suggest that HIV pre- vention efforts should begin at least by early adolescence3 and that they l See, for example, Tables 3-7 and 3-11. 2 Dr. Michael E. St. Louis, HIV Seroepidemiology Branch, Center for Infectious Diseases, CDC, per- sonal communication, April 4, 1990. 3Adolescence, as heated in the psychological literature' is not synonymous with the teenage years. It is generally said to begin between 10 and 13 years of age and to end between 18 and 21 years (Santrock, 1981). This stage of life is characterized by significant physical, psychological, and social 147
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148 ~ AIDS: THE SECOND DECADE should continue throughout this period. Federal funding of such pro- grams has ample precedent in that this country has supported programs to prevent other health problems of adolescents (e.g., unintended teenage pregnancy, drug use). The committee believes that the nation must recog- nize the importance of and unique opportunities for preventing the spread of HIV in the teenage population and that federal agencies must inter- vene accordingly. Adolescents deserve special attention because patterns of health behavior and risk taking are often established during the teenage years. By targeting prevention programs to adolescents, the United States may not only be protecting its youth but also preventing future problems in the adult population. Despite the obvious benefits associated with reaching adolescents, less is known about effective interventions for this age group than for adults. Much of the accumulated knowledge about AIDS prevention has been gained from adult programs, primarily programs for adult gay men. Adolescent health behavior is likely to be different from that of adults, however, and programs designed for adults require modification to accommodate the behavioral, social, and developmental diversity found in the adolescent population. In this chapter, the committee descnbes the scope of the AIDS prob- lem among adolescents, insofar as data on AIDS cases and HIV infection are available for this population. Subsequently, it reviews what is known about the distribution of nsk-associated behaviors in the adolescent pop- ulation, as well as the prevalence of sexual intercourse, condom use, and drug use and the confluence of these high-nsk behaviors. Finally, the committee considers what should be done to prevent further spread of HIV infection in this population. THE EPIDEMIOLOGY OF AIDS AND HIV AMONG ADOLESCENTS Before reviewing available data on the scope of the HIV/AIDS problem among adolescents, the committee notes the inadequacies of those data, a deficiency leading the committee to the conclusion that the precise degree of infiltration of HIV infection into the adolescent population is presently unknown. The relatively few cases reported to date among 13- to 19-year olds (see Table 3-1) do not accurately reflect the scope of the problem, nor should these data be taken as grounds for complacency. changes. Definitions of the exact time of entry into and exit from adolescence vary from study to study, depending on such factors as the theoretical view that has been adopted, the cultural context of the adolescent, and biological and social development factors, as well as the issue or problem of interest. (See Gold and Petronio  for further elaboration of varying definitions of adolescence.)
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AIDS AND ADOLESCENTS I 149 Rather, the pattern of the epidemic in the adolescent population described below should be viewed as an opportunity for primary prevention that should not be overlooked. AIDS case statistics are probably the most reliable epidemiological data base currently available. Yet the counts of current AIDS cases repre- sent HIV infections that were acquired several years before the diagnosis of AIDS was made. The current best estimates of the mean incubation period of the disease (i.e., the mean time between HIV infection and the onset of clinically diagnosable AIDS) are eight to ten years, but as data spanning more time become available and as more effective prophylac- tic treatments become available, it seems likely that this estimate will increased Furthermore, it is possible that the median incubation period for teenagers may be longer than eight years. Natural history studies of hemophiliacs infected with HTV suggest that the incubation period may be longer for chidden (not newborns) and adolescents than it is for adults (Goedert et al., 19891.s Yet even assuming that the incubation periods for adolescents and adults are equivalent, it is likely that few persons that were infected during their teenage years would also be diagnosed as AIDS cases during their teens. Even with the assumption of a median incubation period of eight years, fewer than one-half of persons infected with HIV at age 13 would be expected to develop AIDS dunng their teenage years,6 and even fewer of those infected in the late teens would develop AIDS before age 4The current estimate is that the majority of HIV-seropositive individuals will go on to develop AIDS, and it is not impossible that 100 percent of seropositive individuals may eventually develop full-blown disease (IOM/NAS, 1988:35-36); see also the projections of Lui, Darrow, and Rutherford (1988) and Longini et al. (1989). However, new evidence suggests that the incubation distribution of the disease may be quite different for children, adolescents, and adults, as discussed in footnote 5. SGoedert and colleagues (1989:1144, Table 3) report estimated annual incidence rates for AIDS after HIV infection as 0.83 per hundred for 1- to 11-year-old children; 1.49 per hundred for 12- to 17-year- old adolescents; 2.39 per hundred for 18- to 25-year-old adults; 3.40 per hundred for 26- to 34-year-old adults; and 5.66 per hundred for 35- to 70-year-old adults. The ages cited are the age of the person at the time of HIV infection. It should be noted that annual AIDS incidence rates are not uniformly distributed over time following infection. Thus, for example, rates are close to zero during the first two years following infection, and they rise during the next four to six years. It should also be noted that incubation periods may vary across transmission categories for adolescents. Indeed, some teens may progress from infection to disease more quickly than others. According to case reports, teens who acquired HIV infection through drug use or sexual behavior have progressed more rapidly than adults from infection to AIDS (K. Hein, Adolescent AIDS Program, Montefiore Medical Center, Bronx, N.Y., personal communication, 1989). Other data indicate that the median survival period is shorter for patients less than 20 years of age (9.0 months) than for patients between the ages of 20 and 29 years (13.0 months) or 30 to 39 years (13.2 months) (Lemp et al., 1990). 6It should be realized, of course, that bode the cumulative risk of infection and the rate of risky behav- iors can be expected to increase with age during adolescence (see the evidence presented below).
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150 ~ AIDS: THE SECOND DECADE 20. Those persons who are diagnosed with AIDS during their teens will be drawn mainly from the group of persons whose incubation periods were markedly shorter than the median and who were infected during their early teens. Seroprevalence data for probability samples of individuals drawn from well-defined populations of epidemiological interest would provide a more reliable basis for inferring the prevalence of infection among teenagers. Unfortunately, with few exceptions, seroprevalence surveys conducted in this country have relied on samples of convenience, and most have not included teenagers. The largest samples that provide information on adolescents are derived from the routine HIV screening of applicants for military service and the Job Corps. These data cannot be generalized with knowable margins of error to other populations, but they can provide some insight into segments of the teenage population in which the infection may be established. HIV prevalence estimates derived from blinded testing of newborns for HIV antibody (i.e., CDC's neonatal surveillance activity, which is described in Chapter 1) provide a reliable indicator of the prevalence of infection among women delivering children. (Infants, whether infected or not, carry the maternal antibodies to HIV at birth if the mother is infected with the virus.) Analysis of these data by the age of the mother could provide important information about HIV infection among teenage women who bear children. Unfortunately, tabulations of HIV seroprevalence by mother's age are not presently available for most states. hndeed, the committee notes that, in some states, data on the age of the mother are not being collected. To provide better information about HIV infection and AIDS among adolescents, the committee recommends that the Centers for Disease Control make available to the research community AIDS-related data that permit separate consideration of teenagers and other age groups. Specifically, the committee recommends that: ˇ data on AIDS cases be made available in a form that permits tabulation by specific ages or by narrow age groups (these data should be as complete as possible without threatening inadvertent disclosure of the iden- tity of any individual case);7 every state that participates in the neonatal surveillance . 7 The Committee on National Statistics at the National Research Council and the Social Science Re- search Council have jointly convened a panel to study the broad issues of confidentiality and data access in research. Their report will be available in approximately two years.
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AI:DS AND ADOLESCENTS ~ 151 activity include the age of the mother coded in years or by narrow age group; and ˇ CDC provide data from its family of surveys by specific ages or in narrow age groups, as well as by race, gender, and ethnicity. The Scope of the Problem AIDS Cases. As noted above, the small percentage of AIDS cases diagnosed in the adolescent population does not imply that AIDS and HTV are not a problem for teenagers. Indeed, as Verrnund and colleagues (1989) argue, a substantial fraction of the AIDS cases diagnosed among persons in their twenties reflect infections contracted during the teenage years. As of December 31, 1989, approximately 24,000 cases of AIDS had been reported among teenagers and young adults (ages 13-29~. Table 3-1 shows the distribution of reported AIDS cases by age at diagnosis, using the broad age categories into which CDC has coded the data released to the public. It can be seen that roughly one case in five is diagnosed among persons under the age of 30. The proportion of cases actually diagnosed among teenagers, however, is small. Figure 3-1 displays the case counts by age at diagnosis for persons diagnosed with AIDS between the ages of 13 and 29. Allowing, as noted earlier, for an incubation period that is rarely less than two years and a mean incubation period that may be eight years or longer, one would expect that nearly all of the AIDS cases diagnosed among persons in their very early twenties would reflect HIV infections contracted during adolescence.9 The overall impact of AIDS on teenagers and young adults is reflected in the fact that AIDS was the tenth leading cause of death among 15- to 24-year-olds as early as 1984; it had risen to the seventh leading cause of death for this age group in 1986 and the sixth in 1987 (Kilboume, Buehler, and Rogers, 1990~. The CDC's family of surveys collects data on HIV infection from several subpopulations, including clients attending drug treatment, STD, tuberculosis, and prenatal clinics, patients at general hospitals, and newborn infants. With the exception of the survey of infants, all of the other surveys rely on samples of convenience. Data collected through this program are intended to provide information on the prevalence and incidence of infection in selected populations, to provide early warning of the emergence of infection in new populations, and to target intervention programs and other resources. 9 It may seem intuitively appealing to argue that at least one-half of the 4,268 cases diagnosed at age 28 reflect infections contracted during the teens. This argument is not, however, logically required. Because there is a non-zero probability of an AIDS diagnosis being recorded in each year from roughly two years after HIV infection, it would be theoretically possible (with a suitably large number of HIV infections among persons in their early twenties) to observe 4,000 cases of AIDS among 28-year-olds, none of which had been contracted by teenagers.
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152 ~ AIDS: THE SECOND DECADE TABLE 3-1 Distribution of AIDS Cases Reported Through December 31, 1989, by Age at Diagnosis Diagnosis No. of (years) Cases Percentage < 1 785 0.7 1-12 1,210 1.0 13-19 461 0.4 2~24 5,090 4.3 25-29 18,966 16.1 3~39 54,334 46.1 40~9 24,951 21.2 50t 11,984 10.2 Total 117,781 1OO.Oa Percentages may not sum to 100.0 because of rounding. SOURCE: Special tabulation provided by the Statistics and Data Processing Branch of the AIDS Program, Centers for Disease Control. 6,000 5,000 4,000 oh 111 an C ~ 3.000 Oh 2,000 1 ,000 4,996 2,714 1 ,979 34 38 67 90 188 ~1 863 ~ 289 3,194 3,794 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 AGE AT DIAGNOSIS FIGURE 3-1 Number of AIDS cases reported among 15- to 30-year-olds through December 31, 1989, by single years of age at diagnosis. SOURCE: Special tabulation provided by the Statistics and Data Processing Branch of the AIDS Program, Centers for Disease Control.
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AIDS AND ADOLESCENTS | 153 HIV Seroprevalence. Since October 1985, the Department of De- fense has tested applicantsl° for military service for evidence of HIV in- fection; in January 1986 the armed forces began screening all active-duty personnel. The crude prevalence rate for 17- to 19-year-old applicants screened between October 15, 1985 and March 31, 1989 was 0.34 per 1,000 (Burke et al., 1990~. HIV prevalence rates among military appli- cantsli from October 1985 to March 1986 increased directly and linearly with age from 0.25 per thousand among 18-year-olds to 4.9 per thou- sand among 27-year-olds (Burke et al., 1987:132~.12 Among active-duty personnel during the period October 1985 to July 1989, prevalence rates were found to have a similar distribution by age. The observed rates were lowest among soldiers less than 20 years old (0.5 per thousand), peaked at 3.4 per thousand among 30- to 34-year-olds, and gradually declined among older military personnel (Kelley et al., 1990~. Figures 3-2a and 3-2b plot these age-specific prevalence rates for military applicants and active-duty personnel. The plots demonstrate that roughly parallel age trends are found for the two groups. Data tabulated separately for applicants from the New York-New Jersey metropolitan area suggest a similar trend. The prevalence of HIV among applicants from the New York-New Jersey metropolitan area is several times higher than the rate among applicants from the rest of the nation (see Figure 3-2c). In this case, prevalence rates among military applicants 30 years of age and older are somewhat higher than those of applicants aged 26-30. The other large group of young people who are routinely screened for HIV are persons applying to participate in the Job Corps. The Job Corps is a federal program that provides training and employment for so- cioeconomically and educationally disadvantaged youths. Of the 69,233 applicants between the ages of 16 and 21 years who were screened be- tween October 1987 and November 198S, 3.9 per thousand were infected (St. Louis et al., 1989~. This rate is much higher than the prevalence 10Among military applicants who had been screened between October 1985 and March 1986, 86 per- cent were male and 76 percent were white; 46 percent were less than 20 years old, and only 5 percent reported education beyond a high school diploma (Burke et al., 1987) 11The observed age-specific prevalence estimates largely reflect the rates among older males (434 seropositive among a total of 263,572 men). Overall, HIV prevalence was lower among women, and fewer were tested (26 seropositive among 42,489 women). However, among 17- and 18-year-olds, the prevalence rates for males and females were approximately equal (Burke et al., 1987). Other analyses of military data find prevalence rates among teenage females to be comparable to those among teenage males (Horton, Alexander, and Brundage, 1989; Kelley et al., 1990). 12The authors concluded that HIV prevalence increased linearly with age between 18 and 27 years (Burke et al., 1987:132). Estimated prevalence among males over the age of 27 was lower, however, than the prevalence rates observed among male applicants between 25 and 27 years old.
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154 ~ AIDS: THE SECOND DECADE 6 r a' 4 Q - LLJ He 3 LL > 2 UJ cr ILL > I 1 o ~ Males - /\ \/ _,~ Females / `1/ , , , 1 1 7 1 8 1 9 20 21 22 23 24 AGE 25 26 27 28 29 > 30 FIGURE 3-2A Prevalence of HIV (rate per 1,000 persons), by age, among male and female applicants for military service [N = 306,061] (October 1985 through March 1986). SOURCE: Burke et al., 1987. 3 Q - LLJ Cal A LL G 1 > I o 17-19 20-24 25-29 4 30-34 35-39 40 ~ AGE FIGURE 3-2B Prevalence of HIV (rate per 1,000 persons), by age, among active duty military personnel [N = 1,752,191] (January 1987 through April 1988). SOURCE: Peterson et al., 1988.
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AIDS AND ADOLESCENTS ~ 155 Males - a' 2.0 a) Q LLJ A LL ~ 1.0 0,0 Females 1 1 < 20 21-25 AGE GROUP 26-30 > 30 FIGURE 3-2C Prevalence of HIV (percent), by age, among male and female applicants for military service from New York-New Jersey metropolitan area [N = 44,139] (October 1985 through June 1987). SOURCE: Brundage et al., 1988. rates found among the youngest groups of applicants for military ser- vice, which may reflect differences in the populations represented in applications to these two organizations. HIV Seroprevalence in Childbearing Women. Anonymous anti- body testing of newborn infants provides information on the prevalence of HIV infection among childbearing women (because infants circulate maternal antibody during the first months of life). As noted earlier, data are not available for every state, and some states do not provide infor- mation on the age of the mother. Data have been published for New York City and the rest of New York State (Novick et al., 1989a). Among babies born in New York State between November 1987 and November 198S, the seroprevalence rate was 1.6 per thousand outside New York City and 12.5 per thousand for births in New York City. Figure 3-3 plots the age-specific rates of infection found in New York City. Although these data show an age trend similar to that found in other studies, the rates of infection even among teenage mothers are substantial.~3 A1- most 10 per thousand or ~ percent of black teenagers who delivered children in New York City during this period were infected with HIV. Reanalyses of ZIP Code-specific areas with high rates of drug use (determined by comparing rates of drug-related hospital discharges) found rates as high as 40 per thousand or 4 percent in some ZIP Codes areas of New York City (Novick et al., 1989a).
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156 ~ AIDS: THE SECOND DECADE 35 o o o ~ 30 a' Q AL 25 a: by ILL o CC lo Oh 20 15 10 o _ , _ White Black Hispanic 32.2 _ 1~ N~f 20.3 17 14.7 < 20 20-29 30-39 40 + AGE OF MOTHER FIGURE 3-3 HIV seroprevalence rates (per 1,000 persons) among New York City women giving birth between November SO, 1987, and November 30, 1988. Of 12S,120 New York City women tested, race/ethnicity was unknown for 2,461, and age was unknown for 2,334. SOURCE: Novick et al., 1989a:Table 4. The prevalence of HIV infection among Hispanic teenage mothers was almost as high. In considering Figure 3-3, the committee would note that it is only the contrast with rates of almost 30 per thousand found among 30- to 39-year-old black mothers that make the observed teenage prevalence rates appear relatively low. HIV Seroprevalence in Other Studies. The seroprevaTence rates provided above on women bearing children in New York City are but- tressed by emerging data from serosurveys of nonprobability samples of hospital patients. Ernst and colleagues (1989), for example, recently reported that, among patients aged 15 to 24 at the Bronx Lebanon Hos- pital, 36 per thousand or 3.6 percent of males and 25 per thousand or 2.5 percent of females were infected with HIV. Table 3-2 summarizes se- lected results of this and other small-scale seroprevalence studies among teenagers and young adults. Although the observed prevalence of HIV infection varies from population to population and from study to study, one finding is clear: the AIDS virus is substantially seeded in some segments of the adolescent population. Moreover, although the variation in estimates argues for more comprehensive and standardized monitoring of the spread of infection in this population, the lesson for prevention is nonetheless apparent. HIV infection is already spreading in the teenage
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AIDS AND ADOLESCENTS ~ 157 population, and in some locales and population subgroups, the spread has been substantial. Variation of AIDS and HIV Prevalence by Gender. Just as more AIDS cases are seen among adult males than among adult females, so too are there more cases of AIDS among teenage boys than among teenage girIs.~4 Of all AIDS cases reported as of December 31, 1989, males outnumbered females by a 9:1 ratio.is As the first row of Table 3-3 shows, however, the ratio of male to female cases is much lower among teenagers than among adults in the United States. Thus, it can be seen that the male-to-female ratio, which is roughly 1:1 among cases diagnosed in infants (younger than 1 year), increases to 4:1 among teenagers, to 6:1 among 20- to 24-year-olds, and ultimately to 16:1 for cases diagnosed among persons in their forties. In addition to variations by age, the ratio of male-to-female cases of AIDS and HIV infection varies substantially among populations. Eleven percent of AIDS cases among teenagers have been diagnosed in the New York metropolitan areas and the male-to-female ratio for those cases is approximately 2:1 (Table 3-31. The size of this ratio indicates that girls in the New York area are supporting a greater burden of disease than girls nationally.'7 HIV infection rates calculated for military applicants As of July 1, 1986, there were more than 35 million individuals in this country between the ages of 10 and 19 years, constituting approximately 14.6 percent of the total population. The ratio of males lo females is essentially 1:1 (1.044:1) (U.S. Bureau of the Census, 1987:17). 15As of December 31, 1989, females of all ages accounted for 11,524 cases of AIDS out of a total of 117,781 reported cases. 16As of December 31, 1989, a total of 461 AIDS cases had been reported among 13- to 19-year- olds; 50 of these cases were from the New York Primary Metropolitan Statistical Area. In 1983, the Office of Management and Budget changed the classification system used to define metropolitan areas in federal statistical reports. The basic tern' for such areas, formerly known as Standard Metropolitan Statistical Areas or SMSAs, was changed to Metropolitan Statistical Areas or MSAs. The basic concept of a metropolitan area, however, remained that of an area with a large population nucleus and the adjacent communities, e.g., suburbs, that have a high degree of economic and social integration with that nucleus. Within metropolitan complexes of one million or more population, separate Primary Statistical Areas (PMSA) may be designated under the new classification system. Any metropolitan area containing one or more PMSAs was, in turn, designated a Consolidated Metropolitan Statistical Area (CMSA). The New York PMSA, for example, includes the five counties that comprise the City of New York, plus the suburban counties of Westchester, Rockland, and Putnam. Adjacent areas include other PMSAs, e.g., the Nassau-Suffolk (Long Island) PMSA. The New York PMSA and the Nassau- Suffolk PMSA are 2 of the 12 PMSAs that constitute the Consolidated Metropolitan Statistical Area that bears the awkward name: "New York-Northern New Jersey-Long Island, NY-NJ-CT CMSA." (U.S. Bureau of the Census, 1985, Appendix 2). 17The higher proportion of cases among females of all ages in New York reflects the greater relative proportion of cases attributable to IV drug use and heterosexual transmission in the Northeast than other areas. (See for example, Figure 1-1 in Chapter 1.)
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242 ~ AIDS: THE SECOND DECADE Howard, J., Taylor, J. A., Ganikos, M. L., Holder, H. D., Godwin, D. F., and Taylor, E. D. (1988) An overview of prevention research: Issues, answers, and new agendas. Public Health Reports 103:674 683. Hudson, R. A., Petty, B. A., Freeman, A. C., Haley, C. E., and Krepcho, M. A. (1989) Adolescent runaways' behavioral risk factors, knowledge about AIDS and attitudes about condom usage. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. Hummel, R., Rodriguez, G., Brandon, D., and Wells, D. (1989) Outreach model for HIV positive adolescents and adolescents currently at high risk for HIV infection. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Inazu, J. K., and Fox, G. L. (1980) Maternal influence on the sexual behavior of teenage daughters. Journal of Family Issues 1:81-102. Institute of Medicine (IOM). (1988) [1omelessness, Health, and Human Needs. Wash- ington, D.C.: National Academy Press. Institute of Medicine/National Academy of Sciences (IOM/NAS). (1986) Confronting AIDS: New Directions in Public Health, Health Care, and Research. Washington, D.C.: National Academy Press. Institute of Medicine/National Academy of Sciences (IOM/NAS). (1988) Confronting AIDS: Update 1988. Washington, D.C.: National Academy Press. Jackson, J., and Neshin, S. (1986) New Jersey community health project: Impact of using ex-addict education to disseminate infonnation on AIDS to intravenous drug users. Presented at the Second International Conference on AIDS, Paris, June 25-26. Jackson, J., and Rotl~iewicz, L. (1987) A coupon program: AIDS education and drug treatment. Presented at the Third International Conference on AIDS, Washington, D.C., June 1-5. Jaffe, L. R., Seehaus, NJ., Wagner, C., and Leadbeater, B. J. (1988) Anal intercourse and knowledge of acquired immunodeficiency syndrome among minonty-group female adolescents. Journal of Pediatrics 112:1005-1007. Jessor, R., Chase, J. A., and Donovan, J. E. (1980) Psychosocial correlates of marijuana use and problem drinking in a national sample of adolescents~merican Journal of Public Health 70:6~613. Jessor, R., Costa, F., Jessor, S. L., and Donovan, J. E. (1983) Time of first intercourse: A prospective study. Journal of Personality and Social Psychology 44:608~26. Jessor, S. L., and Jessor R. (1975) Transition from virginity to nonvirginity: A social-psychological study over time. Developmental Psychology 11:473~84. Job, R. F. S. (1988) Effective and ineffective use of fear in health promotion campaigns. American Journal of Public Health 78:163-167. Johnston, L. D., Bachman, J. G., and O'Malley, P. M. (1984) Monitoring the Future: Questionnaire Responses from the Nation's High School Seniors, 1983. Ann Arbor, Mich.: Institute for Social Research. Johnston, L. D., Bachman, J. G., and O'Malley, P. M. (1989) Results of the 1988 National High School Senior Survey (press release). University of Michigan, Ann Arbor, Mich., Februaly 28. Johnston, L. D., O'Malley, P. M., and Bachman, J. G. (1988) Illicit Drug Use, Smoking, and Drinking by America's High School Students, College Students, and Young Adults 1975-1987. Rockville, Md.: National Institute on Drug Abuse
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Representative terms from entire chapter: